Abstract
Objective:
The purpose of this study was to investigate dental hygiene (DH) educational programs’ didactic and clinical curriculum in the management of peri-implant diseases and conditions. The specific aims were (1) assess if evidence-based content for peri-implant diseases and conditions are currently included in didactic and clinical DH curriculum and (2) determine if DH education programs are currently preparing students at a level of clinical competency for the assessment and management of peri-implant diseases and conditions.
Design:
A cross-sectional study of DH faculty member(s) from 331 United States entry-level programs responsible for didactic and clinical curriculum for peri-implant diseases and conditions were surveyed. The survey was disseminated electronically via Qualtricsxm August 2019 for a response rate of 26%.
Results:
The results showed didactic courses taught DH students the etiology of peri-mucositis and peri-implantitis (98%), clinical characteristics (98%), and risk factors contributing to these implant diseases (96%). Evaluation methods to determine student level of competency in a didactic setting included quizzes/examinations (98%), case-based examinations (63%), and written essays (6%). Eighty-five percent reported DH students are not required in a clinical setting to provide care for patients with peri-implant diseases and conditions.
Conclusions:
Study results suggest DH education programs may need to revise didactic and clinical curriculum to ensure students graduate at a level of clinical competency for assessing and managing peri-implant conditions and diseases. DH educational programs should consider requiring clinical patient experiences for the assessment and management of peri-mucositis and peri-implantitis to prepare students for their professional role.
Keywords: dental hygiene curricula, peri-implant diseases, peri-implant management, peri-implantitis, peri-mucositis
1 ∣. INTRODUCTION
Sixty-nine percent of adults 35 years of age or older have lost at least 1 permanent tooth due to periodontal disease, caries, and/or trauma.1 Implant dentistry is a 50-year-old intervention for replacing missing teeth.2,3 From 1999 to 2000, approximately 0.7% of U.S. adults had at least 1 implant.2 Implant placement increased to 2.5% from 2009 to 2010 and 5.7% from 2015 to 2016.2 This increasing trend of implant placement is anticipated to reach 17% by 2026.2 Over the years, significant progress has been made for improved longterm stability. Evidence indicates implant survival is predictable with a 95% success rate.3,4 However, the prevalence of peri-implant diseases and conditions, specifically peri-mucositis (50%) and peri-implantitis (12%–43%) increasing the risk of implant failure, is a problem.5,6
Peri-mucositis is characterized with the clinical appearance of inflammation and bleeding on probing (BOP) at the implant site with no crestal bone loss compared to baseline radiographs.7,8 Peri-mucositis etiology is biofilm, is reversible, and is a known prelude to peri-implantitis.7-9 Peri-implantitis presents with the same clinical characteristics as peri-mucositis, but will also have progressive crestal bone loss when compared to baseline radiographs.7,9 Bone loss at implant sites is concerning because it is generally accelerated as a nonlinear pattern compared to bone loss around natural teeth.7,10-12
Risk factors and indicators for peri-implant diseases and conditions have been identified in the literature. Schwarz et al. concluded from an extensive review of clinical trials from 2003 to 2017 a history of periodontitis, inadequate biofilm control, and lack of implant maintenance were the primary risks/indicators for peri-mucositis and peri-implantitis.13 Karoussis et al. found 29% of subjects with a history of periodontitis developed peri-implantitis in a 10-year longitudinal study.14 Furthermore, individuals with periodontitis were reported to have increase probing depths and bone loss at implant sites.15,16
The 1999 International Workshop for a classification of periodontal diseases and conditions did not include classifications or case definitions of peri-implant diseases and conditions.17 Since then, significant efforts to implement standardized case definitions and classifications for peri-implant health, peri-implant mucositis, and peri-implantitis have been developed not only for future research, but for patient management and prevention of peri-implant diseases as well.7-9,13,18-22 In 2017, the World Workshop developed a new classification scheme of periodontal and peri-implant diseases and conditions.7 The use of standardized peri-implant case definitions and classifications are anticipated to aid in the assessment and management of implants during patient care.7-9
The application of the new classification scheme combined with the role of the dental hygienist may be instrumental in the prevention of peri-implant diseases and conditions. Three known factors for peri-mucositis and peri-implantitis are a history of periodontitis, poor patient oral self-care, and a lack of professional removal of biofilm.9,16,18 Dental hygienists are experts in the field of managing periodontitis, providing oral self-care education, and delivering interventions for professional biofilm removal.23 Additionally, as prevention specialists, dental hygienists are the primary oral health care provider to identify inflammation and BOP at the implant site as the first indication of peri-implant disease.23
To prepare dental hygiene (DH) students for the assessment and management of peri-implant diseases and conditions, they need competency-based education and skills to apply the process of evidence-based decision making (EBDM). Competency-based education is the evaluation of students’ specific knowledge and skills as they progress from novice, to beginner, and then deemed competent to perform tasks for the discipline of DH.24 EBDM is the analytical skill to apply evidence from scientific literature to clinical practice decisions.25
There is currently no available research on curricula focusing on peri-implant diseases and conditions within DH education programs. Preliminary data are needed to provide a baseline on a national level to identify what is taught in DH didactic and clinical curricula for the assessment and management of peri-implant conditions and diseases and whether students are adequately prepared to care for implants upon graduation. The data from this study may inform future curricular development.
