Abstract
Introduction: Promoting oral hygiene and stimulating patient's responsibility for his/her personal health remain challenging objectives. The presence of dental hygienists has led to delegation of preventive tasks. However, in some countries, such as Belgium, this profession is not yet legalized. The aim of this exploratory study was to compare the attitude towards oral-hygiene instructions and patient motivational actions by dental hygienists and by general practitioners/periodontists in a context without dental hygienists. Materials and Methods: A questionnaire on demographics (six items), oral-hygiene instructions (eight items) and patient motivational actions (six items) was distributed to 241 Dutch dental hygienists, 692 general practitioners and 32 periodontists in Flanders/Belgium. Statistical analysis included Fisher's exact-test, Pearson's chi-square test and multiple (multinomial) logistic regression analysis to observe the influence of profession, age, workload, practice area and chair-assistance. Results: Significant variance was found between general practitioners and dental hygienists (in 13 of 14 items), between general practitioners and periodontists (in nine of 14 items) and between dental hygienists and periodontists (in five of 14 items). In addition to qualification, chair-assistance was also identified as affecting the attitude towards preventive oral care. Conclusion: The present study identified divergence in the application of, and experienced barriers and opinions about, oral-hygiene instructions and patient motivational actions between dental hygienists and general practitioners/periodontists in a context without dental hygienists. In response to the barriers reported it is suggested that preventive oriented care may benefit from the deployment of dental hygienists to increase access to qualified preventive oral care.
Key words: Dental hygienists, general practitioners, periodontists, oral-hygiene instruction, patient motivation, questionnaire study
Introduction
Oral hygiene and professional preventive care are essential prerequisites for the management of caries and periodontitis1., 2.. Promotion of good home-care habits, including emphasis on patients' own responsibility for their personal oral health, is paramount for long-term treatment success3. This includes educating patients about self-care, the need for regular dental visits, fluoride application, dental sealants, nutrition advice and smoking cessation4., 5.. In many countries, dental hygienists play an important role in oral health education and preventive measures6. They provide preventive and/or supportive therapy. Their role is established within the medico-legal framework of a country and ranges from independent to supervised practice. It includes, for example, taking dental radiographs, data screening, application of local anaesthetic, calculus removal and root planing, patient counselling and guidance, taking impressions and placing temporary restorations7. In contrast, in some countries dental hygienists are legally not allowed to work, let alone to provide dental treatment. Consequently, dentists and periodontists are responsible for providing preventive therapy8.
Based on epidemiological data, König et al.9 reported differences in periodontal health between countries in Europe. The authors suggested the approach toward periodontal care in a country as an important determinant. Furthermore, a relationship was demonstrated between the prevalence of untreated periodontal disease and limited access to care performed by a qualified dental hygienist10. The above-mentioned studies suggest a positive impact on access to prevention and oral health care in countries where dental hygienists are active. This is further illustrated by Madianos et al.11 who identified better toothbrushing habits in adult patients in health-care systems with dental hygienists, such as the Nordic countries, Germany and the Netherlands, compared with other European countries.
In countries without dental hygienists, both general practice dentists and periodontists have the task of providing preventive and supportive care, in addition to diagnostic, curative and/or specialised care. Pennington et al.12 assumed no difference in treatment effectiveness between general practitioners and periodontists if both clinicians were to spend the same time devoted to care. Consequently, a clinician's allocated time to perform supportive periodontal care was suggested as a good predictor for the overall effectiveness of care. In line with this argument, preventive care by dental hygienists would be highly effective because their work is solely orientated towards prevention and supportive care. Furthermore, it ensures that the level of care reflects the educational level of the caregiver13.
The previous studies illustrate two strategies in the access and provision of preventive and supportive oral health care in Europe, involving dental hygienists, general practitioners and periodontists. Considering the differences in educational level and focus of the professions, one can question whether both dental hygienists and general practitioners/periodontists provide similar preventive/supportive oral therapy.
Hence, the present exploratory study investigated the attitude of dental hygienists, general practitioners and periodontists regarding provision of oral hygiene instructions and performing patient motivational actions as an important attribute for preventing dental caries and periodontal disease. The study aimed to answer two research questions:
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What attitudes have general practitioners and periodontists in an oral health-care system without dental hygienists towards provision of oral-hygiene instructions and performing patient motivational actions compared with dental hygienists?
