Dental hygiene students’ clinical self-confidence and management of pediatric clients: Pilot study

Abstract

Background

Dental hygiene programs must ensure students are competent and confident to meet the oral health needs of pediatric clients. The purpose of this pilot study was to evaluate dental hygiene students’ perceived self-confidence to perform dental hygiene services and manage client behaviour.

Methods

The study was deemed exempt by the institutional review board. A mixed methods approach evaluated 36 first-year dental hygiene students’ perceived self-confidence using an electronically delivered valid survey that consisted of 19 questions on a 5-point Likert scale (1 = not at all confident to 5 = totally confident) and 1 reflective question.

Results

The response rate for the survey was 100% (N = 36). Over 60% reported “totally confident” when completing a medical history; formulating and communicating a treatment plan; providing oral hygiene instruction; and applying fluoride varnish. Only 11% (n = 4) reported “totally confident” in exposing radiographs on pediatric clients. Roughly 42% (n = 15) reported “reasonably confident” and 28% (n = 10) reported “totally confident” when managing behaviour throughout the appointment. The multiple regression model explained 64% of the variance and was a significant predictor of managing behaviour, F (6, 29) = 8.70, p = 0.000. Reflective responses suggest that clients’ age, appointment length, and dental procedures posed behaviour management challenges.

Discussion

The majority of students reported “reasonably” or “totally” confident when performing dental hygiene services. However, more clinical opportunities are warranted to increase self-confidence in managing pediatric clients’ behaviour.

Conclusions

A review of pediatric client content and experiences within dental hygiene programs is suggested to ensure graduates are prepared to meet pediatric needs.

WHY THIS ARTICLE IS IMPORTANT TO DENTAL HYGIENISTS .

• Future generations of dental hygienists must be prepared to meet the oral health needs of vulnerable and diverse client populations.

• Dental hygienists are preventive oral health care providers, who are ideally positioned to reduce dental caries risk among pediatric clients.

• Dental hygiene program curricula should be evaluated to ensure that sufficient training in pediatric oral care is provided.

INTRODUCTION

The incidence of dental caries among pediatric clients remains a public health crisis and a concern for oral health professionals. According to the 2000 US Surgeon General’s report, dental caries is a “silent epidemic” among children.¹ More importantly, 50 million school hours and 164 work hours are lost each year due to dental concerns among US citizens.² The cost of early preventive dental care is significantly less than secondary or tertiary interventions. For example, for every $1 spent on oral health preventive measures, US taxpayers save approximately $50 on restorative and emergency dental procedures.² Minimizing the risk of dental caries, a chronic childhood disease, is the goal of oral health professionals. Dental hygienists are primary care providers who specialize in preventive treatment. Moreover, dental hygienists’ primary role is to recognize, prevent, and manage diseases and conditions that affect oral health and overall health.³

The scope of practice for dental hygienists is evolving in the United States. States such as Minnesota, Maine, and Vermont have adopted mid-level oral health care workforce models to meet population oral health needs.⁴ Approximately 42 states permit direct access to dental hygienists and 18 states allow direct Medicaid reimbursement for dental hygienists.^5-6 The demand for dental hygienists is continuously growing, and many professionals are assuming positions in diverse settings such as health centres, Women Infant and Children (WIC) clinics, schools, hospitals, and primary care offices.³ There are over 185,000 dental hygienists currently in the US.⁴ Moreover, the workforce demand for dental hygienists will increase as the population ages. For example, there is a 20% (248,900) projected growth in the number of dental hygienists who will be in the US workforce by 2026.⁷

Dental hygienists should be the frontline providers in the promotion of pediatric oral health and prevention of oral diseases. More importantly, dental hygienists must feel competent and confident to meet the oral health needs of pediatric clients. In a study conducted by Schroth et al., roughly 5.5 hours were devoted to infant and toddler oral health in the didactic curriculum content among Canadian dental hygiene programs.⁸ Additionally, only 30% of dental hygiene schools reported that students received clinical hands-on experience with infant and toddler oral health examinations.⁸ Competence and confidence develop through didactic and clinical experiences with positive reinforcement feedback systems. Therefore, Canadian and US dental hygiene educators must ensure students have adequate learning experiences in order to provide care for diverse client groups, as guided by the Commission on Dental Accreditation of Canada (CDAC) and the US Commission on Dental Accreditation (CODA) dental hygiene standards.

