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National Dental Hygiene Research Agenda

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• Introduction

A profession involves the acquisition of knowledge and skills in a unique area through formal training. A discipline is a branch of knowledge studied and expanded through higher education and research, while a profession consists of persons educated in the discipline according to nationally regulated, defined and monitored standards. 1 The regulation of a profession and establishment of clinical standards are important aspects of the social contract between a profession and the society it serves.

The American Dental Hygienists' Association (ADHA) acknowledges the importance of a body of research unique to dental hygiene in defining it as a profession and developing it into a discipline. The aim of the dental hygiene research agenda is to provide a framework to guide those members of the profession who desire to add to the body of knowledge that defines the dental hygiene profession. In recognition of the importance of relevancy of the NDHRA to the dental hygiene profession, ADHA is committed to the ongoing updating of the NDHRA as the dental hygiene body of knowledge expands

ADHA defines the discipline of dental hygiene as the art and science of preventive oral health care including the management of behaviors to prevent oral disease and promote health. 2 The ADHA research agenda proposes to continue to develop and add to the body of knowledge that defines the profession. As research builds the discipline of dental hygiene, the profession demonstrates its value to society through the provision of service and care, and ultimately, improved oral health.

Historically, dental hygiene has drawn in part on other disciplines, such as the disciplines of periodontics and public health, for the evidence used to support its own practice and education. The generation of scientific knowledge and utilization of an interdisciplinary approach to knowledge benefits the profession through shared initiatives and perspectives. The goal of increasing dental hygienists' participation in research is to grow beyond reliance on research originating from other disciplines and, instead, build upon existing research so the knowledge base can emerge from within dental hygiene itself. 3 To this end, the framework of the dental hygiene research agenda directs dental hygiene researchers to contribute knowledge that is unique to dental hygiene. The 5 primary objectives that were the basis for the creation of the National Dental Hygiene Research Agenda still remain applicable today: 4

To give visibility to research activities that enhance the profession's ability to promote the health and well-being of the public;

To enhance research collaboration among members of the dental hygiene community and other professional communities;

To communicate research priorities to legislative and policy-making bodies;

To stimulate progress toward meeting national health objectives; and

To translate the outcomes of basic science and applied research into theoretical frameworks to form the basis for dental hygiene education and practice.

The updated research agenda visually illustrates how the areas of dental hygiene research move through discovery, testing and translation into education and practice. Discovery is the phase of research where ideas are generated, testing is where concepts and interventions are implemented and outcomes are generated and evaluated, and translation disseminates findings to the profession and to the scientific community at large.

Translational research aims to “translate” findings from basic science research into interprofessional medical, nursing and dental practice for improving health outcomes. Decisions for practice or subsequent research are based on all phases: discovery, testing and translation. For example, the discovery phase of research might document barriers, while the testing phase considers assessing interventions and improving application of science to practice. Within the translation level of research, the process of translating or moving findings from research into practice is examined. It verifies that the application of these findings results in improved health for clients and populations. Research hypothesis need to be tested and then applied (translated) in real life settings with outcomes measured and assessed.

Using the three phases of research changes the way we conceptualize the dental hygiene research agenda from a linear design with a list of objectives to a visual display showing the inter-relationship existing between the phases of research and themes or areas of research. The new visual display was designed recognizing that all research is interconnected and multifactorial, while also recognizing that results can influence future need for additional research.

• Perspectives on the ADHA Research Agenda

Dental hygiene and research have been linked since the early 1900s. In 1914, Dr. Fones' 5-year study in public schools demonstrated that dental hygienists can positively impact oral disease using education and preventive methods. 5 Dental hygienists today are increasingly becoming involved in research at all levels and are helping to provide data that will impact the profession for years to come.

The first ADHA National Dental Hygiene Research Agenda (NDHRA) was developed in 1993 by the ADHA Council on Research and adopted by the ADHA House of Delegates in 1994. 4 A Delphi study was used to establish consensus and focus the research topics for the agenda. 6 This was the first step to guide research efforts that support the ADHA strategic plan and goals. A research agenda provides direction for the development of a unique body of knowledge that is the foundation of any health care discipline and, as such, should be used to drive the activities of the profession.

In 2001, the Council on Research revised the agenda to reflect a changing environment based on two national reports: The Surgeon General's Report on Oral Health and Healthy People 2010. Input from the 2000 National Dental Hygiene Research Conference sponsored by ADHA was considered in the revision. The revised document was released in October 2001 and prioritized the key areas of research. 7

In 2007, the agenda was revised to reflect current research priorities aimed at meeting national health objectives and to systematically advance dental hygiene's unique body of knowledge. These revisions were based on a Delphi study that was conducted to gain consensus on research priorities. 8

A goal of the present (2016) revision is to allow greater usability of the agenda across the profession and interprofessionally. The cohesive, coherent visual illustration that constitutes this revision might assist educators in disseminating research concepts to students. By showing the relationships among the priorities, the themes and the research process, the Council on Research hopes to improve understanding of how dental hygienists can use the research agenda. Research is an ongoing process. Contributions can be made to it, and priorities can be revised, at any phase in the model, from discovery through testing, evaluation, dissemination and translation.

In this revision, the Council on Research has integrated feedback on the revised presentation of the agenda received from research meetings with representatives of the International Federation of Dental Hygiene, the Canadian Dental Hygienists Association and The National Center for Dental Hygiene Research and Practice. Feedback from graduate dental hygiene program directors and dental hygiene researchers was included. The revised research agenda allows for ongoing study of specific questions to support the growth of the profession. It also allows for investigation and testing of ideas that will further the transformation of dental hygiene as a profession and facilitates interprofessional collaborations.

• Research as a Foundation for Dental Hygiene Education and Practice

Research provides a foundation for continued development of dental hygiene practice guidelines and, ultimately, optimizes care for individuals, groups, communities and global populations through the use of evidence-based practices. Such a foundation supports the development of position papers that inform practice parameters and standards. Clinicians, researchers and educators can thus use the revised research agenda to generate and publish data to support the ongoing transformation of the profession in the various areas proposed, and to drive activities to build upon other areas not yet defined that might emerge as a result of transformation. Educators can use the agenda to support the ongoing growth and development of both clinicians and junior researchers to guide efforts to advance the profession while identifying new research directions that emerge. 9

Research supports ongoing investigation into fundamental topics of concern to clinicians such as oral and craniofacial diseases and their mechanisms and causation, including inflammation, infection, genetics, neoplasm and the microbiome. Findings might be used to identify strategies to manage or eliminate localized or systemic disease through clinical care; improve delivery of preventive and oral health care services; and identify ways to improve access to care for individuals, groups and populations.

In the same way, research supports transformation of the process of dental hygiene education. It seeks new methods for basic and advanced education of dental hygiene professionals and investigates the outcomes of different programs. For example, research might assess differences between baccalaureate and associate level education with respect to outcomes in the areas of patient care, dental hygiene scope of practice, access to vulnerable populations and career satisfaction.

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Phases of Research

• Framework for Dental Hygiene Practice and the Discipline

As dental hygiene research advances, it is important to formulate research questions within the conceptual framework of dental hygiene theory. Some theoretical models have been developed, but many have yet to be tested. Rogers' theory of diffusion of innovations is an example of a model that might benefit dental hygienists wishing to study the translation or possibly the implementation of research into practice. 10 Models or theoretical frameworks of care delivery allow the profession to develop from the discipline. Before posing a research question, it is important to consider from a conceptual level the approach to be used for any given area or phase of research. Using dental hygiene theory to frame individual research questions will assist in building a strong, scientifically sound foundation.

• ADHA Dental Hygiene Conceptual Research Model

The ADHA Dental Hygiene Conceptual Research Model illustrates the interrelationship of the areas of dental hygiene research as they progress through the phases of research and move from the level of professional development to influence client-level care and ultimately population health. As Figure 1 illustrates, the phases of research are not linear; each phase asks and answers questions that are intended to allow progression to the next phase, with the study of dissemination and translation effectiveness ultimately circling back to questions of discovery in the search for better answers and methods. It is important to note that in any of these phases of investigation, there may be a need to go back to an earlier level to re-frame or reconsider moving forward. In other words, this model is dynamic, not static.

Conceptual Research Model

Areas of research are equally dynamic. Professional development begins with education, which influences how the profession of dental hygiene is regulated and vice versa. Both influence client-level care and ultimately population-level health. As new methods for health services and access to care are realized, the profession must circle back to evaluate the education and regulation of dental hygiene. As illustrated in Figure 2 , at the intersection of Areas of Research and each Phase of Research, topics of emphasis are illustrated.

As early as 1994, ADHA selected five paradigm concepts to study and has used these concepts to organize previous agendas. The five major concepts are: Health Promotion / Disease Prevention, Health Services Research, Professional Education and Development, Clinical Dental Hygiene Care and Occupational Health and Safety. The dental hygiene conceptual research model captures these five paradigm concepts and illustrates how they might be approached at different phases in the research process.

Researchers can enter into the process at the intersection of any area of research and any phase to ask and answer questions of importance to the discipline of dental hygiene. The model is intended to help researchers frame how their research has been influenced by a preceding phase of research and how it will lead to the next phase. Additionally, it aims to illustrate how their area of research relates to other areas where research might be conducted. The following descriptions of the topics of emphasis from the conceptual research model ( Figure 2 ) are organized by area of research and include an explanation of how the topic fits into the phase of research where it appears.

• Professional Development

Education 11 - 19

Dental hygiene is based on a specific body of knowledge transferred to new professionals through educational processes. Areas of research associated with education include evaluation of current educational processes during the discovery phase, implementing new educational models during the testing and evaluation phase, and exploration of how interprofessional education as part of the ongoing evolution of dental hygiene as a profession is associated with the translation phase of research. 9

Evaluation within the discovery phase of research for education includes ongoing as-sessment of curricular content, delivery and adaptation of educational programming for addressing evolving models of health care and practice; assessing educational institutional investment in alternative delivery models; alternative educational programming; community return on investment; articulation; transferability and academic educational laddering for ongoing growth of the profession.

Educational models during the testing phase of research for education requires implementation and evaluation of new or redesigned educational delivery models based on evolving global public health needs, direct and indirect assessment of both learners' and educators' performance, examining research associated with the Scholarship of Teaching and Learning (SoTL) and alternative career pathways.

Interprofessional education considers more broadly the translation of dental hygiene education as a component of allied health education, the ability of educators to work collaboratively with other health care disciplines, recognizing diversity of faculty backgrounds for creating synergy, promoting lifelong learning and expanding access to care through all means of delivery of health care for global populations.

Regulation research occurs at the dental hygiene profession level. It encompasses the body of knowledge related to the practice of the profession of dental hygiene.

Emerging workforce models involve discovery. Each state in the nation is a potential source of new models for dental hygiene care delivery. The discovery and development of regulations and rules affect the profession of dental hygiene. Regulation discovery includes new workforce models such as, but not limited to, mid-level providers, advanced dental hygiene practitioners and advanced dental hygiene therapists, as well as their effects on public health and well-being.

Scope of practice involves testing and evaluation of potential changes to professional regulations, often through pilot programs. These regulations may have significant impact on the health of the public and ability of dental hygienists to provide the care they are educated and trained to deliver.