The goal of this survey research is to investigate DH educational programs’ didactic and clinical curriculum, patient encounters, and assessments to measure student competency in the management of peri-implant diseases and conditions. This study had 2 specific aims (1) assess if evidence-based (EB) content for peri-implant conditions and disease are currently included in didactic and clinical DH curriculum and (2) determine if DH education programs are currently preparing students at a level of clinical competency for the assessment and management of peri-implant conditions and diseases.
2 ∣. METHODS AND MATERIALS
The University of Minnesota (UMN) Institutional Review Board (IRB) determined this study was exempt from oversight (STUDY00005661). A cross-sectional study of DH faculty member(s) from 331 U.S. entry-level DH programs responsible for didactic and clinical curriculum for conditions and diseases affecting implants were surveyed. A listserv was developed to include 331 DH program directors email addresses from the DH program’s public website. If the email address of the DH program director was not available on the public website, a phone call was made to request the email address. During the phone call, it was stated the study was IRB exempt from oversight. The survey was developed by 3 UMN School of Dentistry (SOD) DH research investigators. The survey was pilot tested by 5 UMN SOD faculty members considered as experts on the topic and in survey research. Feedback from the pilot test was incorporated to enhance the survey and a modification was submitted to the UMN IRB prior to dissemination.
The survey consisted of 28 questions including yes/no/unsure options, multiple choice, and open responses. The respondents were asked to refer to the definitions provided for peri-mucositis: “inflammation of the soft tissue surrounding a dental implant with no bone loss” and peri-implantitis: “inflammation of the soft tissue and bone loss surrounding a dental implant” for all questions on the survey. There were 6 demographic questions including the institutional category, degree(s) conferred, respondent’s age, years of DH licensure, years teaching, and employment status.
One question asked the number of didactic courses that include the assessment and/or the management of peri-implant diseases and conditions. The following question asked if conditions related to peri-implant tissues, such as peri-implant mucositis and peri-implantitis are taught in a didactic course. Respondents who answered “yes” had 5 additional questions to populate focusing on peri-implant conditions and disease etiologies, clinical characteristics, risk factors, treatment modalities, and evaluation of student competency in a didactic setting.
Regarding DH student clinical patient experiences and requirements, a yes/no/unsure question was asked if students are required to provide care for patients with at least 1 dental implant. Proceeding this question, the respondents were asked for the number of patient experiences students have with at least 1 dental implant. A yes/no/unsure question was asked if students were required to provide care for patients with peri-implant mucositis and/or peri-implantitis. Respondents who reported “yes” or “unsure” were prompted to answer additional questions focusing on the number of patient experiences, evaluation by faculty to a level of clinical competency, tracking for a total number of patient encounters, and treatment modalities students have experience managing a patient with peri-mucositis and/or peri-implantitis.
All respondents were asked a yes/no/unsure question if they were aware the American Academy of Periodontology (AAP) has a new classification scheme for periodontal and peri-implant diseases and conditions. Respondents who reported “yes” or “unsure” had 6 additional questions inquiring if their DH didactic and clinical curriculum needed to be revised to align with the standardized AAP definitions for peri-implant diseases and conditions. Other questions focused on implementation into the DH didactic and clinical curriculum, year and semester planned for implementation, and how student competency will be measured.