CDAC program requirement 2.4.1 states the following: “Graduates of the program must be competent to manage health promotion and oral health care for a range of clients within the life cycle, including children, adolescents, adults, and seniors. Students should have opportunities to provide care for medically-compromised clients and clients with special needs.”⁹ Similarly, the US CODA dental hygiene standard 2-12 states: “Graduates must be competent in providing dental hygiene care for the child, adolescent, adult and geriatric patient.”¹⁰ In both accreditation standards, there are no required hours for didactic content and clinical experiences related to pediatric oral health that students must complete in order obtain a level of competence.

Therefore, dental hygiene curriculum reviews and student self-assessments are imperative to ensure students are prepared to meet the oral health needs of the pediatric population. Two studies conducted by Ruiz et al. and Manski et al. have assessed infant and toddler knowledge, attitudes, and oral health practice behaviours among practising dental hygienists.^11-12 Current literature has not evaluated dental hygiene students’ knowledge, attitudes or oral health practices related to pediatric clients. Therefore, this pilot study serves as a gateway to evaluating dental hygiene students’ perceived confidence in providing clinical care to pediatric clients. The purpose of this pilot study was twofold: 1) to assess a cohort of first-year dental hygiene students’ perceived self-confidence in providing dental hygiene services and managing behaviour of pediatric clients; and 2) to provide recommendations for future exploration in pediatric education within the dental hygiene curriculum.

METHODS

The Human Subjects Institutional Review Committee at Old Dominion University (Norfolk, Virginia) deemed the study exempt. A mixed methods approach evaluated first-year dental hygiene students’ perceived clinical self-confidence in performing dental hygiene services and managing behaviour of pediatric clients. The 25-item survey (Pediatric Clinical Self-Confidence Survey) was developed in Qualtrics^©. A convenience sample of 36 first-year dental hygiene students from the same 4-year public institution with a dental hygiene program not affiliated with a dental school was the target population for this pilot study. Students in this sample received specific didactic content on providing care to infants, children, and adolescents in their second semester. Inclusion criteria for study participation were first-year dental hygiene students who were enrolled in the third semester dental hygiene clinical services course and had seen at least 2 pediatric clients (ages 3 to 12 years old) during the spring and summer semesters. Students were invited to participate in the study through an anonymous survey link that was posted on the Blackboard^® educational learning system. The survey link was posted during the last 2 weeks of summer clinical and didactic courses.

The survey consisted of 5 demographic questions, 19 Likert-scale items (1 = not at all confident to 5 = totally confident), and 1 reflective question with sub-items to guide reflective thinking about the pediatric client experiences. The 19 Likert-scale questions were grounded in the dental hygiene process of care based on the American Dental Hygienists’ Association (ADHA) Standards for Clinical Dental Hygiene Practice, which consist of assessment, dental hygiene diagnosis, planning, implementation, evaluation, and documentation.^13. These clinical guidelines were also used in a study by Simonian et al.,¹⁴ which assessed second-year dental hygiene students’ clinical self-confidence before and after a practicum experience. With permission, the Likert scale and select survey question items were adopted for this survey.¹⁴ The reflective question asked students to “Reflect on experiences with pediatric patients and share ‘wins and challenges,’ that occurred throughout the dental hygiene appointment.” In order to obtain a better understanding of how students manage pediatric clients’ behaviour throughout dental hygiene appointments, students were asked to “Describe if the pediatric patient(s) were or were not easy to manage.”

Due to the adaptation and development of survey items, feedback was obtained and revisions were made accordingly. Additionally, Cronbach’s Alpha was performed for all Likert-scale questions to measure internal consistency and was determined at 0.898. This finding confirmed a shared covariance among survey items, and measurement of the same underlying concept.

IBM Statistical Package for Social Sciences (SPSS) version 24 was used for statistical analysis. Descriptive statistics characterized the study sample. Multiple linear regression analysis using the forced entry method determined predictors of managing behaviour. The forced entry method is the recommended technique for exploratory data collection.¹⁵ Statistical significance was determined at p ≤ 0.05.

