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Implementation of an enriched ultrasonic curriculum into a Canadian dental hygiene program.

ABSTRACT

Research shows that Canadian dental hygiene programs continue to emphasize hand instrumentation for periodontal debridement despite evidence of improved client outcomes with ultrasonic technology. This study evaluated the ultrasonic skills and outcomes of graduates of an accredited Canadian dental hygiene school over a 2-year period. Results revealed a statistically significant improvement in ultrasonic competency among graduates who received enriched preclinical and clinical instruction in ultrasonics. The revised curriculum produced more "consciously competent" graduates without compromising existing content or increasing program length or costs.

Objective: Thorough debridement is the basis of periodontal treatment and a profound segment of dental hygiene expertise. Studies indicate Canadian dental hygiene graduates use ultrasonics with an outdated (traditional) approach resulting in an "unconsciously incompetent" clinician. This study tests a revised ultrasonic curriculum aimed at producing a more "consciously competent" graduate. Methods: This convenience sample study measured ultrasonic process and outcomes for graduates of an accredited Canadian school before (n = 17) and after (n = 18) implementation of a novel ultrasonic curriculum with enriched ultrasonic theory, preclinic and clinic content Graduates were evaluated "in process" using a validated indexed rubric on 4 foci: equipment preparation, infection control, positioning, and instrumentation technique. Post-scaling, teeth were removed from the identical typodonts, anonymized, and scored for "outcomes" using tested grid calculations for 3 types of standardized deposits: heavy/ tenacious, light, and biofilm. Ethics approval was obtained from Niagara College, Ontario. Results: From a potential 510 points for in process skills, the baseline graduates achieved a mean score of 112.3 compared to 295.6 for the enhanced curriculum cohort. The baseline group left 10.5 grids'of tenacious calculus, 23.3 grids of light calculus, and 60.18 grids of biofilm from a potential of 72 each when outcomes were measured. In contrast, the enhanced curriculum cohort left 4.1, 7.4, and 39.3 grids, respectively. A 2-tailed, unpaired t-test measured statistical significance. All p values show statistical significance between the mean scores at the 0.01 level. Conclusions: The enhanced curriculum produced graduates with process improved by 263.1% (p < 0.0001). Debridement outcomes were enhanced similarly. This study suggests that an enriched ultrasonic curriculum can be inserted into an existing dental hygiene program with vastly improved results.

RESUME

Objectif : Le debridement minutieux constitue la base du traitement parodontal et est une expertise fondamentale propre a l'hygiene dentaire. Les etudes demontrent que les diplomes canadiens en hygiene dentaire ont une approche desuete (traditionnelle) en matiere d'ultrasoniques, ce qui en fait des cliniciens << inconsciemment incompetents >>. La presente etude examine un programme d'etudes revise en matiere d'ultrasoniques, qui vise a produire un diplome plus << consciemment competent >>. Methodes : La presente etude, basee sur un echantillon de commodite, a evalue le processus et les resultats en matiere d'ultrasoniques au titre des diplomes d'un etablissement canadien agree, avant (n = 17) et apres (n = 18) la mise en oeuvre d'un programme d'etudes inedit sur les ultrasoniques, qui comprend une theorie enrichie en matiere d'ultrasoniques, ainsi qu'un contenu preclinique et clinique. Les diplomes ont ete evalues au moyen d'une rubrique indexee et validee, axee sur les 4 processus suivants : la preparation de l'equipement, la lutte contre les infections, le positionnement, et la technique d'instrumentation. A la suite du debridement, les dents ont ete retirees de mannequins identiques et depersonnalises, et notees en vue d'obtenir des resultats a l'aide de calculs de cases d'une grille validee, de 3 types de depots standards : les depots epais ou tenaces, les depots legers, et le biofilm. Le College Niagara en Ontario a fourni l'approbation deontologique. Resultats : Sur un potentiel de 510 points en competences sur les processus, les diplomes de base ont obtenu la note moyenne de 112,3 par rapport a la note moyenne de 295,6 obtenue par la cohorte du programme d'etude optimise. Lorsque le debridement a ete mesure, le groupe de base a laisse 10,5 cases de tartre tenace, 23,3 cases de tartre leger, et 60,18 cases de biofilm sur un potentiel de 72 cases de la grille pour chaque categorie de depots. Par contraste, la cohorte du programme d'etudes optimise a laisse respectivement 4,1, 7,4 et 39,3 cases de la grille. Un test t bilateral non apparie a mesure une difference statistiquement significative. Toutes les valeurs p demontrent une difference significative entre les notes moyennes au niveau de 0,01. Conclusions : Le programme d'etudes optimise a produit des diplomes ayant une amelioration des processus de 263,1 % (p < 0,0001). Les resultats du debridement etaient ameliores de facon similaire. Cette etude suggere qu'un programme d'etude optimise en matiere d'ultrasoniques peut etre ajoute a un programme d'hygiene dentaire existant en procurant des resultats grandement ameliores.

