Abstract
Purpose The purpose of this study was to determine dental hygiene students’ perspectives regarding their knowledge and understanding about caries prevention strategies and their intention to use these regimens in clinical practice. Dental hygienists’ knowledge and understanding of caries prevention is critical because they are the primary providers of these regimens and the relevant education.
Methods This 2019 national cross-sectional online survey was designed by the University of Maryland (UMD), structured by the ADA staff for online administration, distributed and collected by the American Dental Hygienists’ Association (ADHA) to 9533 email addresses, and de-identified response data were analyzed by UMD. The survey included questions on three caries preventive regimens: fluoride varnish, dental sealants, and silver diamine fluoride (SDF), and items on community water fluoridation (CWF), respondent’s demographics and intent to use the regimens. Statistical analyses included descriptive statistics and analysis of variance. Significance was set at p<0.05.
Results Of the 235 surveys returned (response rate 2.5%) the majority were female, White and born in the United States. Over half were in associate degree programs; nearly a third were in baccalaureate programs. Respondents reported greater knowledge/understanding and intention to use fluoride varnish and dental sealants than SDF. Less than half (44.7%) reported knowledge/understanding of SDF and only 22.6% had a high level of confidence regarding applying it. Additionally, only 31.1% indicated they were extremely likely to use SDF upon graduation.
Conclusions To reduce the prevalence of caries, dental hygiene graduates must be well-versed with the latest science-based preventive procedures, including non-invasive caries prevention and control therapies. The results of this survey, albeit non representative of the general population of dental hygiene students, suggest a need for a more extensive review of the caries preventive regimen content, especially for silver diamine fluoride, of dental hygiene curricular programs.
- dental hygiene education
- caries prevention
- non-invasive caries preventive regimens
- fluoride varnish
- dental sealants
- silver diamine fluoride
- community water fluoridation
INTRODUCTION
Untreated dental caries is a leading cause of preventable pain, tooth loss, and loss of time from school and work in the United States (US).1 Despite the existence of community-wide and personal cost-effective preventive measures, dental caries is the most common chronic disease among children in the US.2 Available preventive regimens are useful only when they are obtained and used appropriately. Dental hygienists serve as primary health team members to provide caries preventive regimens (CPR) and have received the underpinning education required for a patient to understand the evidence for and the need for the procedure. Dental hygienists’ CPR knowledge and understanding is pivotal to providing state-of-the-art prevention for patients and increasing or maintaining patient’s oral health and oral health literacy. Over the past two decades, there has been modest interest in assessing practicing dental hygienists’ understanding of and use of CPR.3–5
Several studies have surveyed practicing dental hygienists regarding their knowledge and application of CPR.3–5 In some cases, the respondents did not have the most current understanding of some of the preventive regimens available for caries prevention.3 The only national study of practicing dental hygienists showed respondents’ knowledge and understanding of fluorides was low. More than 40% of respondents did not recognize that fluoride’s primary role in caries prevention is fostering remineralization.3 A decade later, a state-wide study found dental hygienists were unsure about whether incipient, non-cavitated lesions could be remineralized with fluorides and they did not know/understand the value of frequent exposure to fluoride in low concentrations such as optimally fluoridated water.6
More recently, a curricular study of one dental hygiene program located in a state where 94% of central water supplies are optimally fluoridated and where many residents opt to drink bottled water, found that their students were not being taught about the importance of community water fluoridation (CWF).7 As a result, the students were not educating their low-income clients about CWF’s use and value.7 The program leaders changed the curriculum to ensure that their students were knowledgeable about the value of CWF and the students were evaluated both clinically and in the classroom on the content and approach to educate their patients.
There is evidence that students, once graduated and licensed, tend to practice what they were taught in school.8 Thus, it was important to assess dental hygiene students’ knowledge, understanding and intended future use of three key CPRs. The rationale for selecting the three regimens, fluoride varnish, pit and fissure sealants and silver diamine fluoride (SDF), was based on the evidence of their efficacy and current use in clinical practice. Currently, fluoride varnish is the most widely used professionally applied fluoride.2,9 In contrast, pit and fissure sealants have been available for decades but are not used as frequently as they could be, particularly in private practice settings.10 Silver diamine fluoride has been on the market in the US for a decade and has yet to be used as widely as it could be given its efficacy.11 The purpose of this study was to determine dental hygiene students’ knowledge and understanding regarding what is being taught about caries prevention from their perspective, and their intent to use the preventive regimens in clinical practice.
METHODS
This descriptive study used a cross–sectional survey design. The impetus for the survey came from the National Advisory Committee on Health Literacy in Dentistry (NACHLD) and the American Dental Association’s (ADA) Council on Advocacy for Access and Prevention (CAAP). The committee’s interest in patient-provider communication stimulated assessing what dental hygiene students are being taught regarding communication techniques and selected CPRs. The NACHLD approved this study and University of Maryland Institutional Review Board (IRB) gave the study exempt status as it was considered secondary data analysis.