A general inductive approach was used for the qualitative data analysis of the reflective responses. Inductive analysis as described by Thomas¹⁶ uses a 3-step coding process consisting of detailed readings of raw data to determine concepts, themes or a model through interpretation by the researcher. Analysis following the inductive approach is characterized by the emergence of findings from the raw data itself rather than from a priori expectations or models.¹⁶ The data analysis process began with an initial reading of the raw data. During subsequent readings, line-by-line coding capturing key words and phrases was conducted. Next, codes were given conceptual labels and organized into like categories. Lastly, defined categories were used to generate the final themes and corresponding sub-themes that emerged from the data. To assure trustworthiness, independent parallel coding was completed in which a second coder conducted a separate independent analysis of the raw data following the coding process described earlier. Next, categories were created by the second coder and compared to the initial data analysis conducted by the researcher to identify the degree of overlap in the findings.¹⁶ Discussion of the analysis between the researcher and second coder identified high overlap of themes and concluded with 100% agreeance on the resulting model. Once the final model was established, an independent peer reviewer confirmed themes, sub-themes, and supporting quotes.

RESULTS

The response rate for the survey was 100% (N = 36). All respondents were first-year dental hygiene students. Approximately 94% of the respondents were females and 6% were males. Twenty-four years was the mean age of the respondents. All respondents provided dental hygiene services to an average of 2 pediatric clients during their first-year clinical experience. Pediatric client ages ranged from 3 to 12 years; the average age of clients seen was 6 years.

Over 60% of the respondents reported “totally confident” with the following dental hygiene services: 1) evaluation of a pediatric client health history; 2) formulation and sequencing of a treatment plan; 3) communication with dental hygiene faculty or dentist about the client’s care; 4) provision of oral hygiene education to the pediatric client and caregiver; and 5) application of fluoride varnish. Only 11% (n = 4) of the respondents reported “totally confident” in exposing radiographs on pediatric clients. Concerning behaviour management of pediatric clients, 42% (n = 15) reported “reasonably confident,” and 28% (n = 10) reported “totally confident” (Table 1).

Multiple regression models were performed to evaluate predictors of managing pediatric clients’ behaviour. The following predictor variables were included in the final model: perform oral exam, evaluate occlusion, identify early childhood caries (ECC and severe early childhood caries [S-ECC]), detect suspicious restorations or dental caries, communicate with medical and dental providers, and apply fluoride varnish. The final model explained 64% of the variance and was a significant predictor of managing behaviour, F (6, 29) = 8.70, p = 0.000. While performing an oral exam, identifying ECC, detecting suspicious restorations or dental caries, communicating with medical and dental providers, and applying fluoride varnish contributed significantly to the model, evaluating occlusion did not (Table 2).

The reflective responses yielded results for the qualitative portion of this study. The following themes and sub-themes were formulated: clinical experience (positive and negative); challenges (client behaviour, appointment length, dental procedures, and age); strategies (client engagement and distractions); and parent involvement (attitudes towards child’s oral health).

Theme 1: Clinical experience

Overall students valued their pediatric clinical learning experiences. However, previous clinical experiences with pediatric clients aided in the management and expectations of the appointment. One student commented, “I have personal experience working with children because of work experience. So overall, I had a great experience working with the children. I was able to work with them really well and meet their oral health needs.” Students also recognized the fundamental difference in providing dental hygiene care to adult versus pediatric clients (Figure 1). One student shared, “With adults you’re used to simplifying things for them to understand what you’re talking about, but with children, you simplify even more and I wasn’t prepared for that as I would have wanted to.”

Table 1.