Key words: curriculum, dental hygiene, dental hygiene education, dental scaling, periodontal debridement, ultrasonic Instrumentation CDHA Research Agenda category: Capacity building of the profession

INTRODUCTION

Dental hygiene education was established as a formal 2-year diploma program in Canada at the University of Toronto in 1951. Although the educational options for type of institution, program length, and course content have diversified over the years, the entry-to-practice requirement for graduates has long been a 2-year diploma.

In January 2010, the Canadian Dental Hygienists Association, in collaboration with the Federation of Dental Hygiene Regulatory Authorities (FDHRA), the Commission on Dental Accreditation of Canada (CDAC), the National Dental Hygiene Certification Board (NDHCB), and dental hygiene educators, released Entry-to-Practice Competencies and Standards for Canadian Dental Hygienists. (1) This document serves as a template for the evidence-based knowledge, self-reflection, and skills dental hygienists require to practise competently and responsibly. All accredited programs are required to use "competence at entry-to-practice" as a benchmark for successful graduates (Figure 1). (2)

Currently, there are 2 accepted methods of tooth debridement included in dental hygiene curricula: hand and power instrumentation. Handheld instruments for tooth "cleaning" were introduced in the early 1900s by Dr. A Fones in a concept known as "odontocure," which involved sending a female assistant, armed with an orange wooden stick, pumice, and a flannel rag, into the neighborhoods of Bridgeport, Connecticut, to clean residents' teeth. Fones eventually trained his cousin and chairside assistant, Irene Newman, in this program, evolving the work to include removal of calcified deposits with bladed instruments, and they opened the first dental hygiene school in North America in 1913. (3)

In the 1950s, Dentsply Corporation developed the "Cavitron," the first ultrasonic instrument aimed at effective supragingival gross calculus removal. (4,5) Initially, ultrasonic scaling was intended to be used as a preliminary debridement instrument followed by root planing with a bladed instrument to strip the tooth of a supposed toxic layer and leave a glass-like surface.

A more conservative approach to treating root surfaces eventually emerged, one aimed at preserving the root structure. (6,7) With the evolution of technology and the development of longer, thinner curved tips for improved access to complex root structure and deep pockets, research began to suggest that these specialized ultrasonic instruments had better, more consistent access to periodontal pockets. (8) Further studies confirmed that the use of these modified tips resulted in preservation; therefore, less damage of the root surface, along with reduced need for surgical intervention to gain access to pocket depths and furcations. (9-11) The growing body of ultrasonic research combined with technological advances have led dental practitioners into an era where ultrasonic instrumentation is now an essential component of all facets of periodontal debridement. (12-20)

Although the evidence base for this improved technology continues to expand and supports the use of ultrasonic instruments for the removal of lighter hard deposits and the removal or disruption of biofilm, 3 recent studies (21-23) show that graduating dental hygiene students still tend to use the ultrasonic approach as historically intended (traditional use; for initial debridement only) (Table 1). (21) These studies also report an incorrect use of equipment and tips, with an admitted lack of confidence in, and knowledge of, the more contemporary evidence-based approach (addressing biofilm and light deposits or scaling to completion). (22-24)