The survey was disseminated electronically via Qualtricsxm August 2019. The survey was sent a total of three times between the months of August and September 2019. An email was sent describing the goal and the specific aims of this study to DH program directors requesting to share with the DH faculty responsible for didactic and clinical curriculum for peri-implant diseases and conditions. Enclosed in the email was a link to the informed consent and the survey. Respondent email address domain names were recorded to identify the respondents per DH institution. Data analysis was performed using R version 3.5.2. Fisher’s exact test was used to evaluate categorical data. In addition, open response questions were themed by category.
3 ∣. RESULTS
Of the 331 electronic surveys sent out, there were 90 respondents who initiated the survey from 87 institutions for a response rate of 26%. From the 90 respondents who initiated the survey, 84 completed the curriculum questions and 82 completed the demographic questions. Table 1 provides a summary of respondents’ educational setting and degree conferred. A total of 74% were from DH programs that conferred an associate degree and 29% conferred a bachelor degree. Eighty-five percent of the respondents reported having a DH licensure greater than 15 years and 89% were full-time employees.
TABLE 1.
Demographics
| n(%) | |
|---|---|
| Institutional categoryb | |
| Community college | 44 (54%) |
| University not associated with a dental school | 15 (18%) |
| Technical/vocational school | 13 (16%) |
| University associated with a dental school | 10 (12%) |
| Degree conferred respondentsa | |
| Associated degree | 61 (74%) |
| Bachelor degree | 24 (29%) |
| Bachelor degree completion | 10 (12%) |
| Master degree | 8 (10%) |
| Certificate | 2 (2%) |
| Age group (years)b | |
| >60 | 26 (32%) |
| 51–59 | 26 (32%) |
| 41–50 | 17 (21%) |
| 31–40 | 13 (16%) |
| Years dental hygiene licensureb | |
| >15 | 70 (85%) |
| 11–15 | 6 (7%) |
| 5–10 | 6 (7%) |
| Years teaching in dental hygiene programb | |
| >15 | 37 (45%) |
| 11–15 | 19 (23%) |
| 5–10 | 17 (21%) |
| <5 | 9 (11%) |
| Employment statusb | |
| Full-time | 73 (89%) |
| Part-time | 9(11%) |
Multiple degrees conferred per institution.
n = 82 (24%).
Table 2 provides an overview of the didactic DH curriculum for the assessment and/or the management of peri-implant conditions and diseases. Respondents indicated didactic courses taught DH students the etiology of peri-mucositis and peri-implantitis (98%), clinical characteristics (98%), and risk factors contributing to these implant diseases (96%). The highest reported treatment modalities taught in a didactic setting were subgingival irrigation/antimicrobial rinses (83%) and instrumentation with a plastic dental implant scaler (76%). Evaluation methods to determine student level of competency in a didactic setting included quizzes/examinations (98%), case-based examinations (63%), and written essays (6%).
TABLE 2.
Dental hygiene didactic curriculum
| Assessment and/or the management of peri-implant conditions and diseases | ||
|---|---|---|
| Number of courses | 2 courses | 33 (39%) |
| 3 courses | 20 (24%) | |
| 1 course | 16 (19%) | |
| 4 or more courses | 12 (14%) | |
| No courses | 2 (2%) | |
| Unable to determine | 1 (1%) | |
| Teach conditions related to peri-mucositis and peri-implantitis | Yes | 82 (98%) |
| No | 2 (2%) | |
| Teach etiologies of peri-mucositis and peri-implantitisd | Yes | 80 (98%) |
| No | 2 (2%) | |
| Unsure | 0 (0%) | |
| Teach clinical characteristics of peri-mucositis and peri-implantitisd | Yes | 80 (98%) |
| No | 1 (1%) | |
| Unsure | 1 (1%) | |
| Teach risk factors contributing to peri-mucositis and peri-implantitisd | Yes | 79 (96%) |
| No | 1 (1%) | |
| Unsure | 2 (2%) | |
| Treatment modalities taughta,d | Subgingival irrigation/antimicrobial rinses | 68 (83%) |
| Instrumentation (plastic dental implant scaler) | 62 (76%) | |
| Instrumentation (titanium dental implant scaler) | 61 (74%) | |
| Dental implant insert for ultrasonic scaler | 56 (68%) | |
| Adjunct antibiotic therapies | 53 (65%) | |
| Subgingival air polisher | 47 (57%) | |
| Laser therapy | 18 (22%) | |
| Otherb | 2 (2%) | |
| Unsure | 2 (2%) | |
| Evaluation method used to determine student competencya,d | Quizzes/examinations | 80 (98%) |
| Case-based examinations | 52 (63%) | |
| Written essays | 5 (6%) | |
| Otherc | 3 (4%) | |
| Unsure | 2 (2%) | |
Respondents selected all that applied.