Frequency table for each variable related to dental hygiene services

Variable	Mean SD		Not at all confident (1)	Lacking confidence (2)	Undecided (3)	Reasonably confident (4)	Totally confident (5)
Evaluate a pediatric client's medical history and vitals (if needed), and incorporate findings into a dental hygiene treatment plan.	4.67	0.48				33% (12)	67% (24)
Utilize all possible resources to facilitate care for the pediatric client including communication with dental and medical providers.	4.44	0.65		3% (1)		47% (17)	50% (18)
Accurately perform an extraoral/intraoral assessment and use findings to create and implement a dental hygiene treatment plan.	4.42	0.73		3% (1)	5% (2)	39% (14)	53% (19)
Evaluate a child's occlusion, growth, and development.	3.56	1.10	6% (2)	17% (6)	8% (3)	56% (20)	14% (4)
Identify early childhood caries ECC and severe ECC (S-ECC).	3.69	1.09	6% (2)	11% (4)	11% (4)	53% (19)	19% (7)
Perform a caries risk assessment on a child.	3.83	1.00		14% (5)	17% (6)	42% (15)	28% (10)
Detect suspicious restorations and/or areas of possible decay and relay these findings to the dental hygiene or dentist faculty member.	3.97	0.97	3% (1)	8% (3)	6% (2)	56% (20)	28% (10)
Expose radiographs on a child in primary or mixed dentition.	3.00	1.24	11% (4)	31% (11)	17% (6)	31% (11)	11% (4)
Interpret radiographs on a child in primary or mixed dentition.	3.72	1.08	6% (2)	8% (3)	17% (6)	47% (17)	22% (8)
Utilize ALL of the assessment data to formulate a sequenced treatment plan for pediatric clients.	4.61	0.60			6% (2)	28% (10)	67% (24)
Determine the appropriate procedures needed in the treatment plan on a pediatric client (e.g., prophylaxis, fluoride varnish).	4.44	0.80		6% (2)	3% (1)	33% (12)	58% (21)
Discuss dental hygiene treatment plan with the pediatric client and their legal guardian/caregiver) including rationale, risks, benefits, possible outcomes, alternatives, and prognosis.	4.58	0.50				42% (15)	58% (21)
Communicate with the dental hygiene or dentist faculty member about a client's overall care.	4.56	0.80	3% (1)		3% (1)	28% (10)	67% (24)
Manage the behaviour of a child throughout dental hygiene treatment.	3.69	1.24	8% (3)	11% (4)	11% (4)	42% (15)	28% (10)
Provide oral hygiene instructions to client and caregiver.	4.67	0.48				33% (12)	67% (24)
Counsel caregiver on client's dental development and oral hygiene habits.	4.42	0.77		6% (2)		42% (15)	53% (19)
Complete a child prophylaxis (using hand instrumentation when needed).	4.36	0.99	3% (1)	6% (2)	3% (1)	31% (11)	58% (21)
Apply fluoride varnish to child's teeth.	4.83	0.70	3% (1)			6% (2)	92% (33)
Determine the necessity for a pediatric client to be referred to a general or pediatric dentist.	4.33	0.79	3% (1)		11% (4)	36% (13)	50% (18)

Table 2.

Predictors of managing behaviour

Final model	b	SE B	β	p
Constant	-5.26 (-7.17, -1.11)	1.32		0.000
Perform oral exam	0.66 (0.10, 1.21)	0.27	0.39	0.022a
Evaluate occlusion	-0.20 (-0.30, 0.45)	0.15	-0.18	0.202
Identify ECC/S-ECC	0.79 (0.30, 1.27)	0.24	0.69	0.003a
Detect suspicious restorations or dental caries	-0.80 (-1.37, -0.22)	0.28	-0.63	0.003a
Communicate with medical and dental providers	0.99 (0.34, 1.63)	0.31	0.52	0.008a
Apply fluoride varnish	0.55 (0.14, 0.96)	0.20	0.31	0.010a

^astatistically significant

Theme 2: Challenges

Respondents described several challenges to managing the client throughout the dental hygiene appointment (Figure 2). In some instances, the dental hygiene appointment was the first experience for the pediatric client. However, all students expressed utilizing positive reinforcement to encourage and ease pediatric clients’ experiences throughout the dental hygiene appointment. The length of appointment posed the greatest challenge for many pediatric clients and dental hygiene students. For example, as the appointment time progressed, students reported that pediatric clients became restless. One student reported, “The 3-year-old lasted about 30 [minutes]–1 [hour] before wanting the parent and becoming tired.” Another student commented, “Unfortunately, by the end of the appointment when scaling and polishing is supposed to take place, the child is exhausted and not the most receptive to care.”

Figure 1.

Clinical experience

Figure 2.

Challenges

Dental hygiene procedures affected behaviour management during the appointment. Some procedures were easier for the student to complete than others (Figure 2). Additionally, type of dentition (primary or mixed) influenced the difficulty level in completing dental hygiene services.