A follow-up study of Canadian dental hygiene school faculty reports a disparity in teaching hours assigned to ultrasonics in theory, preclinical practice, and clinical application, with the majority of surveyed schools reporting only 0 to 8 hours each of theory and preclinic throughout the program. A mere 16% of programs stated that they used a formal rubric for student evaluation of competence with the technology. (22)

This study tests a new evidence-based curriculum encompassing contemporary periodontal debridement strategies. An enriched methodology to teach ultrasonics, based in part on Karplus and Thiers learning cycle, incorporates a novel teaching approach, the Concurrent Debridement Model (CDM), and a realignment in scheduling. Together, these elements enrich all aspects of the educational experience in theory, preclinical and clinical venues, with the goal of producing a more legitimately (or consciously) competent graduate.

METHODS

This study, a quantitative quasi-experimental research design, employs a convenience sample from an established, accredited private dental hygiene school in Toronto, Ontario. Pretest and post-test evaluations were performed by 2 calibrated subject-expert clinicians utilizing pretested and validated indexed rubrics for both process and outcomes. Recent graduates (n = 17, baseline group) from the institution's standard programming were assessed within 6 months of course completion (graduation) and compared to the next year's graduating cohort (n = 18, test group) from the same institute, following the implementation of an enriched ultrasonic curriculum and a revised approach to both preclinical and clinical teaching. Both groups were educated in the same facility by the same faculty, and all other educational parameters remained unchanged apart from the enriched ultrasonic teachings. The program consisted of three 24-week semesters. The enriched didactic and preclinical sessions were delivered by the 2 principal investigators while clinical sessions were staffed by faculty. Regular training and calibration sessions were held with all participating faculty.

The study received ethics approval from the Ethics Review Committee at Niagara College, Welland, Ontario, according to the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2), certificate #CEC-NC2013-05. All participants signed an approved informed consent, and all instruction forms and data collection forms were submitted to and approved by the committee. The principal investigators followed expected confidentiality protocols, and all forms were randomly coded and anonymous. Each participant was awarded a $50.00 gift certificate to compensate for time given to the 2-hour evaluation session at the study's completion.

Framework for enriched ultrasonic curriculum

The enriched ultrasonic curriculum framework (Figure 2) was designed by the investigators in response to the analysis of the data collected as part of the Canadian Dental Hygiene Graduate Survey and also the Canadian Dental Hygiene School Program Directors' Survey. (21-22) Methods chosen addressed identified gaps in the existing curricula of these programs and perceived opportunities to enrich student learning. This study's framework consists of 3 core elements from Karplus and Thier's learning cycle: exploration, concept introduction, and concept application (25), coupled with selected proven teaching strategies, including discovery learning. (26) This specific learning cycle approach has been shown to help students comprehend scientific ideas, improve scientific reasoning, and increase engagement in class. (27-29)

Exploration phase

The bulk of the exploration phase was implemented as part of preclinic and was designed to foster deep, rich learning of a topic especially relevant, conceptually difficult, and counterintuitive to manual debridement. An introductory classroom session preceded the preclinic discovery learning tasks to give the test group sufficient information to enable a reasonable attempt at completing the activities. Here, the students implemented a discovery learning method of inquiry-based activities using magnetostrictive ultrasonic units and inserts (Cavitron, Dentsply Sirona, York, PA) (Figure 3) and customized teaching tools. Students experimented with equipment, drew comparisons, and wrestled with questions such as: "What do I hear when I turn up the power knob?" "What do I feel when I place a tip on a hard surface?" "What do I see when I push with an insert?" The intention was to encourage active engagement; promote responsibility, independence, and motivation; foster creativity and problem-solving skills; and tailor the learning experience to allow students to be present in the moment. (30,31) The investigators aimed this session at preparing the learners for the guided discussion format of the next phase of the learning cycle: concept introduction.

