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Effectiveness of dental students and dental hygiene students in teaching preventive dentistry to adults Sharpe, Linda Evelyn 1973

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c\ THE EFFECTIVENESS OF DENTAL STUDENTS AND DENTAL HYGIENE STUDENTS IN TEACHING PREVENTIVE DENTISTRY TO ADULTS by  LINDA E. SHARPE B.Sc, University of British Columbia, 1964 D.M.D., University of British Columbia, 1970 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS (ADULT EDUCATION) in the Faculty of Education We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA August, 1973  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r  an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e  and  study.  I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may by h i s r e p r e s e n t a t i v e s .  be  granted by  permission.  Department The U n i v e r s i t y of B r i t i s h Vancouver 8, Canada  Date  Aua . ID , i<r] 3,  Department or  I t i s understood t h a t copying or  of t h i s t h e s i s f o r f i n a n c i a l g a i n written  the Head of my  Columbia  publication  s h a l l not be allowed without  my  ii  ABSTRACT The purpose of this study.was to investigate the effectiveness of dental students and dental hygiene students in their teaching of prevention.  Forty new periodontal patients were randomly chosen and  assigned to twenty second year hygiene students and twenty third year dental students.  Three variables were investigated:  (1) patients'  knowledge of oral hygiene; (2) patients' practices of oral hygiene as assessed by a questionnaire administered before and after i n i t i a l preventive treatment and again at a six-month recall appointment; and (3) patients' plaque index as recorded by students performing a visual check on oral cleanliness.  In addition, the student's attitude  toward his role as an educator was assessed by a questionnaire administered prior to any patient contact. The patients' responses were evaluated to determine any changes in knowledge and improvement in preventive habits over the six-month period. The plaque index was used to correlate the patient's actual oral hygiene with his reported oral hygiene practices. The results demonstrated that dental students and dental hygiene students were equally effective in the teaching of correct oral hygiene procedures.  The teaching program i t s e l f was effective in that a l l  patients showed a significant improvement in their oral health by the end of the study. The results of the student questionnaire showed that the hygienists did feel that the task of teaching was more important than did the dental  iii  students although both groups responded favourably in their attitudes toward teaching prevention. The plaque index at follow-up was most influenced by pre-test knowledge score and by habits at the conclusion of the i n i t i a l treatment period.  Such socio-economic characteristics as age and  educational level had l i t t l e influence on the adoption of correct oral hygiene practices.  iv  ACKNOWLEDGEMENTS The writer wishes to express a debt of thanks to the many people who assisted with this study. Special appreciation i s due to the dental students and dental hygiene students who participated i n the study by c o l l e c t i n g the data, and to their patients who co-operated by completing the questionnaire. I should also l i k e to thank George Headley for the preparation of the tables and figures; Gordon B e l l and P a t r i c i a Peterson for assistance i n computing the data; Margaret Robbins and Lucy Stead for their reading of the text; Jean V a l i k o s k i and the other secretaries i n the dental school f o r typing and c l e r i c a l assistance. '  In p a r t i c u l a r , I should l i k e to express my gratitude to Dr.  Gary Dickinson, whose encouragement and i n s p i r a t i o n have made the completion of the thesis possible.  V  TABLE OF CONTENTS PAGE Abstract  i i  Acknowledgements  .  List of Tables.. List of Figures  iv vii  '  viii  CHAPTER I.  INTRODUCTION Purpose and Hypothesis  2  Sample  2  Variables  3  Instrument Construction  3  Patient Questionnaire  4  Student Questionnaire  5  Data Collection  II.  III.  5  Patient Questionnaire and Plaque Index  6  Student Questionnaire  6  LITERATURE REVIEW Learning Domains and Prevention  7  Prevention as an Innovation  11  Instruction i n Prevention  15  ANALYSIS OF DATA Characteristics of the Sample  17  Student Attitudes  18  Patient Knowledge..  21  v i  CHAPTER PAGE III.  IV.  (continued) Patient Habits  23  Plaque Index  23  SUMMARY, DISCUSSION AND CONCLUSIONS Summary  35  Discussion  39  Conclusions  43  BIBLIOGRAPHY....  46  APPENDIX I.  Patient Questionnaire  52  APPENDIX II.  Student Questionnaire  •  5 9  '  vii  LIST OF TABLES TABLE 1.  PAGE Attitude Scores for Dental and Hygiene Students  2.  Item Means for Dental and Hygiene Student Attitude  3.  19  20  Comparison of Patient Knowledge Scores for Dental and Hygiene Students  4.  Changes in Patient Knowledge Scores Over Time  5.  Comparison of Patient Habit Scores for Dental and Hygiene Students  6.  Changes i n Patient Habit Scores Over Time  7.  Comparison of Patient Plaque Indices for Dental and Hygiene Students  24 25  27 28  31  8.  Changes i n Patient Plaque Indices Over Time  32  9.  Multiple Regression: Analysis of Variables  33  viii  LIST OF FIGURES FIGURE  PAGE  I.  Knowledge Means Changes With Time..  22  II.  Habits Means Scores Changes With Time  26  III.  Oral Hygiene Indices Means Changes With Time..........  30  CHAPTER  ONE  INTRODUCTION  In the last decade vast amounts of time, money and energy have been expended on the promotion of preventive dentistry, but only a fraction of the public practises prevention effectively.  The dental  profession must assume responsibility for this lack of total public acceptance of preventive practices.  Although the dental profession i s  concerned with promoting prevention, sufficient research has not been done to accomplish the behavioural changes necessary for the success of such a program.  By .introducing dental hygienists as a part of the  dental team, the profession has acknowledged the importance of patient education, yet the teaching of prevention largely remains a spare-time activity for both the dentist and the hygienist while the paramount concern has remained on restorative dentistry.  It i s the responsibility  of dental schools to change this emphasis by identifying methods of patient motivation and education and to transmit.these findings to their students. The training of dental students has traditionally focussed on restoration, but must be redirected to focus on prevention of dental disease.  The training of hygienists, on the other hand, has always been  concerned with prevention.  Because the whole of a hygienist s training 1  is prevention-oriented, she would be expected to be a better teacher  2  of this concept than the dentist.  This study was designed to investigate  the potential of hygienists in f u l f i l l i n g the role of educator i n teaching preventive practices.  If she i s as effective as the dentist in this role,  then there are several advantages to having a hygienist do a l l the preventive education.  More of the public would be better served, the cost  would be lower, and the dentist would be free to perform more diagnostic and c l i n i c a l dentistry.  PURPOSE AND HYPOTHESES The purpose of this study was to evaluate the effectiveness of the dental hygiene student versus the dental student in the teaching of preventive dentistry. 1.  Three general hypotheses were investigated:  Dental hygiene students are more effective teachers of preventive dentistry than are dental students.  