Lastly, client age was a reported challenge to managing behaviour. Interestingly, younger clients were not always more difficult to manage. One student commented, “My 5-year-old patient was very cooperative throughout the whole appointment, until it was towards the end and almost time to go. This could have been because he had multiple dental appointments before coming to me; whereas, the 3-year-old had never been to the dentist before.” Another student reported, “The second child (8) was much more difficult. It took a lot of repeating to get the child to sit back down or open their mouth when asked. The first child (7) patient was very easy to manage, the patient was calm and listened when given instructions.”

Theme 3: Strategies

While several challenges contributed to managing behaviour, students shared strategies used to successfully complete dental hygiene procedures. Preparing for the pediatric appointment ahead of time, utilizing videos, and colouring materials yielded positive outcomes (Figure 3).

Theme 4: Parent involvement

Complying with the dental hygiene students’ recommendations was not a challenge for most caregivers. In fact, students reported that most caregivers were receptive to treatment and home care recommendations. One student shared, “Both caregivers engaged in communication, asked questions about their oral health and sought recommendations on how to improve on helping their children.” However, some caregivers revealed oral health literacy and communication barriers, which created challenges in understanding the child’s needs (Figure 4).

DISCUSSION

Results from this pilot study revealed the perceived confidence level among a cohort of dental hygiene students in their management of pediatric clients. The qualitative results provided enriched descriptive information about the students’ pediatric client experiences as well as challenges to and strategies for client care.

Figure 3.

Strategies

A majority of the dental hygiene students in this pilot study reported being “reasonably” or “totally” confident in performing dental hygiene services on pediatric clients. This finding is similar to the reported confidence of practising dental hygienists in studies by Ruiz et al.¹¹ and Manski et al.¹² Ruiz et al. used the transtheoretical (stages of change) framework to evaluate practising dental hygienists’ readiness to provide care to infant and toddlers through reported knowledge, comfort, and practice behaviours.¹¹ Approximately 82% of dental hygienists were confident in discussing proper feeding practices for infants and toddlers and 62% reported confidence in providing the proper preventive care.¹¹ Among the 758 dental hygienists who were included in the Ruiz et al. survey, 42% were in the active stage of the transtheoretical model and reported providing preventive care to young children.¹¹ Roughly 39% did not provide services to young children in their respective practices but were willing to provide care. About 19% did not provide dental hygiene care and were not considering providing care at the time.¹¹

Manski et al.¹² identified a knowledge gap among the dental hygienist respondents regarding early childhood caries (ECC) and preventive strategies.¹² Approximately 45% of respondents were unaware of the transmissible effects of dental caries, roughly 88% believed ECC prevention should begin at tooth eruption, and only 25% reported use of fluoride varnish for dental caries management.¹²

The first-year dental hygiene students in this pilot study have foundational knowledge and confidence to identify dental caries and deliver preventive agents. They reported confidence in identifying and managing ECC: 53% were “reasonably confident” in identifying ECC and S-ECC; 42% were “reasonably confident” in performing caries risk assessments. Moreover, 92% reported “totally confident” in applying fluoride varnish to children’s teeth.

In addition to oral assessment and dental caries management and prevention, oral hygiene instruction for the child and caregiver is a critical component in the overall appointment, as it is the ideal time to discuss oral findings, dietary habits, oral home care, and growth and development. In this study, approximately 67% of dental hygiene students were “totally confident” in providing oral hygiene instructions to children and caregivers, and 53% reported “totally confident” in counselling caregivers on a child’s dental development and oral hygiene habits.

Managing behaviour

Since this was the first study to explore dental hygiene students’ perceived clinical self-confidence in executing dental hygiene services and managing pediatric client behaviours throughout an appointment, a regression model was performed to identify any predictors of managing behaviour. A forced entry approach was used to build the regression model since no studies exist that measured managing behaviour among dental hygienists. Future researchers can use a hierarchical entry approach to build a regression model based on the findings from this study.