Concept introduction phase

Based on the learners' acquisition of knowledge from the preclinical sessions, a guided discussion format ensued in all subsequent classroom sessions. Research shows that learners who relate introduced concepts to actual experiences can be more successful. (32) The initial discovery learning method gave the learners experiences to draw from and thus provided the foundation necessary to participate actively in discussions in this phase of the instruction. (33-35)

Concept application phase

Concept application was executed in both preclinic and clinic. Most notable was the integration of a Concurrent Debridement Model (CDM) into clinic to ensure equal development of knowledge, skill, and critical thinking with either manual or ultrasonic instrumentation, each taught as a separate and complete system. The integration of CDM prevented any undue reliance on one method of instrumentation, thereby freeing the student to think critically within either system.

As clinical sessions commenced, students were equally prepared to deliver either manual or ultrasonic instrumentation to primarily light clients (shallow pockets and simple root anatomy). Because the needs of these types of clients could be addressed with either system, the students were assigned half-mouth instrumentation units; one half was "debrided to completion" with ultrasonic instruments while the other half was "debrided to completion" with hand instruments. There was no interinstrumentation between the 2 systems.

The test group eventually moved on from the CDM. More difficult clients were assigned and, based on the changing needs of the clients (an increase in severity of periodontal status/deeper pockets, and complex root anatomy), the test group needed to implement greater ultrasonic usage to achieve safe, effective, efficient debridement.

Measurement tools (data collection indices)

Each participant was evaluated for both process and outcome by 1 of the 2 principal investigators once graduation from the program had been determined. In order to reduce bias, the 2 principal investigators held 2 calibration sessions prior to evaluating each graduating class to ensure interrater reliability. They also reduced subjectivity by following a complex and specific set of rubrics which are outlined below.

Process evaluation

The "in process" evaluation was a 2-hour session in which each participant was assigned, on a typodont, a total of 16 teeth to be completed in a timed 1-hour debridement segment (Figure 4). Each student was observed during this 1-hour exercise by 1 of the calibrated investigators and acquired points according to a comprehensive rubric.

The in process rubric was defined by section, with potential points assigned to each category: equipment preparation (15 points), infection control (15 points), clinician positioning (120 points), and instrument technique (360 points). Each category was further divided into subcategories. Equipment preparation and infection control had 3 subcategories each (3x5 potential points for a total of 15 points per category). Clinician positioning and instrument technique were tooth specific (for each of the 6 indexed teeth) and further broken down into either a buccal or a lingual approach (Figure 5).

The participants were also scored on whether they chose to use only the traditional ultrasonic approach (a single instrument for initial debridement) or continued on to utilize the contemporary approach with more complex insert designs to take them through to full biofilm removal. The clinician positioning category was further broken down into 2 items evaluated for 6 teeth each; 6x5 potential points for both buccal and lingual equaling a total of (2x6x10) 120 points. Instrument technique comprised 6 items evaluated for 6 teeth each; 6x5 potential points for both buccal and lingual for a total of (6x6x10) 360 points. The in process evaluation totaled a possible 510 points (Table 2).

Outcomes evaluation

The "outcomes" evaluation was performed on only selected indexed teeth (16, 12, 24, 32, 36, 44) of the 16 teeth assigned (Figure 4); these teeth represent all 4 quadrants as well as anterior and posterior positions and have been traditionally used in studies where the necessity to record biofilm and mineralized deposit exists. (36,37) To reduce the Hawthorne effect the participants were informed of the full assignment but remained unaware that only the predetermined indexed teeth would be evaluated.

The typodonts were standardized, each tooth being prepared by a single investigator to ensure consistency, using 3 different types of deposit applied to a maximum depth of 6 mm. A consistent thin layer of biofilm circumvented each root and was applied using an opaque, white correction fluid. Hard deposit was simulated by combining' an adhesive with silica; adhesives with 2 types of bond strength were used to ensure varying degrees of tenacity. Prior to the evaluation, the simulated deposit was pilot tested with a small convenience sample to ensure suitability, and necessary modifications were made. Following instrumentation the indexed teeth (16, 12, 24, 36, 32, 44) were extracted from the typodonts for a "deposit remaining'" score. Each tooth was evaluated by both principal investigators in a grid format, according to the index (Figure 6). Each of 4 surfaces (buccal/lingual, mesial/distal) was examined for the 3 types of possible remaining deposit (biofilm, light calculus, tenacious calculus). Since the deposits were observationally different from each other, remaining deposits were easily identified by visual inspection under magnification. Outcomes evaluations were validated by the statistician.