2. '  Dental hygiene students have more favourable attitudes toward the educator role than do dental students.  3.  Socio-economic factors inherent i n the patient influence the learning of prevention.  SAMPLE The sample for the study was chosen randomly from the incoming periodontal patients to the Faculty of Dentistry at the University of British Columbia i n September, 1972.  Forty patients were chosen and randomly  divided into two groups with twenty assigned to the second-year hygiene  3  class and twenty assigned to twenty of the third year dental students who were randomly chosen from a class of forty.  A l l patients were to  receive oral hygiene instruction and prophylactic treatment and they were a l l adults ranging in age from 18 to 45. They had not received periodontal treatment at the school before, nor from a private dentist as far as could be determined.  VARIABLES Information was obtained from patients at three points i n time: when they f i r s t contacted the assigned student, when the program of instruction was completed, and six months after instruction.  Upon  each occasion data were sought from the patient regarding his oral hygiene knowledge and practices.  A plaque index representing the  percentage of teeth covered by plaque was determined by the student at each v i s i t .  At the f i r s t v i s i t , selected socio-economic data  were collected from the patients, including age, sex, educational level, marital status, and occupation. The attitude of the student toward the educator role was determined by an attitudinal scale administered at the time of the f i r s t contact with the patient.  INSTRUMENT CONSTRUCTION Two instruments were constructed to obtain the desired information from patients and students.  4  Patient Questionnaire Knowledge of oral hygiene practices was tested with twenty True-False questions which were developed from material taught in the periodontal department of the Faculty of Dentistry. This cognitive aspect was designed to assess patient knowledge regarding oral hygiene practices and periodontal disease.  In a pilot study  conducted prior to the main study, ten respondents scored between 3 and 18 correct on the twenty item test.  A Kuder-Richardson  Formula 12 r e l i a b i l i t y coefficient of .66 was computed on the i n i t i a l administration of the test with patients in the sample, and the test was therefore deemed sufficiently reliable for use in the study. Oral hygiene practices were assessed with ten multiple-choice questions derived from nine behavioural objectives that students are expected to attain.  Responses to these ten items were taken  to represent oral hygiene practices followed by the patient in the home. Practice scores were found to range from 1 to 8 in the pilot study. A third section of the patient questionnaire was used at the f i r s t v i s i t only.  It obtained information regarding five socio-  economic characteristics as identified earlier. socio-economic  The Blishen  status scale (15) was used to standardize the  occupation of the patients as a numerical score.  5  Student Questionnaire A semantic differential attitude scale was used to determine the students' attitudes toward the educator role.  This consisted  of ten paired objectives descriptive of various feelings about the educator role.  A seven-point rating scale was applied to  each set of adjectives so that the overall score could range from 10 to 70 points. In addition to the questionnaire which was completed once, the students recorded a plaque index upon each contact with a patient.  That index represents the percentage of teeth covered  by plaque.  DATA COLLECTION The patient questionnaire was administered at three different sessions.  The f i r s t was on September 14, 1972 before the patient  had any contact with the assigned student.  The second administration  occurred three weeks later on October 3, 1972, by which time the students had completed their oral hygiene instruction and preventive prophylactic treatment.  The third administration was early in March  1973, at the six-month recall appointment.  The third instrument was  administered at the beginning of the appointment prior to any review of the material presented earlier. The student questionnaire was administered once at the September 14 appointment.  A plaque index was recorded at each appointment.  Due to the d i f f i c u l t y in following patients over a six-month period, five of the original forty were lost during the period of the  6  study.  By the time that the third patient questionnaire was  administered, 17 hygiene patients and 18 dental patients remained.  DATA ANALYSIS Patient Questionnaire and Plaque Index The knowledge and habits sections of the questionnaire were scored separately and the means and standard deviations found for each test session. manner,  The plaque index was tabulated i n the same  t-tests were applied to each group to determine changes  with time for knowledge, habits, and plaque index, and also to determine i f there was a significant difference between the dental group and the hygiene group. A multiple regression analysis was conducted using the plaque index follow-up as the dependent variable with independent variables including the three habits scores, the three knowledge scores, the pre and post plaque index scores, age, sex educational level, socioeconomic status and marital status to determine which factors influenced the oral hygiene of the patient. Student Questionnaire A total score out of seventy was determined, and this figure was sued to compare means of the two groups using a t-test. In addition, the group mean and standard deviation was found for each pair of adjectives.  In this way t-tests could be used to compare  the attitudes of the dental students and the hygiene students on each item.  CHAPTER  TWO  LITERATURE REVIEW  Health planning i s becoming a subject of v i t a l concern for Canadians who now look upon health care as a right and not a p r i v i lege.  Health costs are soaring at such a rate that, projected to  the year 2,000, they could consume 100% of the gross national product (81). As part of this trend, the public i s now demanding total dental care.  If government institutes a dental care plan on a purely res-  torative basis neither the financial nor the manpower needs could possibly be met.  Consequently a denticare system must not be con-  sidered i f i t s main emphasis is not prevention. Fortunately dental research has shown that caries and periodontal disease can be prevented.  It i s now known that dental plaque is the  cause of both caries and periodontal disease.  If this plaque i s  thoroughly removed once i n every twenty-four hours, disease can be prevented. LEARNING DOMAINS AND PREVENTION The principal goal of dentistry, then, is the teaching of prevention and preventive dentistry is an innovation which must be taught to everyone. learning:  The concept of prevention involves three types of  psycho-motor, cognitive, and affective.  8  Psycho-motor learning requires careful instruction, supervised practice, and reinforcement.  In the i n i t i a l instruction the learning tasks  must be defined and taught i n sequential order.  The proper techniques  of brushing and flossing must f i r s t be demonstrated using models of a patient's own mouth.  Then the patient must practise under supervision  to ensure that he i s doing everything correctly.  After he has practised  on his own at home for a few days, he should be checked again at the office to catch any errors and to reinforce the whole procedure. Psycho-motor learning therefore takes time and cannot be accomplished in one appointment. Along with the psycho-motor learning should come the cognitive learning component. A patient i s more apt to practise good preventive measures when he i s aware of the causes and the consequences of periodontal disease.  