Interprofessional collaborations involve professional regulations that translate knowledge into practice through collaborations with other care providers. Collaborations are an endpoint of regulation at the professional level. Areas of interprofessional collaborations include delivery of care in all practice settings, including pediatrician offices, schools and other health care settings that may include hospitals, medical offices, federally qualified health centers and holistic Complementary and Alternative Medicine settings.

Occupational Health

Research in this area focuses predominately on practitioners and their exposure to risks in the oral health care environment. It includes prevention and behavioral issues, as well as compliance with safety measures and workforce recruitment and retention.

Determination and assessment of risks for occupational injury is the discovery phase of research. Uncovering potential hazards to occupational health in the workplace may involve investigating ergonomic impacts, as well as those of aerosols, chemicals, latex, nitrous oxide, noise and infectious diseases.

Methods to reduce occupational stressors involve testing and evaluation of techniques to reduce or eliminate hazards to occupational health. This includes assessing prevention methods, behaviors, compliance with safety measures and error reduction.

Career satisfaction and longevity research assesses the dissemination and translation into practice of methods that reduce the harmful effects of occupational stressors on practitioners. Additionally, it seeks to determine if the successful translation of these methods into practice and the reduction of occupational stressors results in improved careers for dental hygienists.

• Client Level

Basic Science

Basic science research is important at the client level for understanding the mechanisms of health and disease, and investigating the links between oral and systemic health. Areas of research range from caries and periodontal disease to immunology, genetics, cancer, nutrition, pharmacology and exposure to environmental stressors.

Diagnostic testing and assessments in basic science research is discovery of new tools for diagnosis of conditions and diseases and new methods of risk assessment prior to development of disease.

Dental hygiene diagnosis is the testing phase where research is used to evaluate the use of knowledge of emerging science to determine client conditions or needs as related to dental hygiene care.

Clinical decision support tools are the outcome of research validating dental hygiene diagnosis and the translation of those outcomes into tools that can be used broadly in clinical practice. Research in this area confirms the usefulness of the tools developed for this purpose.

Oral Health Care

Research regarding the dental hygienist's role in oral health care encompasses all aspects of the process of care at the client level, including assessment, diagnosis, treatment planning, implementation, evaluation and documentation.

New therapies and prevention modalities for oral health care are developed or improved in the discovery phase of research. This may include new procedures, treatments, behavioral interventions, and instruments/tools/products for delivering client care, new oral self-care products or improved ergonomics.

Health promotion: treatments, behaviors, products in the testing phase means evaluating clinical care products, services, behavioral interventions, and new and alternative treatments developed for these purposes at the client level, often through clinical trials, for safety and effectiveness.

Clinical guidelines are developed as a result of successful treatment and prevention methods and are derived from a strong body of evidence that reflects improved client outcomes. These in turn need translation into routine clinical practice and need to be evaluated through research to assess both their adoption and effectiveness.

• Population Level

Health Services

Health services research is included as part of the population-level area of research. Past agendas identified many objectives in this area. The revised agenda reorganizes health services and access to care to better show the relationship among the phases of research.

Epidemiology in health services research involves discovery. Epidemiological research includes surveys of oral health status and related needs of specific populations and other important health services data related to oral health and dental hygiene.

Community interventions are critical to understanding the testing and impact of oral care interventions on population health. Community interventions have the potential to improve oral health by treating groups rather than individuals. Such programs include school-based oral care programs and public health nutritional campaigns to eliminate or reduce caries, periodontal disease and other preventable oral health problems.

Assurances and evaluation combine as an ongoing strategy to improve translation of population health and community interventions. All programs benefit from the knowledge derived from evaluation of program effectiveness and quality and from assuring that best practices represent outcomes data.

Access to Care

Access to care research involves identifying populations that are challenged to achieve positive health outcomes including good oral health due to recognized and unrecognized barriers to care. Systems of health delivery can be developed, adapted, improved and evaluated for effectiveness in improving access to care and health outcomes in identified populations.

Vulnerable populations are identified in the discovery phase of research through population-level data that link poor health outcomes to various group characteristics. This phase of research also seeks to discover possible barriers to care.

Interventions are developed and implemented in the testing phase of research on access to care. Supporting research might evaluate methods designed to overcome barriers to access or use of risk-reduction strategies in special at-risk populations such as people with diabetes, tobacco users, pregnant women or those identified as genetically susceptible to disease.

Outcomes assessment is a critical aspect of translation of research into population-level health. This phase of research involves verification of improved population health outcomes when presumed barriers or risk-reduction strategies have been addressed across a broad group or identified population.

• ADHA's Strategic Plan Drives Research Priorities

Based on the ADHA's Conceptual Research Model and Strategic Plan, priority areas that researchers are encouraged to investigate include:

Differences between baccalaureate- and associate-level educated dental hygienists.

The impact of dental hygiene mid-level practitioners on oral health outcomes.

Development and testing of conceptual models distinct to dental hygiene that will guide education, practice and research.

Efficacy of preventive interventions across the lifespan including oral health behaviors.

Patient outcomes in varying delivery systems (this can include cost effectiveness, workforce models, telehealth, access to care, direct access etc.).

Focus on these priorities has the potential to accelerate the pace of transformation of the profession to improve the public's oral and overall health. Within these priority areas are research questions to be asked and answered that will impact the future of the profession and the direction of ADHA. Investigators are strongly encouraged to consider how their research might contribute to these priority areas.

• Additional Resources

ADHA's Research Center http://www.adha.org/research-center

Institute for Oral Health, Research Grants http://www.adha.org/ioh-research-grants-main

National Center for Dental Hygiene Research & Practice https://dent-web10.usc.edu/dhnet/

National Center for Dental Hygiene Research & Practice, Dental Hygiene Research Toolkit https://dent-web10.usc.edu/dhnet/research_kit.pdf

The National Dental Practice-Based Research Network http://www.nationaldentalpbrn.org/

American Association for Dental Research (AADR), Student Research Fellowships http://www.aadronline.org/i4a/pages/index.cfm?pageid=3569#.VT_Er7l0xtQ

Centers for Disease Control and Prevention (CDC), Division of Oral Health http://www.cdc.gov/oralhealth/

Centre for Evidence Based Dentistry http://www.cebd.org/

The goal of the revised National Dental Hygiene Research Agenda is to lead the transformation of the dental hygiene profession to improve the public's oral and overall health. The revised research agenda is intended to guide researchers, educators, clinicians and students who seek to support ADHA priorities for advancing the profession through research and the generation of new knowledge within the discipline of dental hygiene. The model provides novice investigators, especially students, as well as junior and experienced researchers, with a visual framework for conceptualizing how their research topic addresses identified priorities. Additionally, this revision prepares the profession to evolve by acknowledging that dental hygiene research is necessary for advancing the profession and improving the health of the public.

The revised research agenda was led by the ADHA 2014-2016 Council on Research, in collaboration with ADHA staff. The members of the Council on Research are:

Deborah M. Lyle, RDH, BS, MS, New Jersey, Chair; Ashley Grill, RDH, BSDH, MPH, New York; Jodi Olmsted, RDH, PhD, Wisconsin; Marilynn Rothen, RDH, MS, Washington.

• Copyright © 2016 The American Dental Hygienists’ Association
• Rizzo Parse R
• ↵ Policy Manual . ADHA Framework for Theory Development . American Dental Hygienists' Association [Internet] . [cited 2016 May 18]. Available from : https://www.adha.org/resources-docs/7614_Policy_Manual.pdf
• Cobban SL ,
• Edgington EM ,
• Spolarich AE ,
• Peterson-Mansfield S ,
• McCarthy MC
• Forrest JL ,
• Gitlin LN ,
• Gadbury-Amyot CC ,
• Doherty F ,
• Connolly I ,
• Spolarich AE
• van Manen M
• Cobban SJ ,
• Zarkowski P
• Overman P ,
• Gurenlian J ,
• Shepard K ,
• Steinbach P ,
• Eshenaur Spolarich A
• Idaho State University. Division of Health Sciences. Department of Dental Hygiene
• Englander R ,
• Cameron T ,
• Ballard AJ ,
• Aschenbrener CA
• ↵ Dental Hygiene Education: Transforming a Profession for the 21st Century . American Dental Hygienists' Association [Internet] . 2015 September [cited 2015 October 12]. Available from : http://www.adha.org/adha-transformational-whitepaper

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• Published: 01 March 2019

Research dental hygienist - whoever knew there was such a role?

• Rachael England 1  

BDJ Team volume  6 ,  pages 21–23 ( 2019 ) Cite this article

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After spotting a job advertisement for a research dental hygienist, Rachael England soon found herself in the job and out on the road .

After 13 years of working clinically, I was feeling the need for a new role outside the surgery and with a Master's in Public Health under my belt, I was particularly interested in academia. When I saw a role advertised for 'research dental hygienist' at University College London, the timing couldn't have been better.

I was joining the British Regional Heart Study (BRHS) as a member of the field team. This longitudinal study began in 1978 to understand why high numbers of men were dying prematurely. Around 7,500 men aged 40-60 were recruited via their local GP surgeries. Over the following 40 years the men have undergone several health screenings, activity monitoring, completed annual questionnaires and every two years the office team liaise with their GP surgeries to check for serious health events. At the outset, the team looked at hard water, cardiovascular disease and socioeconomic factors in 24 towns around the UK. The men are now aged 77-97, making it one of the longest running cohort studies in the UK.

In 2012, Dr. Sheena Ramsay joined the research team as Principal Investigator. Her early career as a dentist meant the study developed a more dental theme. As we know, the effects of oral-systemic disease are significant with this age group who may suffer from chronic diseases such as diabetes and cardiovascular disease. Also in this cohort, we could examine the self-reported diet sheets and carry out frailty assessments and dental health checks to see any associations between the remaining dentition and how 'well' the men are now.

The health screenings were to examine the remaining 1,400 men who are well enough to attend the mobile clinic in the town where they were originally recruited (see figure 1 ). The field team comprised a nurse, a phlebotomist and a dental hygienist (me). In addition to a dental examination, the men would have the following recorded:

blood pressure,

arm, calf and waist circumference

frailty measurements (ie grip strength)

walking speed

time of standing to sitting

lung function.

The participants would also complete a memory test while they waited. The office-based team would find premises suitable for the mobile clinic, contact the participants, send reminders, deal with all administration and book hotels for the field team to stay in.

The first two weeks were spent at University College London training and organising the equipment and, most importantly, developing the study protocol and calibrating the dental measurements. Working with Dr. Ramsay, I developed a coded dental chart that would record:

pocket depth

loss of attachment

number of teeth

functional pairs of dentition,

xerostomia score

any other pathology.

I was also responsible for carrying out the lung function assessment using a Vitalograph machine. This is used to assess how well your lungs work by measuring how much air you inhale and how much and how quickly you exhale. The data it delivers - spirometry - diagnoses asthma, chronic obstructive pulmonary disease (COPD) and other conditions that affect breathing. This is especially appropriate among older people who may have been exposed to damaging substances in their earlier lives. The research manager thought the Vitalograph would fit well with the dental station and I only needed a day of training to get to grips with.

As health professionals we all have heard about the North/South divide and have discussed determinants of health during our training. Yet to see it so starkly, in real life, in front of my eyes was staggering.