RESULTS

The data set for this research consisted of the scores of 35 participants, divided by default (graduating year) into 2 groups. The baseline group and test group had 17 and 18 participants, respectively.

The process evaluation (Table 2) consisted of a potential 510 points dispersed over 4 categories with a total of 14 subcategories. The overall means of each group were compared (with standard error noted). In addition, the percentage of possible points achieved by the baseline and test groups in each of the 4 categories was compared (Figure 7).

The overall means for process evaluation were 112.3 points for the baseline group and 295.5 points for the test group (Figure 8) out of the potential 510 points, indicating an improvement of 263.1% for the test cohort. An area breakdown for percentage of total points possible shows equipment preparation at 15.9% vs 88.0%, infection control at 51.1% vs 95.3%, clinician positioning at 30.4% vs 60.9%, and instrument technique at 17.0% vs 51.8% for the baseline and test cohorts, respectively.

The outcomes evaluation provided an overall tally out of a potential 72 fragments (percentage within grids) of remaining deposit, derived from each of the scores in 3 different categories: biofilm, light calculus, and tenacious calculus. These were then further categorized into 2 subgroups (broad and interproximal surfaces). The broad and interproximal scores were calculated by taking the average of the buccal and lingual scores (broad) and mesial and distal scores (interproximal), while the scores for the biofilm, light calculus, and tenacious calculus deposits were calculated by adding all 4 scores for the buccal, lingual, mesial, and distal for each deposit type. These scores were tallied from the 6 indexed teeth extracted from each of the participants' typodonts. With 35 graduates receiving 12 initial scores for 6 different teeth, there were a total of 2520 individual data points.

The overall remaining deposit fragments were 60.2 vs 39.3 fragments (biofilm), 23.3 vs 7.4 fragments (light calculus), and 10.5 vs 4.1 fragments (tenacious calculus) for the baseline and test cohorts, respectively (Figure 9). An area-specific breakdown for amounts of total remaining fragments averaged over the 6 indexed teeth (out of 18 potential fragments) was as follows: tenacious broad surfaces 1.9 vs 0.6, tenacious interproximal 3.4 vs 1.4, light calculus broad surfaces 3.6 vs 0.6, light calculus interproximal 8.0 vs 3.1, biofilm broad surfaces 13.4 vs 6.4, and biofilm interproximal 16.6 vs 13.3 for the baseline and test cohorts, respectively (Figure 10). The lower score is more desirable in this category given that it reflects fragments (or percentages within grids) of remaining deposit.

A 2-tailed, unpaired t-test was used to determine statistical significance between groups. The p values for all scores show statistical significance for the difference between the mean scores of the two groups at the 0.01 level. The highest single p value was 0.0005 while all remaining p values were 0.0001 or lower, indicating that the study's results were statistically highly significant.

In addition to the 2-tailed t-test, confidence intervals were also calculated to verify the reliability of the differences between the two groups' scores. The intervals were calculated at a 99% confidence level for both the baseline group and test group across all scores. The confidence intervals for the 2 groups did not overlap for any scores. The fact that there were no overlapping confidence intervals illustrates that even if, due to randomness, the test group was comprised entirely of individuals who were above average performers and the baseline group was made up solely of below average performers, the test group scored higher than the baseline group due to the intervention of the enriched curriculum (99% CI) (Figure 11).

Study limitations

Due to the nature of the protocol and the fact that it was implemented at a single accredited school, it was not possible to design the study with randomization. This accredited program was, however, reflective of Canadian dental hygiene schools, and the students were representative of the Canadian dental hygiene population. (21,22)

Additionally, the principal investigators were not blinded, given that it was known the baseline cohort received the original, established curriculum while the test group received the enriched curriculum. It was deemed critical to use the same evaluators given their experience (17 years and 23 years, respectively) in observation and analysis of ultrasonic technique in a study so focused on identification of detailed differences. In order to reduce the potential for bias, extensive calibration sessions were undertaken and a precise and multifaceted index for each measurement was developed and validated.