Of the three kinds of learning affective probably  i s the most d i f f i c u l t to accomplish.  Without an attitude change a  person cannot be expected to go through a relatively complicated timeconsuming ritual day after day.  Each patient must be motivated to  want to save his teeth for the rest of his l i f e (33).  To effect an  attitude change i s very d i f f i c u l t and involves repeated exposures to the topic (6). Attitude change i s most effectively accomplished through conversation, where the patient has a chance to ask questions and to debate points he does not understand (14, 19,29). Kreisberg  9  (54) found that attitude changes resulted from changes in practices. However, his studies were mainly with children where parents had initiated the preventive habits and the necessary attitude changes followed.  These findings seem doubtful in the adult situation where  there i s no one to constantly enforce the habit change. In a recent study conducted at the University of Minnesota, Zacki (90) compared the student's own attitude towards prevention with his knowledge of prevention and his personal oral hygiene habits.  This study comprised three hundred and ninety-eight dental  students.  A test was given to the students to demonstrate how  they  could apply their knowledge to a specific preventive dental health problem.  The students' personal oral hygiene habits were also  examined using the simplified vermillion and green Oral Hygiene Index.  Their attitudes towards oral hygiene procedures were then  assessed by a questionnaire.  The findings showed a statistically  significant correlation between the student's attitude towards prevention and his own personal oral hygiene and there was correlation between the student's knowledge about prevention and his degree of personal oral hygiene.  This investigation seemed to indicate that,  by the fourth year, the class was divided into two groups, thus giving a bi-modal distribution of those who did believe in prevention and those who did not.  10  Educational research has shown (57, 84) that the best method of effecting an attitude-change is by direct discussion on a oneto-one level so that the patient, through his participation, positively reinforces his learning. Many informative papers have been written on the need for patient motivation (3, 14, 16, 22, 23, 28) but very l i t t l e research has been done in this area. Stople (82) conducted a c l i n i c a l study to determine i f an intensive course of dental health instruction would significantly improve the oral hygiene of a group of elementary school children. The study involved fourth, f i f t h and sixth grade students, and indicated that the level of knowledge of oral health can be improved significantly through dental health education, but attitudes about oral hygiene and the practice of oral health priciples are changed very l i t t l e .  This conclusion i s strengthened by Mogley and Pointer  (72) who stated that "factors other than teaching and audio-visual aids exert greater influence on changes in concern for dental health." Insight must be gained therefore about dental attitudes and the factors which influence the acceptace or rejection of dental health education before dental health education can change significantly the habits that affect the practise of oral hygiene.  Stople's  study supported the above conclusions and further concluded that:  11  1.  An improvement in oral hygiene occurs during school years with instruction i n oral health but this improvement i s not retained, and  2.  Intensive instruction i n dental health significantly improves the knowledge of oral health but appears not to be s i g n i f i cantly better than that of instruction by graded text books in the classroom.  Ferris (37) l i s t s the underlying principles of patient educational .psychology as: 1.  People learn best when they have an understanding of the goals of the training and the behaviour  2.  expected;  People learn best when they actually participate i n the learning situations;  3.  Learning proceeds most rapidly when there is immediate feedback on performance;  4.  Material should be presented as fast as the learner's progress permits;  5.  Performance that meets the standard should be reinforced.  PREVENTION AS AN INNOVATION Too much emphasis may be placed on cognitive learning. The public i s becoming very knowledgeable about periodontal disease and  12  its causes and prevention.  However, something appears to be lacking  in our teaching i n the affective and psycho-motor domains for the general public is s t i l l not practising prevention despite a relatively high level of knowledge. The adoption process has been described by Everett M. Rogers (73) as "the mental process through which an individual passes from f i r s t learning about an innovation to final acceptance."  This process  should be distinguished from the diffusion process which i s the spread of a new idea from i t s source of invention or creation to i t s ultimate users or adopters.  Since 1955, the adoption process has been  refined to include five stages which Beal, Rogers and Bohlen, (9) studied.  They concluded that these stages were a valid conceptua-  lisation of the adoption process. Both Rogers (73) and Lionberger (59) have further defined five stages i n the adoption process and these have been generally accepted for purposes of research. 1.  Awareness:  Their stages are as follows:  a person f i r s t learns about a new idea, product  or practice. 2.  Interest:  a person becomes interested in new ideas and  seeks additional information about them to determine possible usefulness and applicability. 3.  Evaluation: a person weighs the information and evidence  13  accumulated in previous stages, mentally applies the idea to his present and anticipated future situation, and then decides whether or not to try i t . 4.  T r i a l : the individual uses the innovation on a small scale in order to determine i t s u t i l i t y i n his own situation.  5.  Adoption:  the individual decides that the innovation i s  good enough for full-scale and continued use and a complete change i s made with that i n view. Since the concept of prevention i s an innovation i t s adoption should follow the five steps noted above.  Stages 1 and 2 can best  be achieved by use of mass media campaigns.  However, stages 3, 4  and 5 have to be achieved at the individual level. Rowntree's paper (76) describes how to design a public campaign in a community in order to make everyone aware of the concept of preventive dentistry and the necessity ultimately to adopt such preventive practices, beginning with mass media campaigns and subsequently focussing at the individual level.  At present the teaching of  prevention has been well publicised to the general public so that stages 1 and 2 are already accomplished.  The focus of teaching  prevention must now move to the individual level in order to achieve the adoption of the innovation.  •  Considerable research has been undertaken on the effect of social  14  class on the adoption of innovations.  Kreisberg and Treiman (53)  found that the higher the socio-economic bracket, the greater the frequency of dental v i s i t s .  They also found that education and  income, separately and together, are highly correlated with preventive dental care.  On the other hand, Freeman and Lambert  (38) found a " s t a t i s t i c a l l y significant correlation between the income of the family and the extent to which mothers engaged in preventive dental practices but no direct statistically significant relationship between the adult preventive behaviour and education."  