Other responses included n = 1 (super floss), n = 1 (referral to a periodontist).
Other = Literature Reviews, Article Review/Paper, or OSCE.
Among respondents answering Yes to “Teach conditions related to peri-mucositis and peri-implantitis” (n = 82).
DH student clinical patient experiences and requirements are provided in Table 3. Eighty-seven percent reported students are not required to provide care for patients with at least 1 dental implant in their education program. Regarding peri-mucositis and/or peri-implantitis, 85% of the respondents reported DH students are not required to provide care for patients with these conditions. The remaining 15% responded as “yes” or “unsure”. Among these respondents, 54% reported students are evaluated to a level of clinical competency for the assessment and/or management of peri-implant conditions and 15% track patient encounters. The proportion of respondents answering “yes” or “unsure” tended to be lower in institutions where the highest degree awarded is an associate’s degree or certificate than in those who award a bachelor’s or higher degree, but this difference was not statistically significant (12% vs. 25%, P = 0.19).
TABLE 3.
Dental hygiene student clinical patient experiences and requirements
| Required to provide care for patients with at least 1 dental implant | No | 73 (87%) |
| Yes | 7 (8%) | |
| Unsure | 4 (5%) | |
| Clinical patient experiences assessing and/or managing patients with at least 1 dental implant | 1–2 patients | 30 (36%) |
| Unsure | 25 (30%) | |
| None | 16 (19%) | |
| >6 patients | 6 (7%) | |
| 3–4 patients | 5 (6%) | |
| 4–5 patients | 2 (2%) | |
| Required to provide care for patients with peri-mucositis and/or peri-implantitis | No | 71 (85%) |
| Yesa | 9 (11%) | |
| Unsurea | 4 (5%) | |
| Clinical patient experiences assessing and/or managing patients with peri-mucositis and peri-implantitisc | 1–2 patients | 7 (54%) |
| Unsure | 5 (38%) | |
| 4–5 patients | 1 (8%) | |
| 3–4 patients | 0 (0%) | |
| >6 patients | 0 (0%) | |
| Students evaluated by faculty to a level of clinical competency for the assessment and/or management of peri-implant conditionsc | Yes | 7 (54%) |
| No | 3 (23%) | |
| Unsure | 3 (23%) | |
| Clinical patient encounters tracked for the assessment and/or management of peri-mucositis and peri-implantitisc | No | 8 (62%) |
| Unsure | 3 (23%) | |
| Yes | 2 (15%) | |
| Students’ experience with treatment modalities for managing patients with peri-mucositis and/or peri-implantitisb,c | Instrumentation (plastic dental implant scaler) | 10 (77%) |
| Subgingival irrigation/antimicrobial rinses | 8 (62%) | |
| Dental implant insert for ultrasonic scaler | 8 (62%) | |
| Instrumentation (titanium dental implant scaler) | 7 (54%) | |
| Adjunct Antibiotic Therapies | 7 (54%) | |
| Subgingival air polisher | 7 (54%) | |
| Laser therapy | 4 (31%) | |
| Unsure | 2 (15%) |
Yes and unsure responses populated questions regarding student clinical experiences assessing and/or managing peri-mucositis and peri-implantitis.
Respondents selected all that applied.
Among respondents answering Yes or Unsure to “Required to provide care for patients with peri-mucositis and/or peri-implantitis” (n = 13).
Table 4 addresses DH educational program’s plan for the AAP new classification scheme for periodontal and peri-implant diseases and conditions. Ninety-three percent were aware peri-implant conditions and diseases are now included in the AAP classification scheme. Of the 78 respondents aware of the AAP classification scheme, 52% provided the planned year/semester to implement the AAP standardized peri-implant classifications and case definitions in the DH curriculum. Forty-three percent reported the AAP standardized peri-implant classification and definitions will influence changes in DH curriculum for students to achieve competency.