Despite it being a relatively simple piece of equipment, the training didn't prepare me for the challenge of instructing patients who have experienced cognitive decline. Thankfully, the patient management skills I had learned through being a dental hygienist helped me through.

We then carried out a pilot study. Our statistician belongs to a church in North London and very kindly recruited members of the congregation. This allowed us to tweak the dental protocol, making it easier to record and ensure the whole set up worked smoothly with the right equipment. After a small electrical fire and an urgently purchased new Vitalograph, we were ready to head to the first town!

©RapidEye/E+/Getty Images Plus

Anxiously heading out of London to Bedford we navigated together. The first venue was a community centre, where we set up the mobile clinic in a conference room. Early the next morning the men started arriving.

Each day we had capacity to see 20 men. However, the number who came in varied greatly. Bedford proved to be quite busy, with fit, well and active men aged 80+, mostly still with the majority of their own dentition - albeit heavily restored. After three days we returned to London for a debrief. These sessions allowed us to deal with any challenges, make some input to the next stage and chat about the results.

Next, we headed off for two weeks in Scotland and the North-West. Dunfermline, Falkirk, Ayr and Carlisle. Far fewer participants attended and they were much frailer and mostly had broken or missing teeth or faded, plastic dentures.

As health professionals we have all heard about the North/South divide and have discussed determinants of health during our training. Yet, to see it so starkly, in real life, in front of my eyes was staggering.

Every town holds its own unique history that has shaped the health of these men and their rate of decline into old age. Taking a walk around in an evening I could observe the ghosts of past industry, Burnley's now converted cotton mills and the traces of a mining history, Scunthorpe's steel mills, Lowestoft's deep-sea fishing and Hartlepool, once a thriving port with ship building and steel making industries. With the decimation of the North-East's industrial age, 10,000 jobs were lost, leaving a town the hallmarks of endemic deprivation - substance abuse, urban decay, crime and twice the national average rate of unemployment.

One participant told me 'you'll never get rich working with your back', a testament to the tough, working lives these men have led. Despite this, I have never spent such precious time with people before, older participants who had served in World War II as well as those slightly younger who regaled us with stories of their National Service. We laughed with them over crazy adventures and cried with them when they described the passing of their beloved wives.

What really struck me was the poor state of dental health in every town - except (perhaps predictably), Guildford, Bedford and Southport. Nothing could prepare me for seeing such terrible neglect in so many men, I kept asking myself - how does this happen? How have we reached a state where our elderly are somehow managing without a functional dentition?

Some of the participants shared their barriers to treatment, such as a lack of:

time - due to being the primary carer for their spouse

availability of NHS access

commitment to caring for themselves.

Many were just happy to maintain the status-quo and have regular check-ups and what we probably consider to be palliative dentistry. Is this acceptable with our current knowledge of the oral-systemic link and frailty in old age related to an ability to eat nutritious food?

Taking a walk around in an evening I could observe the ghosts of past industry, Burnley's now converted cotton mills and the traces of a mining history, Scunthorpe's steel mills, Lowestoft's deep-sea fishing, Hartlepool - once a thriving port with ship building and steel making industries.

We need to improve awareness in this age group that their oral health affects their general health and how important it is to see a dental professional regularly.

The role is intense as you see a participant every 10-15 minutes on a busy day. Ergonomics are pretty much out of the window as you lean over a masseuse bed to complete the examination.

Moving between towns was our greatest challenge, packing the equipment back into the van, driving several hundred miles, finding a new location and setting the clinic back up. The facilities varied from doctors' surgeries and church halls to community centres and conference halls. Being greeted with a friendly smile and a cup of tea was the reassurance we needed the session would run smoothly.

©Mark Waugh / Alamy Stock Photo

After 6 months the data collection was complete. It has been sent for entry and processing which takes up to 12 months before the research teams can begin analysis of the findings.

As a career option this role was a refreshing change from working in a clinic, without being too dissimilar.

Although dental hygienists can get involved with research through epidemiological data collection, I would really encourage dental therapists and dental hygienists to look into the role of Research Dental Hygienist. For me, it is wonderful to be a part of such a historic study that has made an impact on so many lives.

It is both fascinating and disturbing to witness first-hand the inequities in health the population suffer and how the determinants of health shape our lives. Our elderly population have amazing lives to share; we should all take the time to listen.

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England, R. Research dental hygienist - whoever knew there was such a role?. BDJ Team 6 , 21–23 (2019). https://doi.org/10.1038/s41407-019-0004-y

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• Published: 10 April 2024

Dental patients as partners in promoting quality and safety: a qualitative exploratory study

• Enihomo Obadan-Udoh 1 ,
• Vyshiali Sundararajan 1 ,
• Gustavo A. Sanchez 1 ,
• Rachel Howard 1 ,
• Siddardha Chandrupatla 2 &
• Donald Worley 3  

BMC Oral Health volume  24 , Article number:  438 ( 2024 ) Cite this article

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Active patient involvement in promoting quality and safety is a priority for healthcare. We investigated how dental patients perceive their role as partners in promoting quality and safety across various dental care settings.

Focus group sessions were conducted at three dental practice settings: an academic dental center, a community dental clinic, and a large group private practice, from October 2018-July 2019. Patients were recruited through flyers or word-of-mouth invitations. Each session lasted 2.5 h and patients completed a demographic and informational survey at the beginning. Audio recordings were transcribed, and a hybrid thematic analysis was performed by two independent reviewers using Dedoose.

Forty-seven participants took part in eight focus group sessions; 70.2% were females and 38.3% were aged 45-64 years. Results were organized into three major themes: patients’ overall perception of dental quality and safety; patients’ reaction to an adverse dental event; and patients’ role in promoting quality and safety. Dental patients were willing to participate in promoting quality and safety by careful provider selection, shared decision-making, self-advocacy, and providing post-treatment provider evaluations. Their reactions towards adverse dental events varied based on the type of dental practice setting. Some factors that influenced a patient’s overall perception of dental quality and safety included provider credentials, communication skills, cleanliness, and durability of dental treatment.

The type of dental practice setting affected patients’ desire to work as partners in promoting dental quality and safety. Although patients acknowledged having an important role to play in their care, their willingness to participate depended on their relationship with their provider and their perception of provider receptivity to patient feedback.

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Introduction

In recent years, there has been a surge in research related to dental quality and safety from various parts of the world [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. These studies have investigated how adverse events occur in dentistry, identified methodologies for detecting adverse safety events, and focused on developing strategies to reduce the occurrence of adverse events [ 3 , 5 , 6 , 10 , 11 , 12 , 13 , 14 ].

Patient involvement in quality and safety-promoting activities is an emerging area of interest. Dentistry findings from several studies suggest that patient reports can provide meaningful insight and breadth regarding the quest to understand such adverse events [ 15 , 16 , 17 , 18 , 19 ]. In dentistry, previous studies have demonstrated that patients are apprehensive about safety at the dental office and are willing to participate in activities that promote quality and safety when properly engaged by providers [ 7 , 8 , 15 , 16 , 17 ]. However, majority of these studies focused solely on patients attending a single academic institution. We proposed a study that recruited patients from three different dental care settings to provide an array of diverse perspectives. Through this study, we assessed how dental patients perceive their role as partners in promoting quality and safety across various dental care settings.

Study sites

The study was conducted at three different dental practice settings: an academic dental center (Site U), a community dental clinic (Site I), and a large group dental private practice (Site H). Site H is in Minnesota, while both Sites U and I are located in Texas. The academic dental center (Site U) consists of a pre-doctoral teaching clinic, a resident/postgraduate clinic, and a faculty group practice. Patients visiting this center are from diverse racial and ethnic backgrounds. The community dental clinic (Site I) is comprised of a network of small to medium-sized dental offices scattered throughout the city. Affiliated with a religious non-profit organization, this site primarily serves low income and indigent families who lack access to health care. The large group dental private practice (Site H) encompasses over 70 dentists working across 21 dental office locations. The group serves a large range of patients from various demographic and socioeconomic backgrounds.

Study participants

Participants were recruited using a purposive sampling approach. Patients from the study sites were invited to participate through flyers and word-of-mouth invitations. Interested participants were screened by a local site coordinator to confirm that they met the following inclusion criteria: English-speaking, over 18 years of age, able to give informed consent, and attended at least one dental visit at a participating site. Enrolled participants selected one of eight focus group sessions: three of which were hosted at the academic dental center, three at the large group dental practice, and two at the community dental clinic. Ethical approval was obtained from the UCSF institutional review board (#18–25467). A unique participant’s ID was created for each participant using their site name and sex. Females were represented by “X” and males by “Y”.

Study procedures

Eight focus group sessions were held from October 2018 through July 2019. Researchers were provided with a quiet conference room within each dental site to host the sessions. Sessions lasted about 2.5 h and were recorded using two voice recorders. Participants completed an anonymous demographic questionnaire, an informational survey, and an evaluation form at the beginning or end of the session. Prior to the start of each session, ground rules were provided to participants about taking turns, refrainment from disclosure of comments to external parties, and the need to tolerate dissenting opinions. Name introductions were also done prior to starting the recording to ensure privacy. Participants provided verbal consent after reading the study information sheet. All audio recordings were stored safely on a password-protected laptop and de-identified for analysis. Participants received a $30 gift card along with food and beverage in appreciation of their time. The first author (EO-U) served as the lead facilitator/moderator for all the sessions. There were no conflicts of interest, given the authors do not provide patient care at any of the participating dental institutions.

Study instrument

A focus group discussion guide and informational survey were developed using questions from our previous qualitative study and publications by Davis et al. [ 8 , 16 , 17 ]. The discussion guide consisted of eight main topics with sub-topics and probing questions (see Additional file 1 ). The topics were:

Patients’ understanding about “patient safety” and “quality”

Current practices to ensure high quality care in dental care settings

Perceptions about dental patients contributing to dental quality and safety

Approaches to improve patient engagement in dental quality and safety activities

Factors affecting patients’ willingness to participate in dental quality and safety activities

Factors affecting the reporting of poor quality or adverse safety incidents

Features of a “safe” incident reporting system or platform

Patient considerations about the quality and safety of dental offices

The 45-item informational survey comprised six sections that assessed interactional and non-interactional behavior between patients and the dental care team including: asking factual or challenging questions, notifying the team, providing information, gaining information, and adverse event reporting.

Data analysis

Frequencies and descriptive statistics for demographic characteristics of the participants and survey responses were calculated, and audio recordings from the focus group discussions were professionally transcribed using Rev.com. The transcripts were verified against the original audio recordings for completeness by one co-author (VS).

Using Dedoose, two co-authors (VS, GS) independently analyzed each transcript using the following steps:

Repeated reading : After verifying the transcripts, data was read multiple times and memo writing was performed in Microsoft® Word. The research question served as a guide during this step.

Data coding : Bucket codes were created, and relevant texts from transcripts were selected for initial codes and coded for as many potential themes as feasible.

Exploring for themes : After completion of the initial coding process, a list of different codes identified across the data was generated. Within a code, common themes based on similarities, differences, topics, demographics, and approaches were extracted from the content of the focus group discussions. Opinions expressed by individuals that diverged from group consensus were also identified.