Another  factor relating socio-economic status to preventive dentistry i s i  stated by Graham (45):  "Social classes w i l l accept innovations to  the extent that the innovational features and cultural characteristics of the classes are compatible." Because they vary in many respects of their culture, different classes may adopt a given innovation in varying degrees.  Their  self-perception i s essentially the same as Festinger's theory of cognitive dissonance and seems to be compatible with the observations of others concerned with attitudes and behaviour, (10, 28).  In  other words, people tend to follow certain health practices which they feel suit their socio-economic status. Adoption by the individual usually i s effected in the dentist's office through the efforts of the dentist, the hygienist and assistants in a team approach.  Even though the  15  team approach has proven successful, i t i s not widely practised i n dental schools as patients tend to be funnelled either through the hygiene department or the periodontal department.  INSTRUCTION IN PREVENTION At the University of B.C., the dental hygiene students and the dental students are both taught the same techniques for home-care instruction; thus, they have the same basic information,about the causes and control of periodontal disease.  The actual home-care  instruction includes the nine following behavioural objectives: 1.  Using staining tablets for the purpose of detecting the presence of plaque.  2.  Using a multi-tufted, soft-bristled toothbrush.  3.  Using a fluoride toothpaste.  4.  Using a gentle, rotary action to brush the teeth.  5.  Brushing down into the gingival crevice, using a vibrating stroke.  6.  Systematically covering the mouth by dividing the dental arch into a number of areas.  ' 7.  Brushing thoroughly at least twice daily; immediately after breakfast and before retiring at night.  8.  Using un-waxed dental floss to cleanse the interproximal area.  16  9.  Using a horizontal sawing and vertical sweeping motion of the floss i n each inter-proximal area.  The knowledge and techniques of prevention are taught i n two or three appointments.  During the f i r s t appointment with the  patient, the student explains the importance of keeping the teeth clean and does a complete prophylaxis.  He then demonstrates the  proper techniqes of brushing and flossing to the patient and sends him home. On the second v i s i t , disclosing tablets are used to show the patient what areas he has neglected to clean properly and the oral hygiene instruction i s repeated. This completes the preventive treatment.  The patient i s not seen again until a six-month recall  appointment when his progress i s rated.  CHAPTER THREE ANALYSIS OF DATA The data obtained on three administrations of the patient questionnaire and student attitudes toward the educator role were analyzed as described i n chapter one.  In this chapter, the  characteristics of the sample are f i r s t described and then the attitudes of the two groups of students are compared.  Results of the  patient knowledge and habits measures as well as the plaque index are compared for the two groups of patients at three points i n time. The chapter concludes by analysing the combined influence of a l l the variables studied i n relation to the final plaque index i n order to identify factors making the greatest contribution toward the ultimate condition of the patient's teeth.  Throughout the analysis,  the .05 level of significance was used to determine whether hypotheses were to be accepted or rejected. Characteristics of the Sample The population consisted of adult patients ranging i n age from 18 to 45, with 8 under twenty-five, 16 aged 25 to 35, and 11 aged over 35.  The mean age was 31.0. There were 20 males and 15  females in the sample, of whom only 8 were -married.  Many of the  18  patients were university students, a fact which i s reflected i n the average educational level of 13.9 years, with a standard deviation of 3.2. To obtain a measure of socio-economic status, the Blishen-Index (15) was used.  In the case of students, occupational objective was  used in lieu of occupation.  The average index for the group was  43.8 with a standard deviation of 12.9, somewhat higher than the British Columbia overage of 38.7.  No statistically significant  difference between dental students' patients and dental hygiene students patients was observed.  Student Attitudes On-the student questionnaire, there was no significant difference between the mean attitude score of dental students (39.7) and hygiene students (37.5) when the overall averages were compared. (Table I ) .  19  TABLE I. ATTITUDE SCORES FOR DENTAL AND HYGIENE STUDENTS  GROUP  MEAN  S.D.  Dental Students  39.67  4.16  Hygiene Students  37.53  2.45  t =1.86, d.f. = 33, p >'.05 To investigate the students' attitudes further, means, standard deviations, " t " values and probabilities were calculated for each set of paired adjectives. There was a tendency for dental hygiene students to obtain more positive scores than dental students. Furthermore, there was somewhat more agreement amongst the dental hygiene students on the importance of teaching prevention. Analysis of the adjective pairs shows that they may be divided into three groups. teaching:  One group involves a value judgement of preventive  important, useful, large, valuable and successful. A  second group describes the students' subjective feelings about teaching prevention:  interesting, pleasant, relaxed and active.  Finally, a  simple-complex pairing refers to a cognitive aspect of the task. Table 2 shows that both groups of students made consistently positive  TABLE 2. ITEM MEANS FOR DENTAL AND HYGIENE STUDENT ATTITUDE QUESTION  1.  ImportantUnimportant  DENTAL STUDENTS ' HYGIENE STUDENTS. MEAN. STD. DEV. MEAN. STD. DEV.  DIFFERENCE BETW. MEANS  't" VALUE  't" PROBABILITY  5.61  0.50  6.00  0.00  .39  3.29  0.01  2. UsefulUseless  6.28  0.83  6.88  0.33  .29  2.87  0.01  3. InterestingBoring  5.11  1.02  5.35  0.70  .12  0.82  N.S.  LargeSmall  5.44  2.12  6.53  0.62  .53  2.08  0.05  5. ValuableWorthless  5.56  0.62  6.00  0.00  .21  3.06  0.01  6. PleasantUnpleasant  6.22  0.81  6.35  0.49  .07  0.58  N.S.'  4.83  1.15  5.00  0.71  .08  0.52  N.S.  8. ActivePassive  6.22  0.94  6.18  0.81  ,02  0.15  N.S.  9. SuccessfulUnsuccessful  3.22  1.99  5.00  0.87  .87  3.46  0.01  4.83  2.07  3.94  1.56  ,43  1.45 •  N.S.  4.  7.  10.  RelaxedTense  ComplexSimple  Note: To avoid halo effect, the positive and negative poles were reversed on some questions i n the administration of this questionnaire. However, on this table high scores indicate a positive rating.  21  appraisals of preventive practices, and had consistently positive reactions to the task. However, in comparing dental with hygiene students, i t can be seen that there was significant differences on items 1, 2, 4, 5, and 9, the five questions i n the value judgement group, and the hygienists gave more positive responses i n each case.  Thus, while a l l  students reacted positively toward the teaching task, the hygiene students grasped the importance of teaching prevention to a significantly greater degree than did the dental students.  Patient Knowledge From the analysis of the knowledge data, no significant difference was found between the two groups of patients at any point i n time. However, there was a significant increase i n knowledge scores with time. (Figure I.)  The mean scores at the pre-test were 12.7 and 13 for  the dental and hygiene students respectively; the corresponding scores for follow up were 15 and 16.  