Survey Instrument
A 40-item survey instrument that had questions on CPR, demographics, communication techniques, and intent to use the three preventive regimens and communication techniques after graduation was designed by the University of Maryland, School of Public Health. This manuscript is limited to content concerning dental caries preventive regimens. The survey instrument is essentially the same as the one used to survey US dental students which was based on one developed by Horowitz and colleagues in 2011 to survey healthcare providers about their use of CPRs and communication techniques.6,12 The survey was developed using Word (Microsoft; Redmond, WA, USA) and then structured and tested by ADA’s Health Policy Institute (HPI) staff for online administration (Qualtrics XM; Seattle, WA, USA). The survey was distributed to dental hygiene students in the US from the database of the American Dental Hygienists’ Association (ADHA) (n=9533). Response data was de-identified by HPI staff and analyzed by members of the NACHLD at the UMD School of Public Health.
The American Dental Hygienists’ Association (ADHA) distributed the survey to dental hygiene students via an email with a link to the survey. The survey went live on March 18, 2019, and closed on April 16, 2019. Prior to the release of the survey, the ADHA sent a letter to all dental hygiene program directors to make them aware of the survey and to encourage students to participate. Students were also informed of the survey through ADHA’s student online newsletter before the survey was distributed. E-mail reminders were sent on March 27 and April 11, 2019.
Measures
Students were asked about their knowledge/understanding of skills to apply, self-efficacy and intent to use three CPRs (fluoride varnish, pit and fissure sealants and SDF). The response options for the questions about knowledge/understanding of and skills to use the three regimens were “yes” or “no”. The response options for self-efficacy included: “not at all confident,” “somewhat confident,” and “extremely confident.” The intent to use the three regimens after graduation used the following options: “not at all likely,” “somewhat likely,” and “extremely likely.” In addition, students were asked whether and how they had been evaluated on each preventive regimen using the following response options: “yes” or “no” and whether the evaluation was in “clinic only,” “class only,” or “class and clinic.”
Students were asked if they had been trained to assess dental caries risk factors in children, which of the 13 risk factors they used, whether they educate their patients about the benefits of CWF (“yes” or “no”) and their confidence to explain the role of CWF in preventing caries (“extremely confident”, “somewhat confident” or “not at all confident”). Finally, students were asked their year of graduation (“2019” or “2020”), where they were born (“in the United States” or “outside the United States”), gender, ethnicity, race, and whether they had heard of oral health literacy (“yes” or “no”).
Independent Variables
There were three independent variables: 1) knowledge/understanding of the three CPRs; 2) skills to apply the three CPRs; and 3) self-efficacy or confidence to apply the three CPRs. Responses to the knowledge/understanding and skills measures were summed to create an index called “behavioral capability.” This index was calculated by scoring “yes” responses for knowledge/understanding of each of the three CPRs (fluoride varnishes, pt and fissure sealants and SDF) as “1.” Similarly, “yes” responses for having skills to apply each of the three CPRs received a score of “1.” The behavioral capability index values ranged from 0-6. For the self-efficacy index, responses for confidence to use each of the three CPRs were scored “1” for “not at all confident,” “2” for “somewhat confident,” and “3” for “extremely confident.” Index values ranged from 3-9.
Dependent Variable
The primary outcome measure was behavioral intention to use the CPRs. Responses for intention to use each of the three CPRs were scored “1” for “not at all likely,” “2” for “somewhat likely,” and “3” for “extremely likely.” Index values ranged from 3-9. The scores of each index were categorized into three approximately equal groups to represent low, medium and high scores. The low and medium groups were combined and used as the reference group in the analysis of variance (ANOVA) to compare scores of those in the low/medium group to those in the group with the highest scores.
Statistical Analysis
The data were analyzed using statistical analysis software (SPSS version 25; IBM, Armonk, NY, USA). The statistical analyses included distributions (frequencies and percentages) of student characteristics, factors used to assess caries risk in children ages 0-6, and behavioral capability, self-efficacy and behavioral intention related to the CPRs and ANOVA was used to examine associations between eight demographic variables and the dependent variable behavioral intention. The demographic variables included whether the students received training in caries risk assessment, year of graduation, where they were born, gender, whether they identified as Hispanic, race, whether a family member was a dentist or dental hygienist and if they had heard the term “oral health literacy.” The level of significance was set at p<0.05 for all analyses.