Discussing themes and sub-themes : Both primary coders discussed their initial codes. Similar or duplicate codes were merged into sub-themes. All codes were organized into three major themes based on the study objectives:

Patients’ overall perception of dental quality and safety (Theme 1)

Patients’ reaction to poor quality dental care and adverse events (Theme 2)

Patients’ perception of their role in promoting quality and safety (Theme 3)

Tie-breaking : Any code names or code applications that were discordant between both reviewers, were discussed with a third researcher (EO-U) who acted as a tiebreaker in finalizing the themes, sub-themes, and codes. This was only needed once in the study.

Demographic characteristics

A total of 47 patients ( n  = 20 (Site I), n  = 16 (Site H), n  = 11 (Site U)) were successfully recruited to participate in eight focus group sessions (Table  1 ). Participants in the focus group sessions were mostly female (70.2%), and Caucasian (40.4%). Asians (23.4%) and Latinos (21.3%) were the second and third largest ethnicities represented, respectively. The educational level varied among participants, with nearly 50% having at least a bachelor’s degree. Most participants were aged between 25 – 64 years (68.1%).

Informational survey

The informational survey results were analyzed using descriptive statistics (Table  2 ). Patients were asked to assess willingness to engage in various activities at the dental office using a Likert scale (1 = “Definitely Will” through 7 = “Definitely Not”). Thus, lower mean scores represent patients’ willingness to play an active role in promoting quality and safety and higher scores represented an unwillingness to engage in that activity. While patients appeared willing and comfortable to ask factual questions from dental assistants/hygienists and dentists, patients were less willing to ask challenging questions of such providers unless the provider encouraged it (Table  2 ; Sections 1a, 1b, 2a, and 2b). Patients also reported feeling relatively willing to notify their providers as concerns arose regarding their care (Table  2 ; Sections 3a, 3b). Furthermore, while patients were willing to provide or gain pertinent information about their care or dental office, they were less willing to participate in reporting an adverse event occurrence unless it was encouraged by the dental care team (Table  2 ; Section 4, 5, and 6). We defined an adverse event as “the occurrence of any event that the patient perceived as negative or harmful while receiving care”. There was no significant difference between patients’ willingness to engage in safety behaviors with different members of the dental care team (i.e. dental assistant/ hygienist versus dentist).

Theme 1: patients’ overall perception of dental quality and safety (Table  3 , Section 1)

Provider training and qualifications.

Patients trusted that providers who possessed the proper dental licenses and credentials had received adequate training and education needed to provide high quality dental care. Patients found reassurance in public displays of the provider certificates and necessary clinic approvals, many of whom also inquired the names of their provider’s dental school and their experience performing certain procedures.

Patients at the private dental practice and community health center placed more value on the providers’ experience, years of practice, and reviews through websites, such as Yelp. These patients preferred providers who were not recent graduates; however, they also wanted providers to be familiar with recent clinical procedures and guidelines. In contrast, patients who received care at the academic center had tempered expectations about quality. These patients were comfortable with students’ performing treatments because supervising faculty oversaw every procedure.

Communication

Patients emphasized the importance of clear communication in promoting trust between patients and their dental providers. Participants also wanted providers to be honest about the necessary procedures, and their comfort level with performing those procedures. They preferred that providers educated them appropriately about their oral health and the necessary dental treatment using various methods (e.g., pictures, pre-visit videos, after-visit summaries) to facilitate informed decision making.

Unsurprisingly, exemplifying polite and courteous behavior (good chairside manners) as well as establishing a good rapport were often associated with high quality dental care. Older patients preferred more direct or in-person communication, while younger patients preferred more on-demand or virtual communication. Although the preferred communication methods varied, the theme of clear communication was unanimously expressed as a marker of quality dental care across all dental practice settings.

Cleanliness and clinic environment

Irrespective of the dental practice setting, most patients believed that cleanliness and sanitation were important indicators of dental quality and safety. Markers of cleanliness included: sterile instruments within sealed pouches, clean restrooms, clean floors and office space, constant use of gloves around patients, and the physical appearance of dental staff. Markers of uncleanliness included: foul smells, blood on syringes or instruments used for previous patients left lying around, opened sterilization pouches, and re-using dropped instruments.

Durability of dental treatment

Given patients expected their procedures to last, there was a perception of poor-quality care if patients needed to return for repeat procedures or treatment within a short time period.

Dental patients based their overall perception of dental quality and safety on the professional credentialing of providers, their individual dental care experience, the quality of provider-patient communication, the cleanliness of the dental office environment, and the durability of their treatments. Although patients from all dental settings emphasized the importance of cleanliness, perception of other sub-themes varied by dental practice setting. Whereas patients attending the academic dental center gave the benefit of doubt to the student providers and assumed a degree of risk with receiving poor quality dental care and experiencing adverse events, patients at the private dental office placed more emphasis on the quality of provider training and qualifications.

Theme 2: patients’ reaction to poor quality dental care and adverse events (Table  3 , Section 2)

Breach of trust.

When a patient visits a healthcare provider, they expect to receive adequate treatment to ensure good health. In the focus group sessions, patients expressed that experiencing an adverse event negatively impacted their ability to trust their providers, leaving them uncertain about how best to proceed. Some patients chose not to return to the culpable provider and looked for service elsewhere. Others decided to stop seeking dental treatment altogether due to the anxiety from the negative experience.

Fear and embarrassment

During the focus group sessions, some patients indicated that they were afraid to speak up after a perceived adverse event (i.e., received poor quality care or were harmed by dental treatment). Patients also reported feeling embarrassed for their lack of dental health literacy regarding the dental procedure when an incident occurred.

Clinic response to adverse events

Good communication and provider attitude influenced how patients reacted to adverse situations. Patients expressed the importance of dental practices providing a patient support advocate with whom patients can voice their concerns and/or opinions. However, some patients were concerned that speaking with a patient advocate could lead to provider backlash.

Patients had varying reactions to adverse events and receiving poor quality dental care. Most patients across all institutions expressed that they received adequate support from the provider/clinic team whereas others (predominantly from the community health center) described a reluctance to report their experience due to fear of retribution.

Theme 3: patients’ perception of their role in promoting quality and safety (Table  3 , Section 3)

Rationale for participation.

Dental patients had mixed reactions about their role in promoting dental quality and safety. Those who were positively disposed towards engagement activities believed that participation made them feel empowered about their care, stay informed about their choices, and play an active role in improving their oral health. Some believed reporting safety incidents helped make dental care safer for everyone. Patients who were hesitant about their role in promoting dental safety indicated they felt active participation was unnecessary unless they had received poor quality or unsafe dental care.

Timing of participation

Patient willingness to participate in different types of engagement activities depended on the dental care setting. For example, patients at the academic dental center preferred to deliver feedback immediately or shortly after receiving dental treatment, whereas patients at the private dental practice and community-based dental clinic preferred to wait until after they left the clinic or completed their procedure.

Format of participation

Quality and safety-promoting activities that patients were willing to participate in included: advocating for self when they felt that something was going awry, actively tracking their medical/dental health information, writing reviews, participating in dental research, educating themselves about their oral health conditions and dental procedures, and asking their dental providers questions about their dental procedures or safety practices (e.g., hand washing, sterilized instruments, post-procedural instructions). Patients were more hesitant to ask questions that could potentially appear confrontational. Conversely, patients indicated they were more comfortable speaking when providers invited and encouraged their feedback.

Patients also expressed willingness to participate in focus groups, which provide opportunities to voice opinions without fear of any repercussions from the dentist. Others preferred to have fill out surveys, provide comment cards, or speak directly with a dentist or office staff. Patients from the private practice setting appeared more willing to be involved in promoting the quality and safety of their experiences.

Patients preferred different types of communication based on their demographic information. Older patients with less experience using computers preferred printed materials. No comparable differences were observed between male and female participants in the focus groups; although males participated less often than females in the study.

Most patients, especially those at the academic institution, were willing to participate in activities that promote better dental quality and safety and offered various strategies for increasing patient engagement. However, a few patients from the private group practice expressed concerns about “over-engagement” and suggested that patients should be left alone unless they experienced an adverse event. Reactions varied by dental practice setting, with patients at the private dental office indicating that they received more support when things went wrong than patients at the community dental clinic or academic dental center.

This study investigates factors that influence dental patients’ perceptions of their role in promoting quality and safety across various dental care settings. We used multiple focus group sessions to define patients’ understanding of quality and safety and summarize their past experiences of receiving poor quality or unsafe dental care. Given the scarcity of literature on this topic, this study provides novel insight from three diverse dental care settings to jumpstart the conversation about quality of care from the patient’s perspective.

Although patient safety is a complex, multifactorial matter [ 1 , 18 ], our study and others have found that patients consider cleanliness a key component of patient safety. Congruent with our previous work [ 8 ], patients described the term safety using words associated with cleanliness such as “sterilized or clean instruments.” Wearing clean gloves and sterilizing instruments were perceived as important hygienic practices for practitioners to follow. Additional research has concluded that patients view the cleanliness of their units and sterilization protocols, along with maintaining a “clean clinical environment,” as crucial components of patient safety and quality of care [ 20 , 21 , 22 ]. Other studies have reported that patients deemed the use of state-of-the-art equipment as a necessary requirement for ensuring patient safety [ 20 ].

Patients’ expectations for quality of care from their practitioners varied depending on the dental setting they attended. Our previous work found that patients belonging to academic care settings were concerned about how the inexperience of student providers might impact the quality of dental care they received; however, such apprehensions were eased by faculty member oversight [ 8 ]. This finding aligns with results from our present study where patients expressed comfort in receiving care at the academic dental care setting and were more forgiving of mistakes. Another previous study [ 21 ] revealed that the perceived clinical ability of a dental student and the presence of supervisor oversight and assistance with procedures played a critical role in reducing patient anxiety. However, these opinions were not shared by patients at private practices and the community health center in this study, because they expected higher standards of care from their providers and were less forgiving of mistakes.

Our study revealed that patients from the private dental clinic focused on the credentials and training of their providers and only felt safe if the provider had years of experience and extensive training from top tier institutions. This finding is reinforced by prior research that concludes most patients prefer older practitioners whom they perceive as more experienced with refined communication skills [ 20 ]. On the contrary, a separate study found that some patients preferred younger dentists due to their utilization of technology and innovative methods during treatments [ 22 ]. This study also found that patients preferred female dentists because they believed that they had better interpersonal skills than their male counterparts. Together, these studies highlight how the perceived skills of dentists and their demographic characteristics can impact a patient’s perception of receiving quality dental services [ 23 ].

Dental practitioners have experienced a high volume of complaints over the years. Different studies have found that these complaints originate from various sources. While one study found most complaints were made by parents or relatives of patients [ 24 ], another reported that the majority of complaints received were about personal dental treatment [ 25 ]. Nonetheless, most complaints were made by women [ 25 ]. Reasons for complaints included: post-treatment symptoms like pain and eating issues, emotional trauma, unprofessional conduct, and communication breaches [ 25 ]. In the present study, patients expressed the importance of having a patient advocate who could help them discuss negative experiences with their dentists. Others preferred to seek an alternative dentist rather than return to the same practitioner following an adverse event. Fear played a major role as patients decided whether to report their experiences at the dentist. These findings are in accordance with other studies where patients reported losing trust in their dentist and changing providers due to adverse incidents or perceived risks. However, most patients were able to report incidents through advocate mediums that helped advocate for financial compensations and detect preventable injuries [ 25 ].