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In addition to qualification, is the attitude towards giving oral-hygiene instructions and performing patient motivational actions influenced by professional variables, such as age, workload, area of practice or availability of chair-assistance?
Materials and Methods
In response to the research questions, the present study compared the attitude towards oral-hygiene instructions and patient motivational actions by dental hygienists working in the Netherlands and general practitioners and periodontists in Flanders in the northern part of Belgium. The Netherlands and Flanders are neighbouring western developed societies with similar population patterns, in terms of socio-economic breakdown. Both regions speak the same language (Dutch) but have a different organization of oral health care. In the Netherlands, preventive and/or supportive oral care is commonly provided by dental hygienists. Their competences are based on a 4-year educational programme, including clinical training, and they are allowed to practice independently14. Belgian legislation only allows dentists to provide in-mouth oral care. As a result, dental hygiene as a profession is illegal and non-existent. Hence, preventive and/or supportive therapy is provided by general practitioners and recognized specialists. Within the group of specialists, periodontists are directed towards preventive and periodontal care, whereas orthodontists are mainly focussed on orthodontic treatment and oral surgeons on surgery. In order to graduate in Belgium as a general practitioner or a periodontist, students are required to undergo a 5-year undergraduate curriculum followed by an additional year of vocational training or a 3-year specialist training programme, respectively. Comparison between these contexts provides the opportunity to analyse the attitudes towards the provision of oral-hygiene instructions and patient motivational actions between dental professionals in a health-care system, with and without dental hygienists.
A questionnaire was developed to investigate the dental professionals' attitudes; the questionnaire contained 20 multiple choice items about demographics (n = 6), oral-hygiene instructions (n = 8) and patient motivation (n = 6). Items about demographics included qualification of the professional, age, workload, area of practice and availability of chair-assistance. Items about oral-hygiene instructions and patient motivational actions aimed to explore the views of three dental professions (dental hygienists, general practitioners and periodontists), based on personal opinions, reflections and habits in daily-practice. Items included interproximal hygiene instruction, non-compliance, sale of oral-hygiene products, the relationship between efforts and results, factors perceived to contribute to oral-hygiene level and patient motivation. Before the study, the questionnaire was pretested by a panel of five dental experts for validity and ambiguity of wording.
The questionnaire was distributed to participants of three training events on the management of periodontal diseases for dental hygienists in three locations in the Netherlands. Furthermore, during five postgraduate courses on patient management in dentistry, organised in five different locations in Flanders (Belgium), participants were asked to complete an identical questionnaire.
Before each training event/course, a letter was presented to the participants, explaining the background and aims of the study. Furthermore, the participants were instructed to provide one answer per question (i.e. the response that corresponded most to the participant's opinion). The questionnaire was anonymous. Written consent was obtained from all participants involved in the study. Dental professionals who preferred not to participate were asked to mark the questionnaire as ‘unanswered’. The study was conducted in full accordance with the World Medical Association Declaration of Helsinki, and ethical approval was granted by the Ghent University Hospital Ethics Committee.
Demographics were described using frequencies and percentages. To compare the results between dental professionals in the Netherlands and Flanders, three subgroups were created based on their qualifications: dental hygienists in the Netherlands; and general practitioners and periodontists in Flanders. Both general practitioners and periodontists were included because the latter focus on treating periodontal diseases and, given the field of interest, are expected to have a focus towards preventive care which is similar to that of dental hygienists.
The variable age was subdivided into three categories (<35 years, 35–54 years and >54 years). These cut-off points are largely aligned with three types of professional careers. In Belgium, periodontology was introduced as a new discipline in the 5-year undergraduate dental curriculum in 1979. Consequently, dental professionals older than 54 years of age never had the opportunity to study periodontology during undergraduate education. On the other hand, general practitioners younger than 35 years of age all graduated after the recognition of periodontists as specialists was legally adopted. Furthermore, the variable workload was subdivided into two subgroups (<30 hours per week or ≥30 hours per week). This cut-off point coincides with the minimum hours required for Belgian dentists to enter the national convention between the profession and the health insurance system. This convention regulates reimbursement for oral care. The variable area of practice discriminates between urban dental clinics and rural clinics. Rural areas generally have fewer dental professionals per capita and urban clinics are often multidisciplinary and employ a larger number of assisting personnel. The availability of chair-assistance (with or without) was expected to be an important factor influencing the delegation of preventive tasks such as oral-hygiene instructions and patient motivational actions to assisting personnel.