RESULTS
Demographics
The survey link was sent to the email addresses in the ADHA student database (n=9533). Three hundred four respondents started the survey and 235 surveys were completed for a response rate of 2.5%. The majority were female (95.7%), White (81.7%) and born in the US (89.8%). Over half (59.1%) were enrolled in an associate degree program while nearly a third (28.1%) were in a baccalaureate degree program. The respondents were expecting to complete their course of study in either 2019 (54.0%) or 2020 (45.5%). After graduation, over two-thirds (69.8%) planned to practice in a dental office and be employed by a dentist. Over eight in ten (84.3%) had heard of the term oral health literacy (Table I).
Demographics (n=235*)
Assessing Caries Risk
Most students (88.1%) reported receiving training on how to assess caries risk factors in children 0 to 6 years of age. The most frequently reported risk factors respondents reported learning about were sugary food or drinks (86.8%), fluoride exposure (86.4%), visual or radiographically evident restorations/cavitated carious lesions (85.1%) and visible plaque (84.7%). Fewer reported being taught to assess the caries experience of the mother, caregiver and/or other siblings (72.3%) and caregiver level of health literacy (61.7%). Less than a third (30.6%) reported they were taught to assess eligibility for government programs such as the Women, Infants and Children (WIC) and Head Start programs or Medicaid insurance (Table II).
Respondent perspectives regarding their caries prevention education (n=232*)
CPR and Community Water Fluoridation
Most students (89.4%) reported their dental hygiene program evaluated them on the use of fluoride varnishes, dental sealants and SDF, and almost three-fourths (72.8%) reported they were evaluated in both the classroom and the clinic. Only 43% rated their program highly on the inclusion of CWF as a caries preventive regimen. Just over half (55.3%) were extremely confident they could explain the role of CWF in preventing caries and a quarter (26.4%) do not educate their patients about the benefits of drinking fluoridated tap water (Table II).
Knowledge, Self-efficacy and Intention to Use CPRs
Respondents reported having greater knowledge/understanding as well as the skills, self-efficacy and intention to use fluoride varnish and dental sealants versus SDF. Almost all respondents indicated having knowledge of fluoride varnish (99.6%) and pit and fissure sealants (91.9%), but less than half (44.7%) reported knowledge/understanding of SDF. Most students reported having the skills to apply fluoride varnish (98.7%) and pit and fissure sealants (86.0%), but less than a third (31.5%) reported having skills to apply SDF (Table III). Regarding self-efficacy, most all (94.9%) reported they were ‘extremely confident’ in their ability to use fluoride varnish. However, this dropped to 75.7% and 22.6 % for applying pit and fissure sealants and SDF, respectively. For the primary outcome measure of intention to use CPRs with patients after they graduate from dental hygiene school, the majority (97%) reported they were “extremely likely” to use fluoride varnishes and “extremely likely” to use pit and fissure sealants (92.3%). Less than one third (31.1%) reported that they intended to use SDF (Table IV).
Respondents’ perspectives regarding their knowledge/understanding and skills related to three caries preventive regimens (n=235)
Respondents’ perspectives regarding their self-efficacy and intention related to three caries preventive regimens (n=235).
Behavioral intention to use CPRs
In the bivariate analysis, no variables were significantly associated behavioral intention to use fluoride varnish, pit and fissure sealants, SDF (Table IV).
DISCUSSION
The mission of the Healthy People 2030 initiative is to promote, strengthen, and evaluate the nation’s efforts to improve the health and well-being of all people. Within the oral health category, the oral health goal is to improve oral health by increasing access to oral health care, including preventive services. More specifically, Objective 2 states: “Reduce the proportion of children and adolescents with active and untreated tooth decay.”13 Baseline data indicate that 13.4% of children and adolescents aged 3-19 years had active and untreated cavities.”14 The Healthy People 2030 target is to reduce it to 10.2 percent. Using CPRs is pivotal to achieving the HP2030 objective.
Most children and adolescents who have active, untreated tooth decay come from families with low incomes and low levels of oral health literacy.14,15 Thus, it is noteworthy that only 61.7% of respondents reported being taught to assess the level of health literacy of the caregivers and less than one third (30.6%) reported that they were taught to assess eligibility for government programs for families of low incomes such as Women Infants and Children (WIC) and Head Start. Both oral health literacy and the ability to access government programs are important for caries risk assessment in children and adolescents.
The findings indicating greater knowledge/understanding, skills and intention to use fluoride varnish and pit and fissure sealants versus SDF in clinical practice were not unexpected. Silver diamine fluoride is relatively new in the US and there has been controversy regarding who can actually apply it, when it should be used, and for whom it is indicated. However, SDF is now available in all 50 states and all states allow both dentists and dental hygienists to apply it.16 Silver diamine fluoride is being used in young children and older adults especially, and is viewed as being on the forefront of non-invasive therapies for the treatment and prevention of dental caries.11
Fluoride varnish is currently the most frequently used of the operator-applied fluoride products and nearly all (98.7%) of respondents reported having the required skills to apply it. It was also reassuring to learn that over three-quarters (86%) of the respondents indicated confidence in using and placing pit and fissure sealants. As such, these future graduates could be instrumental in establishing a strong preventive program in the dental practices and clinics where they are employed and reinforce the value of this underused caries preventive procedure.