TABLE 4.
DH educational program plan for the American Academy of Periodontology (AAP) new classification scheme for periodontal and peri-implant diseases and conditions
| Awareness of new AAP classification scheme of periodontal and peri-Implant diseases and conditions | Yes | 78 (93%) | |
| No | 6 (7%) | ||
| Planned semester/year to include the AAP standardized peri-implant classifications and case definitions within the DH educational program (n = 45, 52%) | 2019 Winter/fall/spring | 22 (49%) | |
| Spring/summer 2020 | 12 (27%) | ||
| 2019–2020 | 2 (4%) | ||
| 2021 | 1 (2%) | ||
| No plan | 1 (2%) | ||
| Students will get information after they take the NDHBE | 3 (7%) | ||
| 1st year 2nd semester (no year indicated) | 4 (9%) | ||
| Dental hygiene curriculum will need to be revised to align with the AAP standardized peri-implant diseases and conditions definitions | Yes | 40 (51%) | |
| No | 32 (41%) | ||
| Unsure | 6 (8%) | ||
| Plan to implement the AAP standardized peri-implant classifications and case definitions within the DH educational program (n = 45, 52%) | Revise didactic curriculum | 22 (49%) | |
| Revise didactic curriculum and clinical patient | 6 (13%) | ||
| experiences | 6 (13%) | ||
| Revise periodontology curriculum | 5 (11%) | ||
| Revise AAP classification in clinic/or clinic manual | 3 (7%) | ||
| Undetermined to make patient clinical requirement Unsure/no plan | 3 (7%) | ||
| Standardized peri-implant classifications and definitions will influence changes in dental hygiene curriculum necessary for students to achieve competency | Yes | 20 (43%) | |
| No | 13 (28%) | ||
| Unsure | 13 (28%) | ||
| Plan to measure student competency for the assessment of peri-implant conditions (peri-implant health, peri-implant mucositis, and peri-implantitis) (n = 31)a | Case studies | 16 (52%) | |
| Clinical patient experience | 14 (45%) | ||
| Didactic examinations | 14 (45%) | ||
| Unsure | 2 (6%) | ||
| Undecided for clinical requirements | 1 (3%) | ||
| OSCE | 1 (3%) | ||
| Self-assessment | 1 (3%) | ||
| Plan to measure student competency for the management of peri-implant conditions (peri-implant health, peri-implant mucositis, and peri-implantitis) (n = 31)a | Didactic examinations | 16 (52%) | |
| Case studies | 15 (48%) | ||
| Clinical patient experience | 15 (48%) | ||
| OSCE | 4 (13%) | ||
| Unsure | 2 (6%) | ||
| Undecided for clinical requirements | 2 (6%) |
Multiple responses.
4 ∣. DISCUSSION
This study serves as a report of 2 specific aims (1) assess if EB content for peri-implant diseases and conditions are currently included in didactic and clinical DH curriculum and (2) determine if DH education programs are currently preparing students at a level of clinical competency for the assessment and management of peri-implant conditions and diseases. Regarding specific aim 1, nearly all DH programs included the assessment and/or management of peri-implant diseases and conditions in the didactic curriculum. This content was in multiple didactic courses to suggest competency-based didactic education as students’ progress from novice to competent.24 This finding is also supported by the reported 98% evaluation method of quizzes/examinations and 63% case-based examinations to measure student competency in the assessment and management of peri-implant diseases and conditions in a didactic setting.
The majority of the didactic implant curriculum encompassed the etiology, clinical characteristics, and risk factors contributing to peri-implant diseases and conditions. It was found EB factors contributing to peri-implant diseases and conditions are taught in the curriculum. However, the most frequent treatment modalities taught in a didactic setting to manage peri-implant diseases and conditions do not align with the current EB research. In this study, it was reported subgingival irrigation/antimicrobial rinses (83%) and plastic dental scaler (76%) were most frequently taught in a didactic setting for the management of peri-mucositis and peri-implantitis. These treatment modalities have been identified in the literature as ineffective for the management of peri-implant diseases and conditions.