To investigate the differences between subgroups, Fisher's exact tests were used for dichotomous questions and Pearson chi-square tests were used for questions with three or more answer options. P-values were adjusted for multiple testing using Bonferroni correction. In addition, to correct for the variables age, workload, area of practice and chair-side assistance, a multiple (multinomial) logistic regression analysis was applied with bias-corrected accelerated (BCa) bootstrapping (n = 1000) to validate the model and avoid overfitting.
All statistical analyses were performed using SPSS 22.0 (IBM Corp., Armonk, NY, USA). The significance level was pre-set at P ≤ 0.05.
Results
In the Netherlands, 283 of 350 participants in the training events returned the questionnaire, resulting in a response rate of 81%. Questionnaires completed by dentists or dental assistants (n = 42) were excluded from the analysis. Accordingly, 241 questionnaires were included in the study, representing 8% of the Dutch dental-hygienist population15. A total of 1037 questionnaires were distributed among Flemish dental professionals. Seven-hundred and ninety-one questionnaires were returned, resulting in a response rate of 76%. Fifteen questionnaires were marked as ‘unanswered’, indicating refusal to participate and, in addition, 52 questionnaires were completed by dental professionals other than general practitioners and periodontists, including orthodontists, oral surgeons and dental assistants, and were also excluded. Consequently, 724 questionnaires were analysed – 692 were completed by general practitioners and 32 by periodontists, representing 16% and 36% of the population of both professions, respectively16. A detailed overview of demographics concerning age, workload, area of practice and the availability of chair-assistance is depicted in Table 1.
Table 1.
Demographic data, including qualification, age, workload, area of practice and chair-assistance
| Demographic variable | |||
|---|---|---|---|
| Qualification | |||
| (n = 965) | General practitioner (n = 692) | Periodontist (n = 32) | Dental hygienist (n = 241) |
| Age | |||
| <35 years | 62 (7.5) | 7 (21.9) | 117 (48.5) |
| 35–54 years | 380 (55.8) | 20 (62.5) | 100 (41.5) |
| >54 years | 250 (36.7) | 5 (15.6) | 19 (7.9) |
| Unknown | 0 (0.0) | 0 (0.0) | 5 (2.1) |
| Workload | |||
| <30 hours/week | 118 (17.0) | 6 (18.8) | 113 (46.9) |
| ≥30 hours/week | 561 (81.1) | 25 (78.1) | 111 (46.0) |
| Unknown | 13 (1.9) | 1 (3.1) | 17 (7.1) |
| Area of practice | |||
| Rural | 282 (40.7) | 4 (12.5) | 34 (14.1) |
| Urban | 397 (57.4) | 27 (84.4) | 169 (70.1) |
| Unknown | 13 (1.9) | 1 (3.1) | 38 (15.8) |
| Chair-assistance | |||
| With | 157 (22.7) | 27 (84.4) | 46 (19.1) |
| Without | 523 (75.6) | 5 (15.6) | 179 (74.3) |
| Unknown | 12 (1.7) | 0 (0.0) | 16 (6.6) |
Values are given as frequency (%).
When comparing subgroups, statistically significant differences were found in 13 of 14 items between general practitioners and dental hygienists, in nine of 14 items between general practitioners and periodontists and in five of 14 items between periodontists and dental hygienists. General practitioners reported providing oral-hygiene instructions outside the patients' mouth (38%) or in-mouth demonstrations (56.8%), periodontists preferred in-mouth demonstrations (100%) and dental hygienists indicated that they used a combination of strategies (51.9%) or solely in-mouth demonstrations (46.1%). Furthermore, both periodontists (93.3%) and dental hygienists (96.3%) reported that they provided interproximal hygiene instructions to every patient, as opposed to general practitioners (57.8%) who reported only to instruct patients with assumed compliance. A higher proportion of general practitioners (32.3%), than of dental hygienists (23.3%) and periodontists (19.4%), reported difficulties in reprimanding patients on their homecare. In addition, 32.2% of general practitioners indicated lack of time as a complicating factor for oral-hygiene instructions, whilst only a minority of periodontists (10.7%) and dental hygienists (5.0%) reported this barrier. The vast majority of dental hygienists (88.7%) perceived type of toothbrush as important compared with 62.3% of general practitioners and 71.0% of periodontists. Significantly more periodontists (62.5%) and dental hygienists (87.6%) advised the use of electric toothbrushes to more than 50% of their patients, and significantly more periodontists (87.5%) sold in-office home-care products.