Our study also revealed that clear and concise communication was an important strategy for improving the quality of patient care. Participants recommended that practitioners engage in open conversations with patients and give honest opinions on their current oral health status and treatment recommendations. They noted that these strategies could encourage active patient participation in promoting quality and safety by enabling them to make informed decisions. Given the importance of conveying information pre-, during, and post-treatment, study participants viewed failure to properly communicate as a major cause for concern. Similar findings have been reported in other studies, Caltabiano et al [ 21 ].found that 50% of dental patients cited “interpersonal skills” of dental students as a factor that decreased anxiety among their dental patients. Simple descriptions of a patient’s diagnosis and the available treatment options are necessary to attain patient satisfaction and participation [ 26 ]. Research studies have shown that clear explanations during consultations and active listening to patients enable them to grasp the expected outcome of the proposed treatment. Miscommunication, rudeness, and inattentiveness can cause a breach in the relationship between dentists and patients [ 27 ]. Adequate communication is necessary to properly assess a patient’s medical condition or medication use before treatment and to help manage patient behavior during treatments to prevent adverse incidents [ 28 ]. Unclear explanations or indications by professionals can result in poor treatment adherence by patients, thereby compromising effectiveness [ 20 ]. Findings from other studies revealed that patients considered good dental services to include key communication strategies such as empathetic words of encouragement and comfort during the treatment process [ 23 ]. A prior study showed that 40% of patients undergoing dental radiographic treatments never had their dentist explain negative side effects and risk of treatment. More than half of these patients (55%) never or hardly ever made enquiries into the safety measures before undergoing radiography [ 29 ].

Involving patients in the monitoring and reporting process gives them a key role to play in enhancing patient safety, as they can provide provider feedback and report adverse incidents [ 28 ]. Patients in the current study expressed willingness to participate in focus groups that allow them to voice their opinions without fear of repercussions from dentists. Similarly, another study found that patients were willing to actively participate in their care and safety by advocating for themselves and being involved in the decision-making process regarding their conditions. Patients’ participation in care and patient safety measures were used as determinants to assess whether they felt safe or ignored [ 30 ].

Different patients preferred different forms of communication based on certain demographic factors. Older patients preferred to receive printed copies of ‘before’ and ‘after-visit’ summaries and were not comfortable using technological gadgets, while younger patients preferred iPads and other mobile devices, as they considered them to be more effective educational devices for patient engagement during treatment. Though most participants were female, there was no gender-based differences of opinions. A study of internal medicine patients found no difference in participation in patient safety activities based on age, gender, or profession [ 18 ]. However, an alternative study indicated that younger patients with advanced education were more willing to participate in the decision-making process regarding their treatments [ 20 ].

Although our findings have limited generalizability due to the use of convenience sampling, our study provides critical information on the willingness of dental patients across various dental care settings to participate in activities that promote the quality and safety of dental care. This study builds upon the findings from our previous work investigating patient participation at a single academic dental center. The conclusions confirm that dental patients react differently to working as partners depending on the dental care setting in which they receive care. Future studies assessing the patient’s perspective should also assess their oral health literacy, since their knowledge of dentistry may impact their perception. Such studies will help determine accessible and feasible methods for improving patient engagement in quality and safety.

Based on our findings, we offer several recommendations on how to facilitate patient participation in safety and quality care activities. “What to expect” summaries for pre-, during, and post-dental treatment periods need to be developed and customized for each dental procedure. Practices should consider employing patient advocates to handle patient concerns and make the feedback process more approachable. While employing a patient advocate might not be feasible in smaller dental offices, some alternatives could be to designate an administrative staff member to manage patient concerns or partner with other local dental offices to outsource the handling of patient grievances to a third-party patient advocacy or mediation group for resolution. Results from our study emphasize that dental practitioners should be approachable and deliver the necessary information at the right time using various modalities depending on the patient’s needs and preferences. Altogether, implementing these strategies will improve patient participation in quality and safety activities in dental care settings.

Our study revealed that dental patients care about the quality and safety of care that they receive. Their willingness to participate in quality and safety activities depended on their relationship with the provider and their perception regarding the receptiveness of providers to accept feedback. Patients were less willing to participate if an activity if it could potentially be perceived as confrontational. The type of dental care setting slightly impacted how patients perceived their role as partners in improving the quality and safety of dental care.

Availability of data and materials

The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Bailey E, Tickle M, Campbell S, O’Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health. 2015;15(1):152.

Article   PubMed   PubMed Central   Google Scholar  

Black I, Bowie P. Patient safety in dentistry: development of a candidate “never event” list for primary care. Br Dent J. 2017;222(10):782–8.

Article   CAS   PubMed   Google Scholar  

Kalenderian E, Obadan-Udoh E, Maramaldi P, et al. Classifying adverse events in the dental office. 2017.

Google Scholar  

Kalenderian E, Obadan-Udoh E, Yansane A, et al. Feasibility of electronic health record–based triggers in detecting dental adverse events. Appl Clin Inform. 2018;9(3):646.

Maramaldi P, Walji MF, White J, et al. How dental team members describe adverse events. J Am Dent Assoc. 2016;147(10):803–11.

Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from dental patient safety case reports. J Am Dent Assoc. 2015;146(5):318-326.e312.

Obadan-Udoh E, Panwar S, Yansane A-I, et al. Are dental patients concerned about safety? An exploratory study. J Evid Based Dent Pract. 2020;20(3):101424.

Article   PubMed   Google Scholar  

Obadan-Udoh EM, Gharpure A, Lee JH, Pang J, Nayudu A. Perspectives of dental patients about safety incident reporting: a qualitative pilot study. J Patient Saf. 2021;17(8):e874–82.

Wright S, Ucer C, Speechley S. The perceived frequency and impact of adverse events in dentistry. Fac Dent J. 2017;9(1):14–9.

Article   Google Scholar  

Walji M, Yansane A, Hebballi N, et al. Finding dental harm to patients through electronic health record-based triggers. JDR Clin Transl Res. 2020;5(3):271–7.

CAS   Google Scholar  

Kalenderian E, Obadan-Udoh E, Maramaldi P, et al. Classifying adverse events in the dental office. J Patient Saf. 2021;17(6):e540–56.

Franklin A, Kalenderian E, Hebballi N, et al. Building consensus for a shared definition of adverse events: a case study in the profession of dentistry. J Patient Saf. 2022;18(5):470–4.

Kalenderian E, Lee JH, Obadan-Udoh EM, Yansane A, White JM, Walji MF. Development of an inventory of dental harms: methods and rationale. J Patient Saf. 2022;10:1097.

Yansane A, Lee J, Hebballi N, et al. Assessing the patient safety culture in dentistry. JDR Clin Transl Res. 2020;5(4):399–408.

Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002;11(1):76–80.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Patients’ attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Expect. 2013;16(4):e164–76.

Davis RE, Sevdalis N, Vincent CA. Patient involvement in patient safety: How willing are patients to participate? BMJ Qual Saf. 2011;20(1):108–14.

Sahlström M, Partanen P, Azimirad M, Selander T, Turunen H. Patient participation in patient safety—an exploration of promoting factors. J Nurs Manag. 2019;27(1):84–92.

Weingart SN, Price J, Duncombe D, et al. Patient-reported safety and quality of care in outpatient oncology. Jt Comm J Qual Patient Saf. 2007;33(2):83–94.

PubMed   Google Scholar  

Henríquez-Tejo RB, Cartes-Velásquez RA. Patients’ perceptions about dentists: a literature review. Odontoestomatologia. 2016;18(27):15–22.

Caltabiano ML, Croker F, Page L, et al. Dental anxiety in patients attending a student dental clinic. BMC Oral Health. 2018;18(1):1–8.

Furnham A, Swami V. Patient preferences for dentists. Psychol Health Med. 2009;14(2):143–9.

Luo JYN, Liu PP, Wong MCM. Patients’ satisfaction with dental care: a qualitative study to develop a satisfaction instrument. BMC Oral Health. 2018;18(1):1–10.

Thomas L, Tibble H, Too L, Hopcraft M, Bismark M. Complaints about dental practitioners: an analysis of 6 years of complaints about dentists, dental prosthetists, oral health therapists, dental therapists and dental hygienists in Australia. Aust Dent J. 2018;63(3):285–93.

Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Can patients detect hazardous dental practice? A patient complaint study. Int J Health Care Qual Assur. 2015;28:274.

Iqbal W, Faran F, Yashfika A, Shoro F. Evaluation of dental care through patient satisfaction feedback–a cross sectional study at Dental Institute of OJHA Hospital, Karachi. Pakistan Adv Dent & Oral Health. 2018;8(4):0083–91.

Dental Protection Limited. Handling Compliants-England. https://www.dentalprotection.org/docs/librariesprovider4/dental-advice-booklets/dental-advice-booklet-complaints-handling-england.pdf . Published 2016. Accessed 25 July 2022.

Hiivala N. Patient safety incidents, their contributing and mitigating factors in dentistry. 2016.

Al Faleh W, Mubayrik AB, Al Dosary S, Almthen H, Almatrafi R. Public perception and viewpoints of dental radiograph prescriptions and dentists’ safety protection practice. Clin Cosmet Investig Dent. 2020;12:533.

Ringdal M, Chaboyer W, Ulin K, Bucknall T, Oxelmark L. Patient preferences for participation in patient care and safety activities in hospitals. BMC Nurs. 2017;16(1):1–8.

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This project was funded by the UCSF Hellman Family Fund. The views presented here are strictly those of the authors and do not represent the views of the sponsoring organization.

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Contributions

E.O. was responsible for the study design, overall study execution, including obtaining IRB approvals, designing study instruments and recruitment flyers, data interpretation and manuscript, designing study instruments, recruitment flyers, data interpretation and man writing. V.S. assisted with data collection and analysis. G.S. performed data analysis and helped write the results section. RH revised the manuscript and prepared the tables. SC participated in patient recruitment. D.W. participated in study conceptualization, patient recruitment, and data collection. All authors reviewed and approved the final version of manuscript.

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Correspondence to Enihomo Obadan-Udoh .

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Ethics Approval and Consent to Participate: The study was approved by the UCSF institutional review board (#18–25467). The verbal informed consent was obtained from all the participants which was approved by the UCSF IRB.

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Obadan-Udoh, E., Sundararajan, V., Sanchez, G.A. et al. Dental patients as partners in promoting quality and safety: a qualitative exploratory study. BMC Oral Health 24 , 438 (2024). https://doi.org/10.1186/s12903-024-04030-1

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DOI : https://doi.org/10.1186/s12903-024-04030-1

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This capstone project is designed to provide the student with an opportunity to apply their knowledge of concepts and skills through an individually designed project.  Students will execute the project through the development and implementation of a patient treatment plan that culminates in a final paper and presentation on the specific "Periodontal Type II" or greater case identified. 

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1.) In any search bar start with the whole of your research topic. For example: If the topic of the paper is "Periodontal Attachment Loss in Diabetic Patients" and you only search "Attachment Loss," you will get articles and information that do not apply to the topic.  Start with the whole topic and see what comes up.  