The dental students would appear to have  imparted more knowledge to their patients; however, this difference is not significant at the .05 level.  It i s interesting to note that  the change in patient knowledge from pre to post test in the hygiene group was not s t a t i s t i c a l l y significant.  However, i t must have been  reinforced at the post test appointment because the change i n knowledge  SURVEY TIMES  FIG. 1  KNOWLEDGE MEANS CHANGES WITH TIME  23  from post to follow-up appointments was significant at the .001 level.  (Tables 3 and 4).  Patient Habits Analysis of the habits data shows a similar pattern except that there was a significant difference i n the habits scores between the two groups on the pre-test, with the hygienist group having a mean of 4.6 while the mean for dental patients was 3.2. However, this difference was eliminated at the post-test appointment.  It would seem that  the dental students may have had patients with slightly more severe gingival pathology.  Some students changed patients at the last  moment, thus disturbing the random distribution.  This may account  for the slight discrepancy i n scores at the pre-test level.  Like the knowledge scores the habits scores also improved significantly with time.  (Figure 2).  The mean for the dental group went  from 3.2 to 6.7 between the pre-test and follow-up, a difference s i g n i f i cant at the .001 level.  The hygiene group went from 4.6 to 7.0, a  change that was significant at the .01 level.  (Tables 5 and 6).  Plaque Index As a further check on patient habits, a plaque index score was taken by the students on their patients at each appointment.  This  TABLE 3.  Scores  COMPARISON OF PATIENT KNOWLEDGE SCORES FOR DENTAL AND HYGIENE STUDENTS.  Patients of Dental Students  Patients of Hygiene Students  MEAN  STD. DEV.  MEAN.  STD. DEV.  PRETEST  12.72  2.65  13.00  4.64  0.216  >.05 (N.S.)  POST TEST  14.61  3.20  13.94  3.85  0.558  >.05 (N.S.)  FOLLOW UP  16.17  2.12  15.35  3.12  0.807  >.05 (N.S.)  Degrees of Freedom:  33  TABLE 4.  CHANGES IN PATIENT KNOWLEDGE SCORES OVER TIME  Patients of Dental Students " t " Value  PRETEST vs. POST TEST  ' 2.72  PRETEST vs. FOLLOW UP POST TEST VS. FOLLOW UP  Patients of Hygiene Students P  " t " Value  P  <0.01  1.29  >0.05 (N.S.)  5.54  <0.001  3.09  >0.001  2.479  <0.02  3.17  >0.001  DEGREES OF FREEDOM - 33  26  81  MEANS SCORES TOTAL  SURVEY TIMES  FIG.  2  HABITS MEANS  SCORES CHANGES WITH TIME  TABLE 5. COMPARISON OF PATIENT HABIT SCORES 'FOR DENTAL AND HYGIENE STUDENTS  Patients of Scores  Dental Students  Patients of Hygiene Students  MEAN  STD. DEV.  MEAN  STD. DEV.  PRETEST  3.22  1.40  4.65  2.34  2.17  POST TEST  4.89  2.35  6.18  2.74  1.49  >0.05 (N.S.)  FOLLOW UP  6.61  1.88  7.06  2.82  0.55  >0.05 (N.S.)  DEGREES OF FREEDOM:  0.04  33  to  TABLE 6. CHANGES IN PATIENT HABIT SCORES OVER TIME  Patients of Dental Students " t " Value  Patients of Hygiene Students •t" Value  PRETEST VS. POST TEST  2.95  <0.01  2.30  <0.05  PRETEST VS FOLLOW UP  6.24  <0.001  3.23  < 0.01  POST TEST VS FOLLOW UP  3.02  <0.01  1.69  >0.05 (N.S.)  DEGREES OF FREEDOM:  33  29  index i s expressed as the percentage of tooth surfaces covered by plaque and debris, so that oral hygiene improves as the score decreases.  The dental students' group was significantly better  than the hygiene group at both the pre and post appointments. However, this must be considered in light of the large standard .In deviation in these scores and the small sample size.  Another point  of interest i s that the dental students saw a great improvement from pre to post appointment with means going from 81 to 27.9 percent, while.the hygienists' group mean moved only from 71 to 44 percent. (Figure 3).  Yet by the six month follow up appointment the dental  group had slipped back to 30 percent and the hygiene group had progressed to 34 percent.  By this time, there was no significant difference  between the two groups.  There was significant improvement with time  for both groups; thus, the visual check of oral hygiene agrees with the patient's increase in knowledge and professed increase in oral habits.  (Tables 7 and 8).  A multiple regression analysis was performed using the f i n a l plaque index as the dependent variable and a l l other variables as independent variables.  The hygiene and dental groups were run  separately and then together.  (Table 9).  For the dental group, the analysis included only one step and 2 the significant factor was the second plaque index rating with an R value of 54.6.  This indicates that approximately 55 percent of the  FIG. 3  ORAL HYGIENE INDICES MEANS  CHANGES WITH TIME  TABLE 7.  Scores  COMPARISON OF PATIENT PLAQUE INDICES FOR DENTAL AND HYGIENE STUDENTS  Patients of Dental Students MEAN  STD. DEV.  Patients of Hygiene Students MEAN  " t " Value  STD. DEV.  PRETEST  81.33  14.27  71.06  22.40  1.56  >0.05 (N.S.)  POST TEST  27.94  12.98  44.00  25.50  2.26  <0.05  FOLLOW UP  30.39  11.30  34.47  29.75  0.52  <0.05  DEGREES OF FREEDOM:  33  TABLE 8. CHANGES IN PATIENT PLAQUE INDICES OVER TIME  Patients of Hygiene Students  Patients of Dental Students  't" Value  " t " Value  PRETEST VS. POST TEST  3.40  <.01  5.66  £.01  PRETEST VS. POST TEST  3.79  <.01  6.11  <.01  PRETEST VS. FOLLOW UP  2.66  <.01  2.45  <.05  DEGREES OF FREEDOM:  33 LO  TABLE 9. MULTIPLE REGRESSION: ANALYSIS OF VARIABLES  GROUP  DEPENDENT VARIABLE  Dental  Plaque Index Follow up  Hygiene  Plaque Index Follow up  Total  Plaque Index  STEP  STEPWISE SIGNIFICANT VARIABLES  STEPWISE R VALUE  1  Plaque Index Post  0.546  0.001  1  Hab. Fol.  0.847  0.000  2  Plaque Index Post  0.903  0.019  3  Blishen  0.934  0.027  1  Hab. Fol.  0.654  0.000  Plaque Index Post  0.810  0.000  Know. Pre  0.834  0.042  . 2 3  Note:  F. PROB.  2  The following variables were entered: Sex, Age, Educational Level, Blishen Index, Marital Status, Knowledge Pre-test, Knowledge Post-test, Knowledge Follow up, Habits Pre-test, Habits Post-test, Habits Follow up, Plaque Index Pre-test, Plaque Index Post-test, Plaque Index Follow up.  34  variation in the f i n a l plaque rating was accounted for by the second plaque rating. The analysis for the hygiene group ran three steps, yielding 2 habits follow up, plaque index post, and Blishen Index.  The R  value for the third step was 93.4, indicating that those factors were responsible for some 93 percent of the variation found i n the patients of the hygiene students. When the two groups were run together the analysis again ran threee .steps, yielding habits follow up, plaque, index post, and 2 knowledge prescore with an R  of 83.4, indicating that those three  factors were responsible for 83 percent of the variation of the f i a n l plaque index of the patients of both groups combined.  CHAPTER  FOUR  SUMMARY, DISCUSSION AND CONCLUSIONS This chapter comprises a brief summary of the procedure and results of this study and a discussion of the results i n relation to other similar studies and ends with conclusions relevant to the purpose and hypotheses of the study. SUMMARY Forty patients were randomly selected' from the incoming patients to the periodontal department at the University of British Columbia. These patients had not received previous oral hygiene instruction from a dentist or hygienist as far as could be determined.  Patients  were randomly assigned to twenty second-year hygiene students and twenty.third-year dental students.  By the end of the study the  number of patients had dropped to thirty-five. The dental students and dental hygiene students had received the same instruction from the periodontics department regarding preventive practices.  Consequently, their methods of teaching were similar  although their backgrounds i n other areas of dentistry were obviously different. Three instruments were used i n the study.  