Concerning patient motivational actions, both periodontists (93.8%) and dental hygienists (85.9%) were more inclined to always inform patients about their periodontal condition than were general practitioners (38.5%). Furthermore, they were significantly more satisfied with their efforts (87.5% of periodontists and 82.8% of dental hygienists) than were general practitioners (38.8%) and were more inclined to repeat instructions in non-compliant patients (79.3% of periodontists and 86.6% of dental hygienists vs. 64.9% of general practitioners). Nurture was identified by general practitioners as the factor contributing most to the oral-hygiene level of a patient (60.9%), whilst periodontists (62.1%) and dental hygienists (42.3%) emphasized the influence of the dental professional. A patient-centred approach was reported by periodontists (76.6%) and dental hygienists (73.9%) as being the most important approach to enhance patient motivation. General practitioners also considered other options as appropriate, such as fear of losing teeth (21.8%) and the patient's confidence in the dentist (18.3%). A detailed overview of the results and differences between the answers of general practitioners, dental hygienists and periodontists is presented in Table 2.
Table 2.
Responses to the questions on oral-hygiene instructions (OHI) and patient motivational actions (PM) presented as a percentage, according to the answer option given and to the type of dental professional [general practitioner (GP), dental hygienist (DH) and periodontist (P)]
| Question | Answers | GP (%) | DH (%) | P (%) | GP vs. DH (P) | GP vs. P (P) | P vs. DH (P) | |
|---|---|---|---|---|---|---|---|---|
| OHI1 | How do you give oral-hygiene instruction? | Demonstration outside the mouth | 38.0 | 2.0 | 0.0 | <0.001* | <0.001* | <0.001* |
| In-mouth demonstration | 56.8 | 46.1 | 100 | |||||
| Combination of previous options | 5.2 | 51.9 | 0.0 | |||||
| OHI2 | When do you give interproximal hygiene instruction? | To every patient | 37.2 | 96.3 | 93.3 | <0.001* | <0.001* | >0.999 |
| When I assume the patient will comply | 57.8 | 3.7 | 6.7 | |||||
| When I've got some time left | 5.0 | 0.0 | 0.0 | |||||
| OHI3 | Is it difficult for you to reprimand patients on their home care? | No | 67.7 | 76.7 | 80.6 | 0.033* | 0.501 | >0.999 |
| Yes | 32.3 | 23.3 | 19.4 | |||||
| OHI4 | Which factor complicates the provision of oral-hygiene instruction? | There is no such factor | 23.7 | 23.4 | 46.4 | <0.001* | 0.027* | 0.024* |
| Lack of time | 32.2 | 5.0 | 10.7 | |||||
| Lack of patient's interest | 44.1 | 71.5 | 42.9 | |||||
| OHI5 | Interproximal hygiene instruction is not so important | No | 91.5 | 96.2 | 90.0 | 0.042* | >0.999 | 0.411 |
| Indeed | 8.5 | 3.8 | 10.0 | |||||
| OHI6 | For oral-hygiene instruction the type of toothbrush does not matter | No | 62.3 | 88.7 | 71.0 | <0.001* | >0.999 | 0.033* |
| Indeed | 37.7 | 11.3 | 29.0 | |||||
| OHI7 | I advise use of an electric toothbrush to >50% of my patients | No | 59.8 | 12.4 | 37.5 | <0.001* | 0.048* | 0.003* |
| Yes | 40.2 | 87.6 | 62.5 | |||||
| OHI8 | Do you sell home-care products in your practice? | No | 29.8 | 37.5 | 12.5 | 0.090 | 0.132 | 0.009* |
| Yes | 70.2 | 62.5 | 87.5 | |||||
| PM1 | I always give patients information about their periodontal condition | No | 61.5 | 14.1 | 6.2 | <0.001* | <0.001* | 0.831 |
| Yes | 38.5 | 85.9 | 93.8 | |||||
| PM2 | Do your efforts to motivate patients correlate with the results obtained? | No | 61.2 | 17.2 | 12.5 | <0.001* | <0.001* | >0.999 |