2.) Refining the results:

        2a.) TOO MUCH - If you are getting too many articles, try putting quotes around key search terms "Attachment Loss" "Diabetic Patients."  This will limit the search to articles where those terms appear beside each other in context.

        2b.) NOT ENOUGH- Break down the topic into variations . "Diabetes and Dental Care," "Attachment Loss in Dental Care," "Periodontal Care and Diabetes"  

3.) Don't stop at the required number of sources!   Although the requirement says you need three additional resources, always find a few more than required.  Just because you have them, doesn't mean you have to use them.  It is better to have choices when writing a paper than trying to force a paper from limited options.

4.) READ THE WHOLE ARTICLE (Or at the very least 1st Paragraph, a Middle Paragraph, and the Last paragraph)!!!  Your search engine may pull up an article that has your search terms in the article, but that does not always mean the article actually speaks to your topic.  Be sure that the entirety of the source supports your topic, not just a single sentence.

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• Plagiarism Rutgers University This link opens in a new window Entertaining video describing plagiarism and how to avoid it.
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• What is plagiarism and how to avoid it 2 Minute video explaining plagairism
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• FHTC Online Library Quick Link Available 24/7

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• Kansas State Library Quick Link Click on "Online Resources" Scroll down to the "Health" collection to find recommended databases. To Expand click "View All" at the bottom of the list

-For general knowledge of conditions or disorders the "Gale Health Reference Collection" is recommended for starting your research. 

-For research studies, journal articles, and similar academic based materials on your topics go to "Health Source Academic & Nursing;"  " ProQuest Nursing and Allied Health;" or "Medline" 

-For some topics these databases will be of value: "Alternative HealthWatch;"  "Consumer Health Complete;" "Psychology and Behavioral Sciences Collection"

-Remember to only use FULL-TEXT articles.  Never use "Abstracts" as primary research.   

The following databases also provide various articles that may be helpful in your research process.  Remember to consider only FULL-TEXT articles available, the date the article was published , and whether it is research- opinion- or promotion based information before using. Not all articles will be available for free through these databases.  In many cases, just like with Google Searches, you will be able to access the abstract but not a full-text article.  However, if you get the name of an article you are interested in- you might search it in the databases listed above- it might be available.

• Cochrane Library The key to this site is accessing the "free" articles provided. For those articles that are free- some are full-text, but not all. Be sure to check carefully that the articles meet criteria for academic research use.
• Dentistry Today This publication offers searchable article archives and the majority meet the requirements for use in academic research writing. However, there are a few "ad" based articles to watch for.
• PennWell RDH Magazine Again, this site offers a searchable archive of articles from the publication. Most will be usable, but there are "ad" based and "opinion" based articles included.

Q: What does "Scholarly Article" or "Peer-Reviewed Article" Mean?

Coulter, P. (2016). Richard G. Trefry library: American public University System. Libanswers. http://apus.libanswers.com/faq/44354

"Scholarly" and "peer reviewed" are often used synonymously, but they are not necessarily the same thing.   Peer reviewed articles are always scholarly, but not all scholarly sources are peer reviewed.   It may seem confusing, but it makes more sense if you  think of "scholarly" as an umbrella term for several different kinds of authoritative, credible sources .  These include :

• Peer reviewed journals .  These journals primarily exist to publish the  research  findings of experts in a field. The articles that you see in these journals have been closely scrutinized by a panel of reviewers (also experts in the same field) before they are published.    
• Trade or professional journals or magazines .  The articles in these periodicals are also written by and for experts, but there is no peer review.  The articles aren't limited to research...they may be news, best practice tips or opinion pieces. 
• Government Publications  Many government agencies publish books, reports, data or statistics.  Government researchers, like those who publish in peer reviewed or trade journals, are often experts in their field.
• Books.    Many researchers publish books or book chapters.  

How can you tell if an article is scholarly?   You will have to do some detective-work, but there are some telltale signs:

• Author(s) : Ideally, you should rely on information that has been published by an expert,  someone who has studied the topic long and hard.    Most scholarly publications will list an author's credentials (their degrees -- M.S., Ph.D., Ed.D., etc. -  and the institution that they work for) along with his or her name.
• Content:   Look for articles that cover a topic in detail (more than just a few pages long, typically).   It will probably include some kind of literature review, and discuss the work of other authors, in addition to any original research findings.  Make sure it  cites its sources   (a scholarly article will  always  have a "references," "bibliography" or "works cited" list). 
• Audience:   Scholarly articles are written for professionals in the field.  You will probably notice a lot of technical language and/or discipline-specific jargon.  The tone will be formal.
• Publisher.   Visit the journal's website to see what organization publishes it.  Professional associations, universities and government agencies are particularly good signs.  As you become more experienced, you'll also start to recognize major publishing companies in your field of study (Wiley, Elsevier, Sage, etc.).
• Purpose and scope.   When you're on the journal's website, look for an "about" link to learn who the intended audience is and what kind of articles are accepted.
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Broadening the Dental Hygiene Students’ Perspectives on the Oral Health Professionals: A Text Mining Analysis

Yukiko nagatani.

1 Department of Dental Hygiene, University of Shizuoka Junior College, 2-2-1 Oshika, Suruga-ku, Shizuoka-shi 422-8021, Japan

Rintaro Imafuku

2 Medical Education Development Center, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan

Yukie Nakai

Associated data.

The data presented in this study are available on request from the corresponding author.

Professional identity formation, an important component of education, is influenced by participation, social relationships, and culture in communities of practice. As a preliminary investigation of dental hygienists’ professional identity formation, this study examined changes in the dental hygiene students’ perceptions of oral health professionals over the three years of their undergraduate program. At a Japanese dental hygiene school, 40 students participated in surveys with open-ended questions about professional groups several times during their studies. The text data were analyzed through content analysis with text mining software. The themes that characterized their dental hygienist profession perceptions in their programs each year were identified as: “Supporters at the dental clinic”; “Engagement with interprofessional care” and “Improved problem-solving skills for clinical issues regarding the oral region”; and “Active contribution to general health” and “Recognition of the roles considering relationships” (in the first, second, and third years, respectively). The students acquired professional knowledge and recognized the significance and roles of oral health professionals in practice. They gained more learning experiences in their education, including clinical placements and interprofessional education. This study provides insight into curriculum development for professional identity formation in dental hygiene students.

1. Introduction

Dental hygienists specialize in the control of dental diseases; this profession is prevalent and generally professionally licensed in over 30 countries [ 1 , 2 ]. They are primarily responsible for preventive procedures and non-surgical periodontal treatments. Their role is usually to investigate dental diseases, and motivate and instruct patients about dental health [ 1 , 2 , 3 ]. In Japan’s aging society, the necessity of implementing oral health management as primary care is becoming widely recognized by health professionals and the public. It is essential for dental hygienists to prevent and treat dental diseases and support general health by maintaining and promoting the oral environment [ 4 ], and improve the quality of life [ 5 ]. To respond to these social needs, it is necessary to secede from the emphasis on manual procedures in dental clinics [ 6 ] and practice as directed by the dentists; to train the dental hygienists with high qualities and professional skills who can think and practice on their own in the community in cooperation with multiple professionals; and to establish a way of the dental hygiene work that is adapted to the aging society [ 7 ]. Therefore, it is necessary to develop a deep understanding of one’s professional role and expertise, in addition to the roles of the other professionals with whom they work, considering social needs. Moreover, the internalization of this value system promotes the identity formation of a learner who practices in the health profession.

Identity formation is “the process by which an individual self-defines as a member of that profession based on the acquisition of the requisite knowledge, skills, attitudes, values and behaviors” [ 8 ]. It is considered an important component of education in the health profession. In identity formation in health professions, social interactions, experiences, and learning contexts are influential factors. At the collective level, it is influenced by context, including culture and the learning environment chosen by the learner. According to Wenger, gaining practical experience through active engagement and interactions with other members of a community is essential to professional identity formation [ 9 ].

In health profession education, the learners’ profound transformation occurs through learning experiences, most notably the clinical ones [ 10 , 11 , 12 ]. To make the transition from a layperson to a professional, they need learning opportunities that encourage a re-identification of the past (or the present) self [ 13 ]. Furthermore, building social relationships with peers and mentors in clinical education, as well as reflecting and discussing about learning experiences in clinical settings, strengthens professional identity formation through socialization with professional groups [ 14 , 15 ]. Therefore, the health profession education programs need to be structured stepwise from the first year to enable the development of values and professional identity regarding evidence-based practice and professionalism [ 16 ].

The importance of introducing education and support that promotes professional identity formation in dental hygiene education has been internationally recognized. For example, service-learning exercises and curriculum revisions have been implemented to develop students’ attitudes and sense of professional responsibility [ 17 , 18 ]. In addition, Imafuku et al. explored the interprofessional identity formation in dental hygienists [ 19 ]. However, the overall understanding of the process of dental hygienists’ professional identity formation over time, beginning with their first year of study, remains unclear. Clarifying the process of dental hygienists’ professional identity formation could provide insight into students’ actual perceptions of the nature, tasks, and value system of the profession. Analyzing the discrepancy between their perceptions of the profession of dental hygienist and the learning outcomes expected by their teachers would provide a basis for improving and developing new educational strategies and learning support methods in the future. Therefore, in this study, as a preliminary investigation of dental hygienists’ professional identity formation, we examined the changes in their perceptions of the dental hygienist profession during the three years of their undergraduate education.

2. Materials and Methods

2.1. participants.

An observational, longitudinal, and prospective study was conducted in the Department of Dental Hygiene at the University of Shizuoka Junior College. All freshmen in the cohort who enrolled in the school in 2019 were invited to participate in this study, and all consented ( n = 40). They were 18–19 years old at the time of enrollment. Their background prior to enrollment was high school or post-high school graduates preparing for university entrance exams. In addition, none of them had clinical experience in the medical field.

2.2. Data Collection

An open-ended questionnaire was self-administered to 40 students each year for three years, from the second half of their first year to the second half of their third year. The open-ended format allowed the researchers to elicit richer data on students’ perceptions of the professional roles and prospects as health professionals at each stage of their undergraduate education. Specifically, this questionnaire survey was structured by five open-ended questions about their reasons for choosing the profession, their ideal future image as a dental professional, their perceptions of professionalism in dental hygiene, societal expectations, and competencies required for the profession. The actual questions in the survey are as listed below:

• - Why did you decide to become a dental hygienist?
• - What kind of dental hygienist do you want to be?
• - What do you think is the professionalism of dental hygienists?
• - What do you think is required of you as dental health professionals by society and patients?
• - What competencies do you think that dental hygienists need to have for clinical practice?

The data were gathered in October 2019 (at the beginning of the first year’s second semester), October 2020 (at the beginning of the second year’s second semester), and November 2021 (at the end of the clinical practice).

2.3. Data Analysis

Data were transcribed from questionnaires and then subjected to text mining analysis using the software, KH Coder 3 (Koichi Higuchi, Kyoto, Japan) [ 20 ]. The software produced a list of words according to their frequencies and interrelationships. It is a quantitative process of adapting algorithms to discover hidden, useful, and interesting patterns in unstructured qualitative text data [ 21 , 22 , 23 ]. In analyzing the qualitative text data, text mining increases the reliability and validity of the coding [ 23 ]. In addition, it can be used in conjunction with human coding content analysis to enhance the rigor [ 24 ].