A patient questionnaire  was designed to ascertain the patient's knowledge of preventive practices and his present oral hygiene habits.  A third section  36  comprising five socio-economic questions was included to "see i f the adoption of correct oral hygiene procedures was related to age, sex, years of education or social background.  The second instrument  was the Plaque Index score which was recorded by the student for his patient at each v i s i t .  This test required a visual examination to  determine the percentage of tooth surface covered by plaque and debris.  The third instrument was a student questionnaire designed  to investigate the student's attitude towards the importance of teaching prevention. The patient questionnaire was administered three times over a six-month period. The f i r s t administration was prior to any contact with the students and i s referred to as the pre-test throughout this study.  The second administration was at the second appointment and  is called the post-test. The final test was done at the six-month recall appointment and is referred to as the follow up test.  The  Plaque Index was recorded at the same appointments as the patient questionnaire was administered and i s , therefore, designated i n the same way as pre, post and follow up.  The student questionnaire was  administered once at the pre-test appointment. The data from the patient questionnaire, Plaque Index scores, and student questionnaire were analysed through the use of t-tests. Reliability of the instrument was tested  using the Kuder Richardson  37  Formula 21 method (36).  Plaque Index Follow up was used as the  dependent variable in a multiple regression analysis and a l l the other variables served as independent variables. Knowledge, habits and plaque index improved significantly over the six-month period.  The knowledge means for the dental students'  patients was 13 at Pre-test and 16 at Follow up, and the corresponding means for the hygiene students' patients were 13 and 15.  There was  no significant difference between the two groups at any time.  The  habits section showed means of 3.2 and 4.6 at pre-test and 6.7  and  7.1 at follow up test.  The difference between means of the two  groups was significant at the pre-test administration with the dental students having the .lower score.  This indicates that the dental students  started with a poorer group but, as can be seen by the final results, they had caught up since there was no significant difference in scores by the post and follow up administrations.  Thus i t might be surmised  that the dental students were more effective teachers since their group improved more. However, a negating effect to this hypothesis is that the patients may have had a higher internal motivation as a result of their slightly more serious gingival pathology.  Results  of the plaque index scores showed the dental group going from 81 to 27 to 30% while the hygiene group went from 71 to 44 to 34%.  Thus,  at the follow up appointment there was so significant difference in  38  the two groups.  The scores do reinforce the findings of the  habits section of the questionnaire in that the dental students' group had a poorer score to start with but ended up the same by the Follow up appointment.  Again there appeared to be greater  teaching effectiveness by the dental students from,Pre- to Postappointment, demonstrated by the rapid decrease i n Plaque Index scores.  However, this i s negated by the results at. Follow up  where the dental group actually shows a degree of back-sliding. The socio-economic factors obtained from section three of the patient questionnaire were used in a multiple regression analyses along with knowledge, habits and plaque index scores.  The plaque  index follow up was used as the dependent variable, and the data were run for each of the two groups separately and again as a total. The multiple regression ran one step for the dental students' patients and ran three steps i n the other two cases, with the total analysis showing that 83% of the variance i n Plaque Index score was dependent on knowledge pre-test score, habits follow up test score, and plaque index post-test score.  The Blishen Index did appear i n  the third step of the hygienist group, indicating that socioeconomic factors might be responsible for some of the variation. However, when the two groups were combined the influence of the Blishen Index dropped below the 0.05 level of significance.  39  When the total scores for the two groups were examined there appeared to be no significant difference between the dental students and the hygiene students in their attitudes toward the teaching of prevention, with means of 39.7 for the dental students and for the hygiene students.  37.5  However, when each individual set of  adjectives was analysed separately some quite interesting results appeared.  Not only did the hygienists score more positively on a l l  questions, but this difference was significant in five questions dealing with value judgements about the importance of teaching prevention.  Also, the consistently smaller standard deviation in the  scores of the hygiene group shows a greater consistency i n response within the group.' DISCUSSION Some observations can- be made from this study as to where^ in the five stages of adoption outlined by Rogers (73 )> the innovation of correct oral hygiene practices now stands.  As described earlier,  stages one and two, awareness and information, can be effectively accomplished by public campaigns using the mass media.  In the past  five years there has been considerable time and money put into such campaigns on the North American continent.  From the results of this  study i t would seem that the public campaign has met with some success. This success i s reflected in the results from the knowledge section of the patient questionnaire in that the scores at pre-test were  40  reasonably high, thus indicating that the patients were already aware of facts about and reasons for good oral hygiene before the study began.  At post-test, after they had received oral hygiene  instruction twice, the knowledge scores showed only a one point i n crease for both groups.  By the time of the six-month follow-up  there was a further small increase to 16 for the dental group and to 15 for the hygiene group. the habits section showed  However, the low i n i t i a l scores on  a marked improvement by the end of the  study, indicating that individual instruction was necessary for the actual adoption of good oral hygiene practices.  This i s not sur-  prising since the actual practice of oral hygiene involves psychomotor s k i l l s , and the learning of s k i l l s requires demonstration by the  instructor, supervised practice by the individual, and repetition,  feedback, and review after a period of self-practice. Further examination of the results from the patient questionnaire and the plaque index shows that there was an increase i n knowledge and habits scores and a reduction in plaque index scores over time for both groups.  These results agree with Ferris  e_t a l ( 37 ),  who stated that attitude change required multiple exposures to the topic.  These results also agree with Verner and Dickinson ( 84 )>  who state that attitude changes are best accomplished through discussion on a one-to-one basis or in small groups.  This i s clear  41  from the i n i t i a l pre-test scores where the patients had a relatively high knowledge score but a low habits score, indicating that from mass media campaigns they had gained knowledge about prevention but had not been motivated to try preventive practices. The plaque index scores at pre-test also confirm this.  