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Integration of evidence-based decision making within the dental hygiene curriculum.

There has been increased interest over the past decade in using evidence-based decision making (EBDM) as a basis for clinical practice. EBDM is a problem-solving approach to the delivery of care that incorporates the best evidence from well-designed studies in combination with a clinician's expertise and patient preferences and values. (1) Basing practice on research findings is fundamental to any profession, including dental hygiene. However, a gap continues to exist between research and its translation into practice.



To address this, in 2003, the University of Michigan (U-M) Dental Hygiene Program began a systematic effort to integrate EBDM within the curriculum and translate this into clinical practice. Steps to do so occurred incrementally over a five-year period and continue to evolve today. In conjunction with curricular changes, a focus was placed on faculty professional development. Dental Hygiene: Focus on Advancing the Profession, a report by the American Dental Hygienists' Association (ADHA), cited employing evidence-based practice (EBP) as a core competency for dental hygiene educational programs. (2) The literature supports that two major outcomes must be achieved to accelerate the translation of research findings into clinical practice: (a) dental hygiene educators must develop sufficient EBP knowledge and skills to advance evidence-based care in clinical settings, and (b) educators must teach their students the EBP process to instill lifelong skills to deliver the highest-quality care. (3) In addition, the Commission on Dental Accreditation Standards for Dental Hygiene Education requires programs include EBDM in the curriculum. (4)

Although patient outcomes improve substantially when clinical care is based on evidence versus steeped-in-tradition recommendations, only a small percentage of dental hygienists base their practice on the best evidence from research. (5) A survey of 235 U.S. dental hygiene program directors found that over three-quarters of the respondents did not feel their faculty have adequate EBP skills. (6)

Dental hygiene education at both the baccalaureate and master's levels has historically focused on preparing dental hygienists to generate research rather than use evidence to efficiently translate research findings into practice and improve clinical care. Research courses have taught students in-depth content on hypothesis testing and specific research methods, with the end product being a written research proposal or table clinic. (6) Furthermore, critical thinking skills and literature assessment have been taught in isolation of clinical situations and, thus, students have failed to see the application of an evidence-based approach to clinical practice. (7)

Although a few authors have described the need to integrate EBP into dental hygiene curricula, (8-11) there is limited information on strategies employed for exposure to EBDM practices and to what extent the faculty incorporate EBDM into clinical situations with students. However, studies do support teaching students to find, evaluate and incorporate current scientific evidence into their clinical decision making, thus closing the gap between what is known (research) and what is practiced. (5), (10), (11) The U-M Dental Hygiene Program has been addressing this gap. Although U-M confers a baccalaureate degree with students enrolled for three years, the principles and practices outlined can be applicable to any dental hygiene program.

The Millennial Student

To understand how students best learn and integrate EBDM into their practice, their learning profile should be assessed. A significant number of U-M dental hygiene students are from the "millennial generation," the name sociologists have given to those born between 1982 and 2002. (12) These students are technologically competent and rely heavily on electronics. (13) They multi-task with many activities, function well in group environments, and need the reassurance of immediate feedback. (12), (13) In helping others and identifying social problems, millennials are both generous and practical, in addition to being optimistic about their professional future. (12), (13)

A study conducted by Blue determined that millennial dental hygiene students strive for accuracy. (13) Thus, making subjective judgments and application-based decisions is not initially within their comfort zone. Their learning is processed in the context of their own life experiences. So if an experience is "new," faculty members are faced with assisting students in understanding why content is important. Faculty are also challenged to guide students to successfully apply content to real-life situations.

To maximize the learning of the millennial student, the U-M Dental Hygiene Program utilized experiential evolutionary scaffolding. (14) This model incorporates authentic, active learning with students engaged in exploration and analysis of real-world experiences. (15) Evolutionary scaffolding consists of prompted content, materials and tasks used in conjunction with peer and instructor support. (16) Through combining authentic learning and scaffolding theories, the complexity of the learning experiences increases over time (evolution). This allows the millennial student to move from externally developed scaffolds to those that are internal, driven by their own learning experiences. (14) This model was used as the basis for integration of EBDM throughout the U-M Dental Hygiene Program.
Table I. University of Dental Hygiene EBDM Curriculum Overview

Year of      EBDM content     Learning activities
program      incorporated in

First year   Clinical         Clinical case
(Sophomore)  Seminar I & II   scenario/topic
                              application of:
             Survey of        * PICO question
             Dental Hygiene
             Oral Anatomy     * PubMed searching
             Special          * Paraphrasing,
             Patients         citations

Second year  Research         Literature-based
(Junior)     Methods          readings, review skills
                              and EBDM application
                              activities for:
             Clinical         * Cases
             Seminar III &
             Periodontics 2   * Products
             Nutrition        * Conditions
             Community        * Community program
             Dentistry        development
             Community        * Clinical care