Upon reflection, it was noted that, although the test group participants were significantly improved in both their ultrasonic technique and outcome, it cannot be determined from this study design which of the enhancements to the curriculum produced the improvement. This study was not focused on the ranking of individual curricular elements, but rather on testing a holistic approach, drawing on the evidence base in current education techniques and addressing the gaps identified in the 2 previous survey studies. (21,22)

DISCUSSION

This study implemented and evaluated a new evidence-based curriculum for periodontal debridement based on an improved approach to ultrasonic teaching in the theory, preclinical and clinical venues with the goal of producing a more legitimately (consciously) competent graduate. The findings demonstrate the profound impact of an enriched ultrasonic curriculum on competence among dental hygiene graduates.

Despite the evolution of ultrasonic technology, Canadian programs have not adapted their approach, nor assigned the necessary time to develop this intricate skill. (22) Even the compelling evidence from current scholarly publications (21-23) has not yet prompted the redesign of the ultrasonic curriculum; programs persist in a strategy most heavily weighted on teaching hand instrumentation in preclinic.

In the clinical setting the imbalance is perpetuated by teaching debridement to completion either with hand scaling exclusively or with a combination of the two systems, despite a lack of evidence to support such a blended approach. (38) No consideration is given to using ultrasonics alone. In addition, faculty report assigning treatment sections according to hard deposit with no consideration given to the technology's microstreaming and cavitational effects on biofilm or treatment of inflammation. (22,23) Some programs even limit (with questionable rationale) the type of "ultrasonic clients" students are allowed to treat. (22)

This outdated, traditional approach misguides students, forcing them to resolve ultrasonic problems with manual solutions. The suppression of critical thinking sabotages a clinician's chances of elevating his or her skill set, allowing little opportunity to reach proficiency. The Concurrent Debridement Model developed by the authors to facilitate critical thinking is, to our knowledge, the first to provide insights into a "scaling to completion" learning strategy which addresses proficiency in both treatment modalities. This study demonstrates that ultrasonic competency can be achieved in significantly fewer hours than current programs allot for manual instrumentation without extending the length of the program or adding remediation time. It prompts the question: "If we are bound by our Entry-To-Practice Competencies and Standards for Canadian Dental Hygienists which state: 'Each dental hygienist maintains and continually improves her/his competence in response to changes in health care, scientific information, technology, and professional expectations,' (1) why have we not adjusted our curricula to reflect the current evidence?"

This research draws on the following studies:

1. The recent Canadian Dental Hygiene Graduate Survey, which revealed that a majority of clinicians uses ultrasonic technology as their primary instrument with high levels of confidence, despite the fact that the data revealed they used it inappropriately and/or incorrectly.

2. The Canadian Dental Hygiene School Program Directors' Survey, which reported that, although Canadian dental hygiene programs are properly equipped with both traditional and contemporary ultrasonic equipment, they do not utilize these tools in alignment with the published evidence.

3. The clinical study, which shows that we are graduating dental hygienists who have not achieved entry-to-practice ultrasonic competence, specifically contemporary methods aimed at biofilm disruption and resolution of inflammation.

In 2003, the US Institute of Medicine engaged in a focused discussion (Clinical Research Roundtable) and published its consensus, entitled "Central challenges facing the national clinical research enterprise." (39) The authors concluded that the failure to translate new knowledge into clinical practice and decision making in health care is a major barrier preventing human benefit from advances in biomedical sciences. (39,40) Given the compelling research demonstrating the advantages of ultrasonic debridement beyond initial calculus removal and as an effective treatment to disrupt and remove biofilm, coupled with the fact that we have an epidemic of oral inflammation and new research pointing to systemic links, it is worth asking: "What will it take to change?"