Kriesburg (54) found that with  children attitude change followed habits change, but in this case i t would appear that habits change followed attitude change.  This i s  probably true of the adult patient where there i s no parental figure' to enforce the habit change prior to the attitude change.  Again the  results would agree with Stople ( 82 ), who found that knowledge could be greatly increased through the use of educational materials . but that habits were affected very l i t t l e .  He concluded that  attitudes had to be changed before habits could be changed. The Blishen Index was used to determine socio-economic status in this study.  From the work of Kriesburg and Treiman (53 ) one would  expect that socio-economic status would have considerable effect on the adoption of preventive practices. However, this study did not indicate such, as shown by the multiple regression analysis. This analysis showed that 83 % of the final change in plaque index score was due to pre-knowledge, habits follow-up and post-plaque  index.  Like Lambert, ( 38 ) this study found no relationship between social class and the adoption of innovations.  However, Graham  (45)  42  found that social classes w i l l accept innovations to the extent that the innovational features and cultural characteristics of the classes are compatible.  Again, this study failed to substantiate this finding.  Possibly the sample size for this study was too small to demonstrate any change related to social class, or perhaps there was not a wide enough range of social classes i n the study, as the group tended to be  mainly middle class. The total results of the patient questionnaire considered with  the results of the plaque index indicate that the preventive education program, as taught by both the hygiene students and the dental students, is effective.  Patients are being activated to practise good oral  hygiene techniques and seem to continue to do so, at least over a six-month period. The results also show that there is no significant difference between the hygiene students and the dental students as to their teaching effectiveness.  However, the final plaque index  scores suggest that the dental group was starting to show a degree of back-sliding, while the hygiene group continued to improve. Both groups could be observed at a later date to ascertain i f this trend continues. Results from the student questionnaire indicated no overall difference between the two groups.  Evidently they both considered  the teaching of prevention an important and worthwhile task; yet  43  when each individual question was examined i t was found that the hygienists consistently scored more positively, and that this d i f f erence was significant on the questions related to value judgements. This agrees with the original premise that, because the hygienists' whole training i s oriented toward the teaching of prevention and because the dental students' training i s mainly oriented toward restoration of teeth, the hygienists would show a more positive attitude. In the study of dental students, by Zacki (90) they found that by the senior year, the class was divided into two groups consisting of those who believed i n the importance of prevention and practised good oral hygiene themselves, and those who were not convinced of i t s importance and did not practise i t themselves.  Although there i s no s t a t i s t i c a l  evidence i n this study to confirm these findings, the less positive responses on the attitude questionnaire and the tendency for backsliding of the dental group on the plaque index follow-up would lend credibility to this hypothesis. CONCLUSIONS The scores of the two groups for knowledge, habits, and plaque index did not differ from each other significantly, thus indicating that the dental hygiene students were as effective as the dental students i n teaching prevention.  This hypothesis has importance i n  regard to manpower shortages i n the dental f i e l d .  Hygienists can  44  be trained in less than helf the time necessary to train dentists, therefore the training i s less expensive.  They can be ready for  employment sooner and they can work at a lower hourly rate.  Also,  the dentist's time can be better utilized and he can be freed for diagnostic and restorative procedures. The second hypothesis of this paper was the dental hygiene students are more aware of their roles as educators than are dental students.  The student questionnaire results certainly verify this,  since the hygienist consistently scored more positively on a l l questions and since the difference was significant on five questions dealing with value judgements about teaching. That the hygienists' patients scored slightly higher on their Habits Follow up and that their plaque index scores continued to drop lend further evidence that the hygienists are more motivated to teaching than are the dental students. From the multiple regression data i t was found that the three factors having a significant effect in determining the f i n a l plaque index were habits follow up, plaque index post, and knowledge pre-test score. 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"Preparing Instructional Objectives", Fearon Publishers, Palo Alto, California, 1962. Mechanic, D. "The Influence of Mothers on Their Children's Health, Attitudes and Behaviour". Journal of Paediatrics, 33:444-453, March 1964. Mittelman, J.S. "Getting Preventive Dentistry Through to Patients", D.C.N.A., 14:309, April 1970.  50 65.  Mork, G.M.A. "Psychology of Learning Applied i n Graduate Education", Proceedings of a Workshop for Teachers in Periodontology at the University of Minnesota, ed. Perry A. Ratcliff, Minneapolis, 1960.  66.  Morrow, Ronald G. "Communication with Patients in a General Practice", D.C.N.A., 14:241, April 1970.  67.  National Opinion Research Center. "Marginal Results and Basic Crosstabulations; Public Attitudes and Practices in the Field of Dental Care", Chicago, University of Chicago, 1960. (Unpaged, mimeographed.)  68.  O'Leary, T.J. et a l . "How Patients are Motivated and Taught to Practice Effective Oral Hygiene", Periodontal Abstracts, 16:98-101, September 1968.  69.  Ramirez, A. et a l . "Effect of Home Visitation on Patient Motivation to Receive Dental Prophylaxis", Ala. J. Med. Sci., 7:395-7, October 1970.  70.  Rayner, J.A. "Socio Economic Status and Factors Influencing the Dental Health Practices of Mothers", Am. J. of Public Health, 60:1250-8, July 1970.  71.  Reid, O.K. Why Preventive Dentistry: No. 3, "Why of Preventodontics in General Dentistry", J. A. Society of Preventive Dentistry, 1:14-15, October 1970.  72.  Robinson, B.A., U.L. Mogley and M.B. Pointer. "Is Dental Health Education the Answer?" American Dental A. J. 74:124-8, January 1967.  73.  Rogers, E.M. Diffusion of Innovations. pp. 12-20.  74.  Rossi, R.E. "Introducing Your Patients to Preventive Dentistry", Northwest Dent., 50:221-5, May-June 1971.  75.  Rosenstock, I.M. et a l . "A National Study of Health Attitudes and Behaviour", Ann Arbor, University of Michigan School of Public Health, 1964. 15 p. + 5 tables, mimeographed.  76.  Rowntree, R. St.D. "Dental Health Education and Publicity", Health Education Journal, 18:21, 1960-63.  77.  Rudko, V.I. "Basic Oral Health Survey Methods", Can. Forces Dent. Serv. Q., 2:1, July 1970.  78.  Schwartz, Robert. "Administrative Systems for Patient Communication", D.C.N.A. 14:341.  New York:  Free Press, 1962,  51 79.  Shiller, W.R. "Personal Factors in Dental Disease Prevention, 1. A Test to Measure Dental Health Knowledge", Report No. 578 of the U.S. Naval Submarine Medical Centre, pp. 1-14, May 1969.  80.  Shuval, Judith et a l . Social Functions of Medical Practice. Jossey Bass Inc., 1970. In Press.  