While quantitative data revealed a majority of students perceived themselves as “reasonably or totally confident” to deliver dental hygiene services for pediatric clients, qualitative data revealed behavioural management challenges during appointments. For example, 19% of dental hygiene students reported “not at all” or “lacking” in confidence to manage a child throughout dental hygiene treatment. Additionally, 11% reported “undecided” in their confidence. Increased exposure to pediatric client experiences will yield greater competence and confidence. Dental hygiene programs utilize a variety of experiences to increase clinical confidence among students. These experiences include service learning, outreach programs, and practicum experiences, to name a few. In studies that have used such settings to increase experiential learning, confidence improved among dental hygiene students.^{17 -19}

Figure 4.

Parental involvement

There are benefits to experiential learning in dental hygiene programs. Dental hygiene students in this pilot study complete pediatric and adolescent clinical requirements as they matriculate through the curriculum. Additionally, these students are exposed to experiential learning in community and public health centres, head start, primary, and secondary schools in their last year. Through these platforms, students perform oral screenings, fluoride varnish applications, and education prior to completing the program.

Application to dental hygiene practice

Dental hygienists are well positioned to provide care to pediatric clients and address the national goal of decreasing dental caries incidence and risk. In 2017, roughly 188,970 dentists were working in the US.²⁰ Of those dental providers, 149,061 were general dentists and 6,153 were pediatric dentists.²⁰ Only a small portion of general dentists provide care to children under 3 years of age.²¹ Due to the dental provider shortage, non-dental professionals such as advanced practice nurses, physicians, pediatricians, and physician assistants have been charged with assisting in meeting the oral health needs of children.^{22 -23} For example, US licensed non-dental professionals such as physicians, physician assistants, and advanced practice nurses are able to perform oral health assessments, apply fluoride varnish, and receive reimbursement for these services for children under 3 years of age.^{24 -26}

The American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) support an interprofessional approach to early prevention among children.²⁷ However, dental hygienists must remain vigilant to ensure medical and dental professionals understand their role as an oral health care provider. More importantly, dental hygiene educators must ensure that dental hygiene students are well prepared to provide dental hygiene services to pediatric clients and caregivers.

Application to education

T he Canadian and US accreditation standards are similar, thus making results from this study applicable to Canadian dental hygiene programs. Like the US, Canada has no requirements for the number of hours or experiences students must complete in order to be deemed competent in providing care to children, adolescents, adults or geriatric clients. Therefore, dental hygiene programs must ensure adequate hours of didactic content and clinical experience occur for each student. Variations in didactic and clinical experiences suggest the need for future exploration of both US and Canadian dental hygiene graduates’ knowledge, attitudes, and oral health practices related to pediatric clients.

Recommendations for future exploration

Schroth et al.⁸ evaluated infant and toddler curricula content among Canadian dental and dental hygiene programs. Since the CDAC requirements are similar to the US CODA standards, an evaluation of US dental hygiene curricula content related to pediatrics is beneficial. Manski et al.¹² suggested the need for continuing education related to ECC management based on data collected from the dental hygienists in their study. An overall evaluation of practising dental hygienists’ and recent dental hygiene graduates’ knowledge and pediatric oral health practices would provide insight into translation of knowledge to clinical practice. Once this information is obtained, continuing education content can be developed to address knowledge and best practices gap for pediatric client care.

Limitations and Strengths

Limitations of this study include use of a convenience sample, data collection from one dental hygiene program, one-time data collection, recall bias, and self-reporting of information. Therefore, results can be generalized only to this specific population. While this study has limitations, there are also strengths that add to the current body of knowledge. This was the first study to measure confidence related to performing the dental hygiene process of care and managing behaviour in a pediatric population utilizing a descriptive mixed-methods approach. The qualitative data collected help to explain the challenges students encounter while providing care to pediatric clients. While not the focus of this study, the qualitative data highlighted behavioural management strategies and parental involvement during the appointment, which also influence the appointment and delivery of care.

CONCLUSIONS

This pilot study assessed and described the perceived level of clinical confidence in a cohort of first-year dental hygiene students. While a majority of dental hygiene students perceived themselves as “reasonably or totally confident” in providing dental hygiene services, managing behaviour of pediatric clients posed challenges. This pilot study was essential in providing insight into a portion of dental hygiene curricula content that is not frequently discussed in the literature. Continuous evaluation of curricula and pediatric practices is essential to providing recommendations for pediatric workforce preparedness.

CONFLICT OF INTEREST

The author has no conflict of interest to disclose.