Historically, plastic dental scalers and irrigation with an antimicrobials have been used for biofilm removal around implants, despite the evidence concluding these methods are ineffective. Schwarz et al. 2005, 2006 respectively, reported failure of bacterial deposit removal to restore biocompatibility of the dental implant surface with the use of plastic dental scalers and irrigation with chlorhexidine gluconate (CHX).26,27 Systematic reviews by Louropoulou et al. reported plastic dental scalers are ineffective in the removal of biofilm.28,29 Augthun et al. reported it is “impossible” to remove biofilm from the threads of a dental implant surface with a plastic dental scaler.30
Although the evidence dates back to 1998 showing the ineffectiveness of plastic scalers and 2005 for the uselessness of irrigation with antimicrobial rinses, this study shows they are still taught as a treatment modalities in a didactic setting. Forrest et al. identified discrepancies of “what is known and what is practiced” in DH education and it appears this was evident from the findings in this study.25 These findings align with the challenge to keep up with emerging evidence to implement EBDM in clinical patient care.25,31 This is particularly true in novel fields of research with rapidly emerging evidence, such as implant maintenance.
In contrast, 57% taught subgingival air polishing in a didactic setting for the management of peri-mucositis and peri-implantitis. BOP is a primary indicator for peri-mucositis and a precursor for peri-implantitis and is used as a primary outcome in studies examining the effects of subgingival air polishing on peri-implant disease.32,33 Experts from an international working group on the clinical application of subgingival air polishing for the management of peri-implant diseases reported significant improvements in BOP compared to mechanical biofilm debridement.33 A consensus report by a working group of the FDI World Dental Federation in September, 2019 recommended treatment modalities for biofilm removal include air polishers, Er: YAG lasers, titanium curets, and ultrasonic scalers with plastic sleeves.34 In this study, slightly over half reported teaching subgingival air polishing as a treatment modality. This may be reflective of the lack of sufficient evidence to support the various treatment modalities in implant maintenance until recently. Using current journal articles for course readings updated yearly may promote EB implant maintenance as textbooks may quickly become outdated. Setting up literature alerts using PubMed or other platforms can aid faculty in staying current with emerging evidence.35
For specific aim 2, it appears DH education programs are not preparing students at a level of clinical competency for the assessment and management of peri-implant diseases and conditions. The majority (87%) reported students are not required to provide clinical care to a patient with at least 1 implant. Furthermore, 85% reported DH students are not required to provide clinical care to patients with peri-mucositis or peri-implantitis. Didactic curriculum and competency-based evaluation methods were reported robust in this study. However, this study found a gap in bridging the theory of content taught in a didactic setting to clinical application and practice. A study assessing implant curriculum in DH and dental therapy (DT) programs in the United Kingdom (U.K.) and Ireland found similar results. Chin and colleagues surveyed 23 DH/DT programs with a 60% response rate (n = 14).36 They found that while 100% of the programs included implant dentistry in their didactic curriculum, only 64% provided clinical experiences.36
In this study, 54% (n = 7) reported DH students have 1-2 implant patient encounters and are evaluated at a level of clinical competency. Only 13 respondents (15%) reported DH students are required to provide clinical care for patients with peri-mucositis or peri-implantitis, with only 14% (n = 2) reported DH student implant patient encounters are tracked for the assessment and/or the management of peri-mucositis and peri-implantitis. While there are no Commission on Dental Accreditation (CODA) Standards specific to peri-implant diseases and conditions, several Standards infer DH programs must prepare students in EB care of implants. The intent statement of Standard 2-8c clarifies DH programs must provide students with sufficient knowledge to use sound judgment in clinical decision-making.37 Standard 2-13 states students must be competent in the DH process of care, arguably including the assessment and management of peri-implant conditions.37 Standard 2-14 states students must be competent in assessing all forms of periodontal diseases.37 Peri-implant diseases and conditions are now included in the new AAP periodontal classification scheme.7 It can be argued that students may not graduate with the knowledge and EBDM skills to manage peri-implant diseases conditions without clinical experience. Therefore, solutions to fill the gap in clinical patient encounters and evaluation at a level of competency for patients with peri-implant diseases and conditions is an area that needs further investigation.
The majority (93%) of DH education programs are aware of the new AAP classification scheme for periodontal and peri-implant diseases and conditions. In addition, the majority reported their DH curriculum has already implemented the new classification scheme or has a plan to implement by 2021. CODA Standard 2-14 states programs must track patient encounters, have policies of patient selection criteria, and implement clinical evaluations to ensure students are able to demonstrate competency.37 The inclusion of standardized case definitions and classifications of peri-implant conditions and diseases7 may impact DH educational programs meeting CODA Standard 2-14.