Third year   Scientific       * Literature-based
(Senior)     Communications   readings and
             Clinical         * Original research or
             Seminar V & VI   review of the
                              literature project
             Practice         * Critical analysis,
             Management       review of the
                              literature papers
             Periodontics 3   * Comprehensive case
                              * Discussion focusing
                              on challenges/solutions
                              of utilizing EBDM in

Integration within the Curriculum

With EBDM identified as a critical element in dental hygiene education and clinical patient care, it was determined to introduce this to U-M students within the first month of the program. Students are provided foundation knowledge about EBP in a didactic course that integrates an application-based learning activity within the library orientation. The hands-on orientation session includes an introduction to accessing electronic databases. Through the use of a basic inquiry about "halitosis," students are guided through the process of developing a PICO (Patient/Problem, Intervention, Comparison, Outcomes) question. Then, using the keywords that emerge from the PICO question, students complete a PubMed search for relevant literature on the subject.

Following this introductory activity, student teams are provided with a patient-care-related clinical scenario (e.g., difference between waxed and unwaxed floss, power brush verses manual brush effectiveness). A worksheet guides teams to search PubMed to find five journal articles on the clinical question, determine the three that most appropriately address their question, and identify three to five key points from those articles.

Several days later, students attend an orientation with the university's writing center. At that time, they work with additional elements of the worksheet, including citing the journal articles and synthesizing the key elements of each article into a paraphrased summary paragraph. The student teams also orally present their clinical scenario, PICO question and the evidence-based results within the didactic course.

This type of learning activity is repeated using case simulations and topic-specific research (e.g., medical history condition, special patients) an additional six times throughout the first year of the program within five courses (Table I). Use of technology, group work, and application to real life are all pillars of these assignments. With faculty guidance, students begin to develop their understanding of why EBDM is important to practice and how it supports quality patient care.

In the junior year of the U-M program, scaffolding of EBDM expands with more complex content and learning activities (Table I). The important millennial learner pillars of technology, group work and application continue to combine as the foundation of assignments this year and the next. The Research Methods course introduces skills to review primary research using a series of team-based worksheets. Students move on to develop case presentations using the literature to support their information and/or care plans. EBDM is integrated within two community dentistry courses through incorporation of the literature in developing community profiles and needs assessments, providing the basis of support for oral health promotion programs. In Biomaterials, student teams choose from a list of whitening products and are required to identify associated clinical trials and their results, as a component of their presentation. Journal articles that support topics within a number of courses are included as readings and are applied to discussions within class and clinic.

The senior year culminates with a greater infusion of literature-based readings and application-based discussions (Table I). Within Scientific Communications, student teams develop a poster presentation based on involvement in original research or a review of the literature on a selected topic. In conjunction with this, students write a critical analysis paper evaluating a research study, compose a literature review, develop a comprehensive case presentation from their patient care experience, and engage in a discussion about challenges/solutions related to utilizing EBDM in practice. This final year of the program provides students with a greater understanding of the value of EBP as well as opportunities to apply it to their professional practice and recognize it as an ethical responsibility of providing patient care.

As students gained EBDM experiential evolutionary scaffolding, so did the faculty. Time was scheduled during in-service for EBDM presentations. To build upon the EBDM basic concepts, sessions were scheduled in the School of Dentistry computing lab so that faculty could gain hands-on database searching skills. Multiple noon-time sessions were offered in an effort to capture all part- and full-time faculty. Faculty meetings incorporate journal articles with discussion about application to student learning and clinical patient care. As the faculty is dynamic, strategies for professional development and updating EBDM skills are ongoing.

Translation into Practice

Access to evidence-based information is an important component of EBP. About a decade ago, the U-M School of Dentistry Patient Care Clinics introduced Internet access to the four clinics, one computer per clinic. In 2008, each cubicle was equipped with its own computer. However, in the midst of providing patient care, searching databases for scholarly information and reading/synthesizing information from research studies are most often not feasible.

The translational practice emphasis in the U-M program is on the importance of practitioners staying current on professional research related to oral/systemic issues, trends in treatment, products, and health promotion and disease prevention. Students are challenged and assessed to be sure that their clinical decision making and care are evidence-based. As questions arise from patients, taking time to investigate an appropriate evidence-based response after the appointment and then following up with the patient to provide them with recommendations is an appropriate strategy. Discussion among faculty and students during patient care is another approach to integration of EBDM.

Student Perspective

With millennial students being practical and optimistic about their professional future, they tend to see EBP as an important element of their patient care and are serious about the importance of its application. U-M seniors were asked about their EBDM skills acquired and applied during their dental hygiene education.
  Faculty expect and encourage us explore our own recommendations using
  the skills we have developed. Only after the student thinks
  critically and looks for supporting scientific information are the
  faculty members willing to share their viewpoints and their clinical

  Because the faculty members have the understanding that EBDM is the
  standard, it makes it easier for students to learn and utilize EBDM
  in the clinic. If we didn't have faculty with a unified
  understanding, it would be very difficult to apply these skills.