Regarding students’ opinions about the inclusion of water fluoridation as a regimen to prevent dental caries, only 43% rated their dental hygiene education program as having a strong emphasis on this measure. Additionally, only 55.3% were extremely confident that they could explain the role of CWF plays in preventing tooth decay to another person. Finally, over a quarter (26.4%) reported they do not educate their patients about CWF. These findings suggest a low emphasis on the benefits of CWF in their programs, limited confidence in explaining the role of CWF (only 55.3% were extremely confident), and a lack of emphasis of water fluoridation as a regimen to prevent dental caries. Dental hygiene programs may benefit from evaluating and reorganizing their course material regarding CWF. In a study conducted at the University of Maryland, dental hygiene students’ understanding of and ability to communicate caries preventive strategies to low-income populations during a community service-learning program were assessed. In spite of increased knowledge regarding the benefits of CWF, less than half of the students correctly ranked drinking fluoridated water as the best caries prevention strategy and only 8% of the caregivers ranked this option first even after counseling.7 Based on these findings, the dental hygiene program made revisions to the curriculum to increase student’s knowledge of caries prevention strategies.7
Bivariate analysis of predictor variables and behavioral intention (BI) to use three caries preventive regimens (n=235)
Moreover, the Commission on Dental Accreditation (CODA) accreditation teams should consider increasing their evaluation of dental hygiene curricular content regarding CWF. Such an effort is especially important because the consumption of bottled water that contains little or no fluoride continues to increase in the US.17 The dental profession has not been effective in educating the public about the benefits of optimally fluoridated tap water even though nearly 80 percent (79.6%) of US central water supplies are considered to be fluoridated at optimal levels.15,18 If the public is unaware of the benefits of consuming fluoridated tap water, they are less likely to use it. Well-educated dental hygienists could be instrumental in advancing the knowledge and understanding of the benefits of CWF especially for families of low income. Similarly, CODA should ensure their accreditation requirements include an emphasis on other non-invasive caries therapy regimens such as SDF.
The results of this survey of dental hygiene students parallel those of dental students in that both groups were more knowledgeable about and more likely to report their intent to use two of the three CPRs, fluoride varnish and pit and fissure sealants, in clinical practice.12 Similarly, both groups were far less likely to be knowledgeable about the benefits of SDF and the confidence to use SDF upon graduation. Dental hygiene students, however, were even less well prepared and less likely to indicate they will use SDF in practice than the dental student cohorts.
LIMITATIONS
The main limitation was the low response rate which curbs any generalization of the findings. The low response was likely a result of multiple factors including the time of the academic year the survey was distributed, the short window when the survey was available, and the fact that no incentive was offered. In addition, not all dental hygiene programs were represented, only student members of the ADHA were in the sample population. Thus, it is unlikely the respondents were representative of the diversity of dental hygiene educational programs. Despite these limitations, the information provided by the respondents provides a “window” into this important aspect of dental hygiene education and practice preparation.
CONCLUSION
While there has been some effort in assessing practicing dental hygienists’ knowledge, understanding and use of CPRs and community water fluoridation, relatively little research has been conducted with dental hygiene students. Dental hygiene graduates can and should be instrumental in reducing the prevalence of dental caries through the appropriate use of science-based, non-invasive caries preventive regimens. The results from this limited sample suggest dental hygiene programs are doing well in teaching about the use of fluoride varnish and pit and fissure sealants but need to significantly increase their focus on the benefits and use of silver diamine fluoride and understanding of community water fluoridation. A national survey is recommended to explore deeper into these issues and gain a more comprehensive understanding of dental hygiene students’ education and intent to use CPRs in clinical practice and to better understand and teach the value of community water fluoridation.
ACKNOWLEDGMENTS
The authors would like to extend thanks to Matthew C. Mikkelsen, Manager, Education Surveys and Rachel W. Morrissey, Research Analyst at the American Dental Association Health Policy Institute for their assistance in creating and testing the online survey, and for their feedback on the survey items. The authors also wish to thank the American Dental Hygienists’ Association for distributing the survey to dental hygiene students and for encouraging students to participate. Lastly, the authors are grateful to all the students who participated in this important research study.
Footnotes
NDHRA priority area, Professional development: education (educational models).
DISCLOSURES
Alice M. Horowitz and Dushanka V. Kleinman are members of the National Advisory Committee on Health Literacy in Dentistry (CHLD), ADA Council on Advocacy for Access and Prevention. The CHLD suggested this research study.
- Received October 20, 2023.
- Accepted December 29, 2023.
- Copyright © 2024 The American Dental Hygienists’ Association