CONCLUSIONS

The implementation of an enriched ultrasonic curriculum in dental hygiene programs can result in a statistically significant improvement in the ultrasonic skills and outcomes of new graduates. This result can be achieved without compromising existing content or affecting program length or expenditures.

The results of this study could serve to promote necessary dialogue among dental hygiene educators on the need for a more balanced and evidence-based focus on curriculum planning for teaching debridement. These findings could also provide the basis for further discussion within accrediting and regulatory bodies on the equal competency levels of our graduates with both instrumentation systems to ensure safe, effective, and efficient practice.

Future studies need to examine earlier introduction of ultrasonics within dental hygiene programs. Additionally, verifying the impact of each of the elements of the enriched curriculum model could further inform educators as they strive to improve their programs.

WHY THIS ARTICLE IS IMPORTANT TO DENTAL HYGIENISTS

* Canadian dental hygiene graduates are not competent in contemporary ultrasonic instrumentation at an entry-to-practice level.

* An enriched ultrasonic curriculum for dental hygiene programs can significantly improve ultrasonic skills and outcomes of graduates without affecting program length or cost.

* Dental hygiene graduates who are competent in contemporary ultrasonic instrumentation remove more calculus and biofilm deposits, and can debride to completion with this technology.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge Ms Evie Jesin, Ms Cathy Edson-Frauts, and Ms Christine Ryan who were instrumental in securing the study site and made various accommodations to ensure the successful execution of the research. The authors would also like to thank Weiler Ross and Robert Dunford for statistical consultation and analysis, as well as APLUS Institute (Toronto, Ontario) for its participation as the study site.

Source of funding: This study was supported in part by an unrestricted educational grant provided by Dentsply Sirona Canada.

CONFLICT OF INTEREST

Dani Botbyl is an educational specialist employed by the granting agency. Marilyn Goulding began this project while a professor at Niagara College in the dental programs and, during the later stages of manuscript preparation, accepted the position of manager of clinical research with the granting agency.

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Dani Botbyl *, RDH; Marilyn J Goulding ([section]), MOS, RDH

* National Clinical Educator, Clinical Affairs, DentsplySirona Canada; Undergraduate student, Brock University, St. Catharines, Ontario, Canada

([section]) Manager, Clinical Research, Global Clinical Affairs, DentsplySirona Preventive

Correspondence: Dani Botbyl; dani.botbyl@dentsplysirona.com

Manuscript submitted 14 November 2017; revised 12 January 2018; accepted 22 January 2018

Caption: Figure 1. Continuum of competence

Caption: Figure 3. Ultrasonic instruments included in the students' kits

Caption: Figure 4. Student assignment outlined in rectangles on the odontogram with index teeth "buried" within the exercise (Teeth 16, 12, 24, 36, 32, 44)

Caption: Figure 7. Process evaluation graph (by category)

Caption: Figure 8. Process evaluation graph (overall)

Caption: Figure 9. Outcomes evaluation graph (overall)

Caption: Figure 11. Results of baseline cohort vs test cohort overlaid on the continuum of competence
Table 1. Comparison of Traditional Ultrasonic Debridement
Approach and Contemporary Ultrasonic Debridement Approach

Traditional                          Contemporary

Thick diameter inserts               Thin or ultra-thin diameter
                                     inserts; straight and curved
                                     designs

Subgingival access limited           Subgingival access is superior

Moderate to heavy calculus removal   Light calculus removal with
                                     focus on biofilm/plaque removal

Instrument contacts calculus         Instrument contacts calculus
                                     and/or cementum/dentin

Medium to high power settings        Low power setting typical;
typical                              medium power may be an option

Basic level of knowledge/skill       Higher level of knowledge/skill
and short "time on task"             and a longer "time on task"
to achieve competence                to achieve competence

Complete debridement requires        Complete debridement
use of hand instruments              possible with ultrasonics

Client/patient comfort challenging   Client/patient comfort most usual

Source: Asadoorian J, Botbyl D, Goulding M. Dental hygienists'
perception of preparation and use for ultrasonic instrumentation.
Int J Dent Hyg. 2015;13(1):30-41.