  EBDM is incorporated into the curriculum through the whole
  educational experience. The faculty are very knowledgeable about EBDM
  and demonstrate it well. Many class sessions focus on taking an issue
  or chief concern and thinking it through using the PICO process to
  create a researchable question. It is great that we learn this right
  from the beginning and have experience using these skills when we
  graduate. We analyze data from creditable sources and provide our care
  based on that, experience, and what the patient thinks will work for

  We learn about EBDM from the very beginning of this program so that
  we can use this skill when treating patients. Although it may have
  been overwhelming at first, we learned how to properly ask a
  question, research it, evaluate the research, and utilize the
  information learned to apply it to patient care.

EBP is fundamental to the profession of dental hygiene and EBDM a skill that is important for all dental hygienists to acquire. It is a responsibility of educational programs to integrate EBDM within their curricula as well as to facilitate its translation to clinical practice. The process of integrating EBDM and EBP is one that has been a work in progress for close to a decade at the University of Michigan. Graduates and faculty acknowledge the importance of EBP and value it as critical element of patient care.

This article is sponsored by an educational grant from Procter & Gamble.


(1.) Sackett DL, Straus SE, Richardson W, Haynes RB. Evidence-based medicine: how to practice & teach EBM. 2nd ed. London: Churchill Livingstone, 2000.

(2.) American Dental Hygienist's Association. Dental hygiene: focus on advancing the profession. 2005. Chicago: American Dental Hygienist's Association; Available at: Accessed Apr. 24, 2011.

(3.) Forrest JL, Spolarich AE. A Delphi study to update the American Dental Hygienists' National Dental Hygiene research agenda. J Dent Hyg. 2009; 83(1): 18-32.

(4.) American Dental Association. Commission on Dental Accreditation: Accreditation standards for dental hygiene education. 2007. Chicago: American Dental Association. Available at: Accessed May 1, 2011.

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(7.) Burke LE, Schlenk EA, Sereika SM et al. Developing research competence to support evidence-based practice. 3 Prof Nurs. 2005; 21: 358-63.

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(9.) Forrest JL. Treatment plan for integrating evidence-based decision making into dental education. 3 Evid Base Dent Pract. 2006; 6: 72-8.

(10.) Chichester SR, Wilder RS, Mann GB, Neal E. Utilization of evidence-based teaching in U.S. dental hygiene curricula. 3 Dent Hyg. 2001;75: 156-64.

(11.) Cobban SJ. Evidence-based practice and the professionalization of dental hygiene. Int J Dent Hyg. 2004; 2: 152-60.

(12.) Elam C, Stratton T, Gibson DD. Welcoming a new generation to college: the millennial students. 3 Col Admis. 2007; 195: 20-5.

(13.) Blue CM. Do dental hygiene students fit the learning profile of the millennial student? J Dent Educ. 2009; 73: 1372-8.

(14.) Venn VL, Coleman D. Training the millennial learner through experiential evolutionary scaffolding: implications for clinical supervision in graduate education programs. 3 Genet Counsel. 2010; 19: 554-69.

(15.) Howe N, Strauss W. Millennials rising: the next generation. New York: Vintage Books; 2000.

(16.) Lombardi M, Oblinger D. Authentic learning for the 21st century: an overview. 2007. Washington, D.C.: Educause Learning Initiative Report No.: 1. Available at: Accessed Apr. 21, 2011.

L. Susan Taichman, RDH, MS, MPH, PhD, and Anne Gwozdek, RDH, BA, MA

L. Susan Taichman, RDH, MS, MPH, PhD, is a recipient of the Procter & Gamble ADHA/Institute for Oral Health Fellowship. She is an assistant professor/research scientist at the University of Michigan School of Dentistry, Ann Arbor, Mich. She graduated from Lansing Community College in 1986 and holds a BSDH, MS, MPH and PhD from the University of Michigan. Her research focuses on women's oral health, specifically investigating oral health for breast cancer patients/survivors. She teaches the research methodology and evidence-based practice courses for both the U-M E-Learning (online) degree completion and the entry-level dental hygiene programs.

Anne Gwozdek, RDH, BA, MA, is director of dental hygiene degree completion programs at the University of Michigan, Ann Arbor, Mich. She has served in leadership positions in the American Dental Hygienists' Association and the American Dental Education Association. A 1973 graduate from the University of Michigan's dental hygiene program, she obtained her BA in journalism and public relations from Madonna University and her MA in educational media and technology from Eastern Michigan University. Her research interests include education with a focus on learning technologies and program evaluation.
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Title Annotation:education
Author:Taichman, L. Susan; Gwozdek, Anne
Geographic Code:1USA
Date:Jul 1, 2011
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