In this study, the software was used for the research participants’ perceptions of the dental hygienist profession to obtain an overall picture of the diversity, type, and distribution as a framework for understanding the data before conceptualization. A hierarchical cluster analysis was conducted on the pupils’ perceptions of the oral health professionals at each of the three data collection points; moreover, frequently occurring words were extracted. Subsequently, the co-occurrence of the strength of the association between the extracted words was calculated using the Jaccard coefficient. In these analyses, the Key Word in Content (KWIC) concordance function was used to identify words with three or more occurrences to qualitatively examine students’ interpretations of their perceptions of the dental hygienist and how they changed over time. The resulting associations were visually represented on a Co-Occurrence Network Map and coded and categorized by the first and second authors to increase rigor and explore the meaning of the data in conjunction with the qualitative analysis. The authors discussed and identified underlying themes in the visualization of the results. Preliminary results were then discussed and a consensus was reached by all members of the research team. The chi-square test was applied to assess the significance of differences in the distribution of students’ perceptions of oral health professionals at each of the three data collection points using KH Coder, version 3 (Koichi Higuchi, Kyoto, Japan). Statistical significance was set at p < 0.05.

In addition, the relationship between the results of each period and the content of the curriculum taken up to that point, as well as a comparison of the data at the end of the third-year field training with the diploma, were also examined.

2.4. Study Context

This study was conducted at the Department of Dental Hygiene, Junior College of the University of Shizuoka, involving students enrolled in a three-year education program. Regarding the educational philosophy, this school follows the diploma policy, which entails the student learning outcome objectives and graduation approval/degree awarding program; it is set to train dental hygienists who can respond to the oral health needs of the community. A junior college bachelor’s degree is awarded to those who have studied in an educational program to acquire the abilities listed below and have earned the necessary credits.

• - Professional knowledge, abilities, and communication skills related to dental hygiene
• - Logical thinking and problem-solving skills
• - Awareness of their roles and responsibilities as dental hygiene practitioners and the ability to perform them appropriately
• - A rich sense of humanity and high ethical standards, and ability to collaborate and cooperate with other professionals
• - Contribution to the development of people’s health and a striving for lifelong learning.

In the training school included in this study, the curriculum was designed to enable students to achieve the above-mentioned diploma. As shown in Figure 1 , in the first year, students attend lectures on liberal arts, basic specialties, and dental hygiene. In the second year, they opt for specialized clinical subjects, on-campus training related to dental hygiene work, and subjects related to interpersonal support and well-being in collaboration with students from other departments. In addition, elective subjects related to health and medical well-being have been established from the second semester of the first year to the first semester of the second year. After studying these subjects, the third year includes off-campus practical training in dental clinics, oral surgery departments of general hospitals, nursing homes, and disability support facilities.

Three-year curriculum of dental hygiene at the research site. (The intensity of the color indicates the volume of the subject’s content.)

2.5. Ethical Considerations

This study was approved by the University of Shizuoka Research Ethics Committee [approval number 1-19]. Furthermore, informed consent was provided by all the study participants.

3.1. Changes in the Word Frequency

Overall, 333 statements were related to the professional role and attitude of dental hygiene, of which 120, 177, and 192 statements were categorized for the first, second, and third years, respectively. The following five words were found to occur over 30 times in total:

• Oral: 90 times
• Patient: 64 times
• Dental: 62 times
• Health: 51 times
• Knowledge: 35 times

3.2. Number of Code Occurrences

The occurrence rate of the aforementioned words varied from year to year ( Figure 2 ). In the first year, “oral” was the most frequently appearing word, followed by “prevention”, “dental”, “health”, “knowledge”, and “patient”; in the second year, “oral” was the most frequently occurring word, similar to the first year, followed by “patient”, “dental”, “health”, “whole body”, and “knowledge”. The increased utilization of the words “patient” and “whole body” was characteristic. The former occurred 12, 24, and 28 times in the first, second, and third years of school, respectively, and the number of occurrences tended to increase as the school year progressed. In the third year, “oral” was the most frequently used word, followed by “patient”, “dental”, “health”, “do”, and “knowledge”, similar to the first and second years. Although “do” did not occur in the first year, it showed an increasing trend with 5 and 13 occurrences in the second and third years, respectively. However, the number of occurrences of “prevention” tended to decrease with increasing grade level, from 16 to 8 and 6 times in the first, second, and third years, respectively.

The number of the extracted words of expertise perceived by the dental hygiene students over time.

3.3. Code Occurrence Rate

Figure 3 visualized the changes in the occurrence rate of the specialty codes as perceived by the dental hygiene students over time. The square size indicates the occurrence rate of each code (showing “percent”), and its color corresponds to the standardized residuals (Pearson residuals). Therefore, a larger square represents a higher rate of occurrence, and the darker color represents the larger residual. According to Figure 3 , only “do”, which did not appear in the first year, showed a significant difference in the proportion of the occurrence of the three points ( p < 0.05, Chi-square test).

Changes in the occurrence of the specialty codes as perceived by the dental hygiene students.

3.4. Recognition of Professional Roles, Competence, and Attitude at the Three Time Points Based on the Strength of the Relationship between the Words

From the co-occurrence network model diagram showing the strength of the association between the words with three or more occurrences, the characteristic themes were extracted for the dental hygiene students’ perceptions of their professional roles, competence, and attitude at each of the three time points, using the KWIC concordance function to assess the word usage.

3.4.1. At the Beginning of the First Year’s Second Semester

During the first year, the following two themes were extracted ( Figure 4 ):

The co-occurrence network diagram of the first-year dental hygienists’ perceptions of professional role and competencies.

Supporters at the Dental Clinic

The dental hygienists were identified as assistants in the dental clinic, professionals who help patients improve their health by providing expert knowledge and skillful care in the prevention and treatment of dental caries, alleviating their fear of treatment, and supporting the dentists during the dental treatment.

• - “How to comfort the patients at the dental clinic, a place where they are considered to be uncomfortable”.
• - “Supporting the dental treatment to run smoothly”.

Understanding the Relationship between Oral and General Health

The participants were aware that the oral region and the whole body are deeply related; however, as professionals in oral health, they believed that they must enhance their knowledge, treatment, instruction, and care techniques for “improving the health of the whole body through oral care”.

• - “Understanding better than anyone else that the teeth and oral health are linked to general health”.
• - “Dental caries prevention and understanding the relationship between the oral region and the whole body”.
• - “The ability to communicate the importance of oral health in various settings, both in the medical and educational fields”.

3.4.2. At the Beginning of the Second Year’s Second Semester

During the second year, the following four themes were extracted: ( Figure 5 ).

The co-occurrence network diagram of the second-year dental hygienists’ perceptions of professional role and competencies.

Dental Hygienists’ Work Frames

Participants recognized the framework of the three main tasks of a dental hygienist in Japan, including caries prevention treatment through fluoride application, assistance work for smooth dental treatment by standing between patients and dentists, and oral health instruction.

• - “Must be able to assist in the dental treatment, provide the oral health instruction, and perform the caries prevention procedures”.
• - “A person who can stand between the dentist and the patient and contribute to enhanced treatment”.

Engagement with Interprofessional Care

The participants felt they must have a broad knowledge of medicine, not only regarding oral health, which is their profession, but also systemic diseases. They aimed to confidently collaborate and communicate with multiple professionals and develop the ability to handle interprofessional medicine that could provide patient-centered care.

• - “To acquire an awareness of the whole body, not just the oral, and to be able to perform team medicine with other professionals”.
• - “Have a patient-centered attitude and the communication skills to practice in a team-based environment”.

Health Support from the Perspective of the Oral Health

The need for dental hygienists to acquire medical information along with oral health knowledge in order to demonstrate support for general health from the perspective of oral health has been recognized. These skills help prevent infection and improve general health and quality of life by helping to maintain and promote oral health throughout life, including the perioperative period and old age.

• - “To improve the quality of life as well as the oral health of patients”.
• - “Promoting and maintaining general health through the oral health”.

Improved Problem-Solving Skills for Clinical Issues Regarding the Oral Region

The participants were aware of their role in solving and improving oral problems. Therefore, participants recognized the need for the ability to provide medical care, including instruction, care, and hygiene management, to identify and resolve issues based on each person’s condition status and needs, and to build a relationship of trust with the patient.

• - “Perceive the patients’ condition, their oral health situation, understand their problems, and provide them with appropriate care to resolve those issues”.
• - “I think it is about improving oral health, instructing about oral health, and building trusting relationships to solve oral health problems”.

3.4.3. At the End of the Third-Year Clinical Practice

At the end of the third-year clinical practice, the following four themes were identified: ( Figure 6 ).

The co-occurrence network diagram of the dental hygienists’ perceptions of professional role and competencies in the third year.

Active Contribution to General Health

Participants mentioned the need for evidence-based and correct professional knowledge and skills, as well as the ability to make decisions in clinical practice. They recognized that acquiring these competencies would enable them to respond to patient complaints and work smoothly with multiple health care professionals from an oral health perspective.

• - “Dental as well as medical knowledge and working with various professionals to approach problems”.
• - “As a dental hygienist, we must have the knowledge to answer patient complaints”.

Recognition of the Roles Considering Relationships

As professionals supporting patients’ autonomous oral health care, they recognized their role in improving self-care and providing professional care based on their relationship with patients; they were able to incorporate specific preventive approaches such as dietary instructions and periodontal treatments. In addition, they recognized their role based on their clinical relationship with the dentist, which included managing the patients overall health during treatment and paying attention to the intentions and feelings of both the patient and the dentist.

• - “We are professionals in terms of prevention; thus, hygienists are required to provide care and prevention so that we do not get to the treatment stage”.
• - “To support the patients’ feelings (chief complaint) and to help them feel comfortable through the dentist”.

Protecting the Oral and Overall Health

The students expressed their intention to be actively involved in the whole health management not limited to oral health care, such as supporting the daily quality of life from a holistic perspective.

• - “Improvement of the overall health and quality of life through oral health”.
• - “To enhance the quality of life by improving and maintaining oral health that is closely related to the everyday life, such as eating, speaking and laughing”.

Intervention in the Life Context

In the approach to oral health maintenance and promotion, participants recognized the need to not only understand the oral and general condition of patients, but also to actively incorporate their oral function and hygiene into their daily lives by intervening in their life background, such as their diet and lifestyle.

• - “To be able to provide health instruction from a dental perspective, including dietary instruction and lifestyle modification”.
• - “To provide instruction for the patients’ own oral health self-care, so that they themselves can maintain a good oral health”.

4. Discussion

This study found that dental hygiene students’ perceptions were strongly influenced and shaped by their learning experiences during college. This included lectures on their specific duties, the interdisciplinary education program, and clinical placements in dental facilities. As previous studies have shown, it is critical that they gain a clear understanding of the core values, expectations, and behaviors of the profession during health professions education and are encouraged to develop their own identities in addition to acquiring knowledge and skills [ 14 , 25 ]. Accordingly, the present longitudinal research demonstrated four aspects of changing the perceptions of the oral health professional among dental hygiene students.