Table 2. Total process evaluation scores

Ultrasonic skills                 Maximum category score
(observed over 1 hour)

Equipment preparation             15 points
Infection control practices       15 points
Ergonomie clinical positioning    120 points
Ultrasonic instrument technique   360 points
Potential total score             510 points

Figure 2. Enriched ultrasonic curriculum framework

Discovery Learning

                     Guided Discussion

                                         Concurrent Learning

Exploration          Concept             Concept
                     Introduction        Application

Figure 5. In process evaluation rubric

Buccal         Lingual       0 points = clinician does not meet
                             expectations/inappropriate action

                             3 points = clinician meets minimal
                             expectations/lack of ease

                             5 points = clinician exceeds
                             expectations/shows expertise
                             and ease of use

Contemporary   Traditional   A score for each indexed tooth on
                             each of 2 sides (buccal ft lingual)
                             was averaged and assigned to each of
                             the 2 types of instrument categories
                             (traditional approach vs. contemporary
                             approach). Therefore, each tooth
                             "square" could have a total of
                             10 points-a potential score of
                             60 points for each skill (see below).

Clinical positioning         1. Clinician Is positioned economically
skills (120 points)             and has direct sight line for each
                                area of use (without compromising
                                evacuation or aerosol control)
                                (60 points)
                             2. Clinician uses light maximally
                                for each area

Instrument technique         1. Uses a gentle, balanced grasp and
skills (360 points)             establishes an appropriate fulcrum
                                for each area (60 points)
                             2. Demonstrates appropriate adaptation
                                a angulation to tooth (60 points)
                             3. Keeps the tip in motion using
                                a light overlapping and
                                multidirectional, sweeping
                                brush-like stroke or tap/tap
                                stroke (60 points)
                             4. Sets power levels appropriately;
                                considers insert and deposit type
                                (60 points)
                             5. Examines surface periodically with
                                non-powered Instrument tip
                                (or explorer) for adherent deposits
                                or to establish debridement strategy
                                (60 points)
                             6. Utilizes an appropriate combination
                                ft sequence of tips which work
                                systematically to complete the
                                task (60 points)

Note: This is not intended for faculty/school use; for research
purposes only.

Figure 6. Outcomes evaluation rubric

Biofilm:           Buccal           Lingual   Mesial          Distal
Tooth #16

Surface averages   Broad surfaces             Interproximal
                                              surfaces

Light              Buccal           Lingual   Mesial          Distal
Calculus: #16

Surface averages   Broad surfaces             Interproximal
                                              surfaces

Tenacious          Buccal           Lingual   Mesial          Distal
Calculus: #16

Surface            Broad surfaces             Interproximal
averages                                      surfaces

Biofilm              * 0 = no biofilm
                     * 1 = present <1/3
                       of surface
                     * 2 = present > 1/3 < 2/3
                       of surface
                     * 3 = present > 2/3
                       of surface

Light Calculus       * 0 = no light calculus
                     * 1 = present < 1/3
                       of surface
                     * 2 = present > 1/3 < 2/3
                       of surface
                     * 3 = present > 2/3
                       of surface

Tenacious Calculus   * 0 = no tenacious
                       calculus
                     * 1 = present < 1/3
                       of surface
                     * 2 = present > 1/3 < 2/3
                       of surface
                     * 3 = present > 2/3
                       of surface

Figure 10. Outcomes evaluation graph (by surfaces)

Debridement outcomes by debris remaining

                Original Cohort   Enhanced Cohort

Tenacious
Broad                1.882             0.639

Tenacious
Interproximal        3.382             1.389

Light
Broad                3.647             0.639

Light
Interproximal       8                  6.361

Biofilm
Broad               13.441             6.361

Biofilm
Interproximal       16.647            13.278

Note: Table made from bar graph.
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Article Details
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Title Annotation:ORIGINAL RESEARCH
Author:Botbyl, Dani; Goulding, Marilyn J.
Publication:Canadian Journal of Dental Hygiene
Article Type:Report
Geographic Code:1CONT
Date:Feb 1, 2018
Words:6436
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