| Yes | 38.8 | 82.8 | 87.5 | |||||
| PM3 | Do patients with poor oral hygiene show less respect for your work? | No | 25.7 | 60.8 | 50.0 | <0.001* | 0.024* | 0.933 |
| Yes | 74.3 | 39.2 | 50.0 | |||||
| PM4 | What if patients do not comply with your instructions? | I repeat over and over again | 64.9 | 86.6 | 79.3 | <0.001* | 0.249 | 0.267 |
| I don't address the issue | 20.2 | 7.1 | 3.4 | |||||
| I would refer to an auxiliary such as a DH | 14.9 | 6.3 | 17.2 | |||||
| PM5 | Factor contributing most to the oral-hygiene level of the patient? | Nurture | 60.9 | 36.8 | 20.7 | <0.001* | <0.001* | 0.519 |
| Socio-economic status | 17.6 | 19.7 | 13.8 | |||||
| Influence of partner | 3.3 | 0.4 | 0.0 | |||||
| Influence of media | 2.4 | 0.8 | 3.4 | |||||
| Influence of dentist | 15.8 | 42.3 | 62.1 | |||||
| PM6 | What factor contributes most to motivate patients? | Patient-centred approach | 52.0 | 73.9 | 76.7 | <0.001* | 0.057 | 0.408 |
| Patient's confidence in dentist | 18.3 | 10.8 | 0.0 | |||||
| Fear of losing teeth | 21.8 | 5.8 | 13.3 | |||||
| Persuasiveness of dentist | 7.9 | 9.5 | 10.0 |
Differences between subgroups (GP vs. DH, GP vs. P, P vs. DH) are displayed by P-values based on Fisher's exact tests (used for dichotomous questions) and Pearson chi-square tests for questions with two or more answer options. Values of P were adjusted for multiple testing using Bonferroni correction.
P ≤ 0.05.
Multivariate analysis demonstrated significant variance in answers between the subgroups of variable qualification in 12 of 14 items, chair-assistance in nine of 14 items, age in five of 14 items and area of practice in two of 14 items. Workload did not influence the responses to the questions about oral health instructions and/or patient motivational actions.
The professionals in the younger age groups considered interdental cleansing as being of greater importance than did their counterparts in the eldest age group. Dental professionals in urban clinics were more inclined to always inform patients about their periodontal condition than were dental professionals in rural clinics and assisted professionals reported to experience greater job satisfaction.
Table 3 presents a detailed overview of significant differences between the subgroups of the investigated variables per dichotomous question. Table 4 presents a detailed overview of significant differences between the subgroups of the investigated variables per question with more than two answer options. Some confidence intervals appeared non-estimable because of quasi complete separation and are indicated as ‘NE’ in Table 4.
Table 3.
Logistic regression analysis of dichotomous questions on oral-hygiene instruction (OHI) and patient motivational actions (PM)
| Question (answers) | Factor comparison | P-value | OR | 95% CI for OR | ||
|---|---|---|---|---|---|---|
| Lower | Upper | |||||
| OHI3 | Is it difficult for you to reprimand patients on their home care? (no, yes) | >0.999 | ||||
| OHI5 | Interproximal hygiene instruction is not so important (no, indeed) | <35 years vs. >54 years | 0.016 | 0.255 | 0.075 | 0.672 |
| 35–54 years vs. >54 years | 0.002 | 0.321 | 0.164 | 0.549 | ||
| OHI6 | For OHI the type of toothbrush does not matter (no, indeed) | GP vs. DH | 0.001 | 4.233 | 2.237 | 9.679 |
| P vs. DH | 0.003 | 4.208 | 1.257 | 12.404 | ||
| OHI7 | I advise use of an electric toothbrush to >50% of my patients (no, yes) | GP vs. DH | 0.001 | 0.095 | 0.054 | 0.150 |
| P vs. DH | 0.001 | 0.155 | 0.063 | 0.365 | ||