The first aspect is the relationship between knowledge acquisition and professionalism. The establishment of a knowledge system in a professional domain has a significant impact on identity formation [ 26 , 27 ]. Moreover, self-efficacy has been related to professional recognition, skill mastery, and knowledge [ 28 ]. In this research, the first-year students were expected to acquire knowledge related to the “oral and general health promotion” such as “dental caries prevention and understanding the relationship between the oral region and the whole body” and “the teeth and oral health are linked to general health”. In the second year, the concept of the “dental hygienists’ work frames” learned in lectures such as “assist in the dental treatment, provide the oral health instruction, and perform the caries prevention procedures”, was often mentioned as a competence of dental hygienists. Specifically, in the first and second years, their professionality was frequently viewed from the aspect of knowledge acquisition reflected in the content of the specialized clinical courses. Knowledge acquisition is also essential in forming the professional identity foundation [ 26 ]. Nevertheless, in the first and second years, the students tended to focus excessively on obtaining the expertise of a dental hygienist. As it is said that identity formation is facilitated by active engagement and interaction in the community [ 9 ], therefore, education programs that promote the pupils’ understanding of “Recognition of the roles considering relationships”, such as communication training, interprofessional education, and early exposure program need to be developed and incorporated into the basic education stage. For example, early exposure is an educational strategy to help students adapt to the clinical environment, improve their skills of reflection and evaluation, and establish their professional identity [ 29 , 30 , 31 ].

Regarding knowledge acquisition, enhancing logical thinking and problem-solving skills are key for curriculum development. Specifically, it is important to incorporate research and exploratory activities into each subject area step-by-step in dental hygiene education. These skills are necessary to apply the acquired knowledge in practice. In medical education, undergraduate research courses in which pupils independently conduct research for a certain time have been offered; further, efforts to improve their logical thinking and evidence-based medicine have been reported [ 32 , 33 ]. Similarly, in the three years of dental hygiene education, it is necessary to promote a continuum of learning through exploratory activities about assessment, planning, implementation, and evaluation to develop logical thinking and problem-solving skills for evidence-based medical practice [ 34 ]. Therefore, educational objectives and content should be jointly determined by the clinical practice organization and the educational institution, and research activities should be integrated into the curriculum.

The second aspect is the students’ broadened perceptions of their professional roles and responsibilities, which influence professional identity formation [ 35 , 36 , 37 ]. Thus, this study indicated the changes in the pupils’ perceptions of the role and responsibilities of a dental hygienist. Specifically, the first-year students limited the place of work to the “dental clinic” and viewed dental hygienists as professionals involved in the dental care there; further, there was a limited term or phrase indicating a professional role of caring for people at different life stages, such as oral function management in the elderly and perioperative oral care. In the second year, the pupils acquired the perspective of the “patient” and the theme of supporting patient health from the oral health perspective was extracted. In the third year, the theme of protecting the patient’s overall health as a role of a dental hygienist was obtained. These results suggested that health is not limited to the oral region but is also considered from the standpoint of the whole body and that the students had been taking more initiative in “protecting” the patient’s health. Furthermore, the vague image of the role of a dental hygienist in the first year was transformed into a more concrete image and gained a more generalist view. They were able to think about the clinical issues from a patient’s standpoint in the third year. Their text data included “improving and maintaining oral health that is closely related to everyday life, such as eating, speaking and laughing”, and the “improvement of the overall health and quality of life through oral health”. This result is consistent with that of the study by Imafuku et al., that explored the identity formation processes of dental hygienists in the field as interprofessional collaborators [ 19 ]; however, the significance of this research is that it showed that such a change in perception might be occurring among the undergraduate students.

In dental hygienist education, for example, it is essential to provide opportunities for the students to reaffirm professional values and beliefs, including what kind of a dental hygienist they want to become, and to clarify their vision for the future in their education’s early stage. In clinical education, dental hygienists and other professionals can assume specific roles within the community of practice through collaborative practice. To encourage group-level socialization, opportunities to meet role models who are active in various situations [ 8 , 38 ] and internships in a community of practice can be used. It is also important to incorporate into the curriculum supportive methods that internalize the values of the dental hygienist during these social experiences [ 8 , 25 , 38 , 39 , 40 ]

The third aspect is a change in perception from individual to team care. Over three years, this study’s participants modified their perceptions of the dental hygienist’s professional role and responsibilities from a focus on the “individual” as a specialist involved in the dental treatment to an “interpersonal” or “team” perspective, such as interprofessional collaboration and patient communication. In the first year, many of the texts referred to their skills, such as “dental caries prevention and understanding the relationship between the oral region and the whole body” and “the ability to communicate the importance of oral health in various settings, both in the medical and educational fields”. Similarly, in the second year, there were several statements about their skills; however, the concepts related to the professions in which they work with the people they care for, such as “provide them with appropriate care to resolve these issues” and “have a patient-centered attitude and the communication skills to practice in a team-based environment”, were more common. During this time, students are believed to have gained a deeper understanding of the relationship between oral and general health, as well as a perspective on the importance of the dental hygienist’s intervention to a person’s general health through the study of specialized clinical subjects. In addition, learning about welfare, management, and clinical psychology, planning dental health instruction, and experiencing being in the role of a patient during campus clinical training may have fostered an awareness of the need for interprofessional collaboration, the ability to provide interpersonal support, and the responsibility to solve health problems. In the third year, students interacted with patients and dental hygienists in clinical practice. They noted the relationships between patients and medical staff, patients and dental hygienists, and dental hygienists and various professionals. Students mentioned the need for clarification of the relationship and their own roles between dental hygienists and multidisciplinary professionals, the ability to respond to patient complaints, the ability to make judgments that allow active participation in multidisciplinary care confidently, and scientifically sound clinical skills.

This finding corroborates the results of previous studies, which show that students focus more on enhancing teamwork and collaborative practice, and their identity confidence is increased after interprofessional education programs [ 41 , 42 ]. However, this study did not confirm the pupils’ improved collective learning skills, such as consensus-building and leadership, and the relationships between their interprofessional learning experience and quality care provision, as suggested by Cooper and Imafuku [ 41 , 42 ]. A possible factor influencing this is that during their clinical practice at the university, the pupils themselves had limited opportunities to experience interprofessional collaborative practice with professionals other than dentists.

Regarding interprofessional collaboration, most clinical practice hours were spent in private dental clinics, presumably because there were not enough opportunities to experience situations of interprofessional collaboration with other professionals. During the five-day oral surgery clinical practicum in the general hospital, students did not proactively practice interprofessional collaboration due to the severity of patients’ illnesses, systemic management issues, and limited skills; it is assumed that they only observed the instructor and had difficulty recognizing interprofessional collaboration. Furthermore, there is a strong perception that they are employees who perform their duties under the instruction of the Dental Hygienists Act, which states that “dental hygienists are those whose work is to perform the following acts under the instruction of dentists and preventive measures for diseases of the teeth and oral” [ 43 ]. Annan-Coultas indicated that observations of real-life teamwork environments can be a meaningful way to teach interprofessional teamwork concepts [ 44 ]. Similarly, although it is difficult for pupils to practice interprofessional teamwork on high-risk patients in a clinical setting, it may be useful for them to observe a multidisciplinary conference and how dental hygienists practice collaborative medicine in such a situation to deepen their awareness of interprofessional collaboration.

Finally, analysis of the textual data suggests that dental hygiene students have a stronger sense of ownership as health care providers. It suggests that participation in the clinical placements strengthened students’ professional identity and sense of responsibility. Specifically, text analysis in the third year showed that the verbs “to do” and “to protect”, which indicate proactive action in terms of professional role and responsibility, were frequently described. This change may be primarily due to their insertion into the dental clinic community during their field training and gaining experience in clinical practice, albeit in a peripheral role, while building relationships with the dentists and dental hygienists in the dental clinic. Students’ identities are formed not only by their associations with professional networks, but also by their actual experiences and participation in the community [ 9 ].

The increased sense of ownership is related to student’s attitude toward lifelong learning. Thus, further educational support is needed from the first-year education to continuously enhance their awareness of the importance of self-learning in healthcare. Lifelong learning is an integral part of the communities of practice, with time and expectations for reflection [ 45 ]. Encouraging pupils to reflect on their experiences in clinical placements deeply can enhance their awareness of lifelong learning and cultivate their self-learning skills. Some studies in medical education show that medical students’ identities are promoted in relationships through reflective activities and the need to provide educational spaces for them to understand their identity as a doctor by recounting their clinical experiences [ 14 , 46 , 47 ].

In this study, we conducted a content analysis of an open-ended questionnaire related to the role and competencies of oral health professionals in dental hygiene students. The results of this study have implications for society as a whole, particularly in the areas of dental education and health care. However, the questionnaire survey did not reflect the background of the students’ descriptions, what they could not express, and the depth of their insight. In particular, we did not explore the kind of individuality and specific experiences from which their perceptions emerged, how they perceived their experiences, and what kind of identity they formed in the narrative process. In addition, although we related the changes in students’ perceptions to the curriculum, we were unable to examine the influence of extracurricular factors, such as extracurricular activities and prior learning experiences. As the data in this study were compiled and compared across all participants at the three time points, changes in individual perceptions over time could not be tracked and the effects of individual personalities and environments could not be analyzed. Therefore, further qualitative interview studies are needed to more fully incorporate students’ experiences behind their perceptions of professionals and to shed light on professional identity formation among dental hygienists.

5. Conclusions

The dental hygiene students in this study acquired professional knowledge, became aware of the importance and role of oral health professionals in practice, and broadened their perspectives as dental hygienists through their health care education, which included lectures, clinical placements, and interprofessional education. Therefore, this study provides insight into the development of curricula to promote the professional identity of dental hygiene students.

Acknowledgments

We would like to thank the dental hygiene students who participated in this study.

Funding Statement

This study was supported by the research grant of the University of Shizuoka and JSPS KAKENHI Grant Numbers JP22K17279.

Author Contributions

Conceptualization, Y.N. (Yukiko Nagatani) and R.I.; methodology, Y.N. (Yukiko Nagatani) and R.I; software, Y.N. (Yukiko Nagatani); validation, Y.N. (Yukiko Nagatani), R.I. and Y.N. (Yukie Nakai); formal analysis, Y.N. (Yukiko Nagatani) and R.I.; investigation, Y.N. (Yukiko Nagatani) and R.I.; resources, Y.N. (Yukiko Nagatani) and R.I.; data curation, Y.N. (Yukiko Nagatani) and Y.N. (Yukie Nakai); writing—original draft preparation, Y.N. (Yukiko Nagatani) and R.I.; writing—review and editing, Y.N. (Yukiko Nagatani) and R.I.; visualization, Y.N. (Yukiko Nagatani) and R.I.; supervision, Y.N. (Yukie Nakai); project administration, Y.N. (Yukiko Nagatani); funding acquisition, Y.N. (Yukiko Nagatani). All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and the national and institutional ethical standards. The ethical approval for the study protocol was obtained from the Human Institutional and Regional Biomedical Research Ethics Committee, the University of Shizuoka Research Ethics Committee [approval number 1-19].

Informed Consent Statement

Written informed consent was obtained from all participants involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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