81.  Shuvall, J.T. "Social and Psychological Factors i n Israel's Dental Health", J. of Public Health Dentistry, 179:94, Summer 1970.  82.  Stople, J.R. "Effectiveness of an Educational Program on Oral Health in Schools for Improving the Application of Knowledge", J. Publ. Health Dent., 31:48-59, Winter 1971.  83.  Tucker, C.W.A. "Comparative Analysis of the Subjective Social Class, 19451963", Social Forces, 46:508-514, June 1968.  84.  Verner, Coolie, Dickinson, Gary. "The Lecture, an Analysis and Review of Research", Adult Education, Vol. 17, No. 2, Winter 1967. pp. 85-100.  85.  Weckstein, Marvin. 397.  86.  Weir, J.M. "New Forms for Dental Health Educ", J. Public Health Dent., 30:218-22, F a l l 1970.  87.  Winslow, Erik K. and'Robert T. Ferris. "Developing Desired Patient Behaviour", D.C.N.A., 14:269.  88.  Wolff, R.M. "Preventive Dentist, Through Patient Education", J. Tenn. State Dent. Assoc., 50:217-20, Oct. 1970.  89.  Young, W.O. and J.D. Zwemer. "Objectives and Methods of Teaching Preventive Dentistry and Community Health", J. dent. Educ, 31:162-167.  90.  Zaki, H.A. "An Evaluation of the Effectiveness of Preventive Periodontal Education", Educ. J. Periodont. Res. Suppi., 3:1-30, 1969.  San Francisco:  "Basic Psychology and Dental Practice", D.C.N.A., 14:379-  APPENDIX I  PATIENT QUESTIONNAIRE Chart  no.  This questionnaire has been designed to survey the effectiveness of several teaching methods used by the students In this school. We are asking you to participate i n this study by f i l l i n g out the attached questionnaire. Do not put your name on the form. Please be honest i n answering the questions. Do not try to put down the answer you think we want you to give. Remember, i t i s not a test, we are looking for group averages and not the individual's sec-revThank you for your cooperation. Dr. Linda E. Sharpe  53  SECTION I Please complete t h i s s e c t i o n by c i r c l i n g e i t h e r T or F f o r each question.  1.  2.  3.  4.  5.  6.  7.  8.  9.  F l o u r i d a t i o n of water supplies has been proven b e n e f i c i a l i n reducing tooth decay.  T  F  When water supplies are not f l o u r i d a t e d c h i l d r e n should r e c e i v e f l o u r i d e drops to help strengthen t h e i r teeth.  T  F  Painting the teeth with f l o u r i d e i s not b e n e f i c i a l i n reducing tooth decay a f t e r the age of twelve.  T  F  Dental plaque must be removed from the teeth a f t e r each meal.  T  F  T.  F  T  F  Dental plaque always appears as a hard c a l c i f i e d deposit the teeth.  on  Dental f l o s s i s used to remove dental plaque from the teeth.  Normally unwaxed dental f l o s s i s b e t t e r f o r cleaning teeth than waxed dental f l o s s .  the  A hard b r i s t l e nylon toothbrush i s more e f f e c t i v e f o r cleaning the teeth than i s a s o f t m u l t i t u f t e d nylon b r i s t l e brush.  I  F  T  F  T  F  D i s c l o s i n g t a b l e t s should be used everytime you brush your teeth to check on the e f f i c i e n c y of toothbrushing.  54  10. I t Is normal f o r your gums to bleed sometimes when you brushing them.  11.  12.  are T  F  T  F  T  F  X  F  T  F  T  F  T  F  T  F  Bad breath i s often a s i g n of periodontal disease.  G i n g i v i t i s i s inflammation of the gums which can lead to 8evere periodontal disease i f not c o n t r o l l e d .  13. A f t e r the age of f o r t y i t i s more common to have teeth extracted because of periodontal disease than due to decay.  14. The majority of young people i n Canada today w i l l be wearing dentures by the time they reach l a t e middle age.  15.  Smoking may  a f f e c t the condition of your gums.  16. An e l e c t r i c toothbrush toothbrush.  17.  i s twice as e f f e c t i v e as an ordinary  Commercial mouthwashes are b e n e f i c i a l i n maintaining o r a l hygiene.  good  18. Thoroughly r i n s i n g your mouth i s an adequate s u b s t i t u t e f o r brushing your teeth when you are i n a hurry.  55  19. Fresh f r u i t s and vegetables are s u i t a b l e between meal snacks because they contain f r u c t o s e rather than glucose. T  F  T  P  T  F  T  F  2 0 . Periodontal disease can be a s i g n of a d i e t a r y d e f i c i e n c y .  21. There was an extensive campaign designed to ATTACK PLAQUE conducted on the radio and i n the papers e a r l i e r t h i s year.  22. The above campaign was sponsored by one of the leading toothpaste companies.  56  SECTION I I In t h i s section please c i r c l e the number o f the answer you consider to describe most accurately your own dental hygiene habits. Please c i r c l e only one answer f o r each question.  1.  How many minutes per day do you spend brushing your teeth? 1. 2. 3. 4.  2.  Which type of toothbrush do you use? 1. 2. 3.  3.  up and down stroke short back and f o r t h v i b r a t i n g stroke sweeping back and f o r t h stroke r o t a r y motion  Do you use dental f l o s s ? 1. 2.  6.  Yes No  What a c t i o n do you use when brushing your teeth? 1. 2. 3. 4.  5.  hard b r i s t l e nylon soft multitufted b r i s t l e natural b r i s t l e  Do you use a f l o u r i d e toothpaste such as Crest or Colgate with MFP? 1. 2.  4.  about one minute 1 to 3 minutes 3 to 4 minutes 5 minutes or more  Yes No  I f you use dental f l o s s , how frequently do you use i t ? 1. 2. 3. 4.  d a i l y on problem teeth d a i l y between a l l teeth s e v e r a l times a week on a l l teeth not a p p l i c a b l e (do not use dental f l o s s )  57  7.  8.  I f you use dental f l o s s , which way do you use i t ? 1.  Push the f l o s s through the contact, wrap i t against the side of the tooth, and s l i d e i t back and f o r t h to clean the tooth.  2.  Push f l o s s down between the teeth and p u l l i t back out the same way to clean the area the brush cannot reach.  3.  Push f l o s s through the contact and draw i t out to the side to remove food p a r t i c l e s stuck between the teeth.  4.  Not a p p l i c a b l e  Do you p e r i o d i c a l l y use d i s c l o s i n g t a b l e t s at home to check on your brushing e f f i c i e n c y ? 1.  2.  9.  (Do not use dental f l o s s . )  Yes No  when brushing down i n t o the g i n g i v a l c r e v i c e what a c t i o n do you use? 1. 2. 3. 4.  up and down stroke short back and f o r t h v i b r a t i n g stroke sweeping back and f o r t h stroke rotary motion  10. Every time you brush do you move systematically from area to area to ensure cleaning of a l l your teeth? 1.  2.  Yes No  58  SECTION III In this section please f i l l i n the blanks. 1.  Sex  M  F  2.  How old are you?  3.  How many years of schooling have you completed?  4.  a) What is your occupation?  Years  b) If you are a student please state degree program on which you are enrolled.  5.  What i s your marital status?  Married Single_ Other  Years  59 APPENDIX II STUDENT QUESTIONNAIRE PATIENT CHART 783 The purpose of the following scale i s to determine the meaning that you attach to the educational role that you may perform as a dental hygienist or a dentist. Think about your notion of the importance of patient education in your profession, then complete the ten items shown below. There are seven choices for each item. Consider the item carefully, then place an X i n the middle of the space that best indicates the strength of your, feeling towards your educational role. 1.  important  unimportant  2.  useless  useful  3.  interesting  boring  4.  small  large  5.  valuable  worthless  6.  unpleasant  pleasant  7.  relaxed  tense  8.  passive  active  9.  successful  unsuccessful  complex  simple  10.  ORAL HYGIENE INDEX FIRST VISIT  SECOND VISIT  FINAL VISIT  

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