The implementation of EBDM for clinical practice for the prevention of peri-mucositis and peri-implantitis should be carefully evaluated in DH curriculum. Although EB content is taught in the didactic setting, attention must be given to the barriers to clinical application of that knowledge. Students must be given the opportunity to apply EB knowledge clinically to facilitate critical thinking skills needed for the EBDM process.38 The integration of theory and practice in DH education can be challenging when relying on patients with specific clinical characteristics. A limited patient pool was cited in this study as a reason for the lack of clinical implant experiences. One respondent reported, “It is impossible to afford every student the opportunity to provide care to a patient with an implant.” This may be particularly true for DH programs not associated with a dental school. Programs with a limited implant pool reported using case studies to compensate for the lack of direct patient care.
Dental hygienists play a key role in systematic postimplant maintenance (SIT), which has been found to be significantly associated with lower peri-mucositis and peri-implantitis incidence.39 However, DH programs may be deficient in training students for competency in implant care, specifically in clinical experiences treating peri-implant diseases and conditions. The Star Model of Knowledge Transformation40 may provide a framework for EB implant curriculum in DH programs. The Star Model is a set of 5 progressive stages of knowledge transformation: Discover, Summary, Translation, Integration, and Evaluation.40,41 The first 2 stages, Discovery (knowledge generating) and Summary (synthesis of literature), can be achieved through didactic course content covering implantology, peri-implant conditions, and treatment modalities. Learning activities may include lecture, case studies, and literature review papers. Building on these first stages is Translation (clinical practice guidelines and decision-making). This stage could be achieved through simulations. Finally, the last 2 stages, Integration (knowledge into practice) and Evaluation (evaluating clinical outcomes) can be achieved through clinical dental implant experiences. Programs should have required patient implant experiences and clear guidelines of clinical protocols for assessing and managing peri-implant diseases and conditions. To ensure student competency in the assessment and management of implant care, students’ clinical implant experiences should be evaluated and tracked by faculty.
Future research should explore the perceptions of practicing dental hygienists regarding their formal educational preparation for implant care. Ward and colleagues surveyed dental hygienists to assess their strategies for implant maintenance and explored associations between dental hygienists’ formal education and continuing education-seeking habits regarding implant maintenance. They found that over half of the respondents did not receive training in implant maintenance during their formal education.42 This is in contrast to our study showing nearly all DH programs surveyed are training students in implant maintenance in a didactic setting, possibly reflecting recent advances in implant dentistry. However, little is known about graduates’ perceptions of preparedness to maintain implant health in a clinical practice setting.
The results from this study cannot be generalized. A limitation of this study was the low response rate. In addition, the reported DH student clinical experiences for patients with peri-mucositis or peri-implantitis was low. Therefore, no robust data on how student clinical competency is measured or how didactic curricula is applied in a clinical setting can be determined. Although one of the greatest risk factors of peri-implant disease is biofilm, the survey used in this study did not offer patient education as a response item in the treatment modality category nor did any respondent write patient education for the category of “other” that allowed open responses.
5 ∣. CONCLUSION
This study sought to assess DH educational programs’ didactic and clinical curriculum, patient encounters, and assessments to measure student competency in the management of peri-implant diseases and conditions. DH education programs may need to revise didactic and clinical curriculum to align with the standardized case definitions and classifications of peri-implant conditions and diseases to ensure students graduate at a level of competency. Didactic treatment modalities taught need to be revised to incorporate EB clinical practice methods. DH educational programs should consider requiring clinical patient experiences for the assessment and management of peri-mucositis and peri-implantitis to prepare students for their professional role. Additional research is needed to explore changes in the DH didactic and clinical curriculum as emerging evidence becomes available for the management of peri-implant diseases and conditions.
ACKNOWLEDGMENT
The authors would like to thank Danna Hickey, RDH, MSDH Researcher 5 and Jill Horman, RDH, MSDH, Clinical Assistant Professor at the University of Minnesota School School of Dentistry for their contributions to this study.
FUNDING STATEMENT
This research was supported by the National Institutes of Health’s National Center for Advancing Translational Sciences, grant UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences.
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