| Ass+ vs. Ass− | 0.040 | 1.455 | 1.044 | 2.085 | ||
| OHI8 | Do you provide oral-hygiene products in your clinic? (no, yes) | GP vs. DH | 0.001 | 2.273 | 1.408 | 3.924 |
| P vs. DH | 0.014 | 3.480 | 1.115 | 10.849 | ||
| Ass+ vs. Ass− | 0.003 | 1.689 | 1.150 | 2.656 | ||
| PM1 | I always give patients information about their periodontal condition (no, yes) | GP vs. DH | 0.001 | 0.129 | 0.073 | 0.200 |
| Ass+ vs. Ass− | 0.001 | 2.168 | 1.416 | 3.323 | ||
| Rural vs. Urban | 0.002 | 0.586 | 0.431 | 0.788 | ||
| PM2 | Do your efforts to motivate patients correlate with the results obtained? | GP vs. DH | 0.001 | 0.114 | 0.070 | 0.163 |
| Ass+ vs. Ass− | 0.001 | 1.919 | 1.376 | 2.765 | ||
| PM3 | Do patients with poor oral hygiene show less respect for your work? (no, yes) | GP vs. DH | 0.001 | 0.129 | 0.078 | 0.196 |
| Ass+ vs. Ass− | 0.001 | 2.168 | 1.459 | 3.206 | ||
| Rural vs. Urban | 0.001 | 0.586 | 0.438 | 0.773 | ||
The results are presented as level of significance (P-value), odds ratio (OR) and confidence interval (95% CI for OR). Only statistically significant outcomes are displayed, including qualification [general practitioner (GP) vs. dental hygienist (DH); periodontist (P) vs. DH], assistance (Ass+ vs. Ass−), area (Rural vs. Urban), age (<35 years vs. >54 years, 35–54 years vs. >54 years). Bias corrected accelerated (BCa) bootstrapping (n = 1000) was applied to validate the model and avoid overfitting.
Table 4.
Multinomial regression analysis of compound questions about oral-hygiene instruction (OHI) and patient motivational actions (PM)
| Question | Answer options | Factor comparison | P-value | OR | 95% CI for OR | ||
|---|---|---|---|---|---|---|---|
| Lower | Upper | ||||||
| OHI1 | How do you give OHI? | Demonstration outside mouth | GP vs. DH | 0.001 | NE | ||
| Demonstration outside mouth | Ass+ vs. Ass− | 0.009 | 0.401 | 0.195 | 0.837 | ||
| In-mouth demonstration | GP vs. DH | 0.001 | 16.119 | 7.776 | 39.409 | ||
| In-mouth demonstration | P vs. DH | 0.002 | NE | ||||
| OHI2 | When do you give interproximal hygiene instruction? | To every patient | GP vs. DH | 0.001 | NE | ||
| To every patient | Ass+ vs. Ass− | 0.005 | NE | ||||
| OHI4 | Which factor complicates the provision of OHI? | There is no such factor | Age <35 years vs. Age >54 years | 0.014 | 0.409 | 0.181 | 0.830 |
| There is no such factor | Age 35–54 years vs. >54 years | 0.023 | 0.603 | 0.382 | 0.941 | ||
| Lack of time | GP vs. DH | 0.001 | 6.560 | 3.093 | 19.492 | ||
| PM4 | What if patients do not comply with your instructions? | I repeat over and over again | GP vs. DH | 0.002 | 0.333 | 0.155 | 0.593 |
| I repeat over and over again | Ass+ vs. Ass− | 0.015 | 0.576 | 0.373 | 0.912 | ||
| I don't address the issue | Ass+ vs. Ass− | 0.001 | 0.319 | 0.165 | 0.524 | ||
| I don't address the issue | Age <35 years vs. Age >54 years | 0.020 | 0.291 | 0.091 | 0.709 | ||
| PM5 | Factor contributing most to the oral-hygiene level of the patient? | Nurture | GP vs. DH | 0.001 | 5.983 | 3.473 | 11.588 |
| Socio-economic status | GP vs. DH | 0.002 | 2.883 | 1.470 | 6.290 | ||
| Influence of partner | Age <35 years vs. Age >54 years | 0.019 | NE | ||||
| Influence of media | GP vs. DH | 0.004 | NE | ||||
| PM6 | What is the most important factor to motivate patients? | Patient-centred approach | Ass+ vs. Ass− | 0.007 | 0.487 | 0.303 | 0.789 |
| Patient's confidence in dentist | GP vs. DH | 0.040 | 2.319 | 0.975 | 5.479 | ||
| Patient's confidence in dentist | Ass+ vs. Ass− | 0.001 | 0.298 | 0.145 | 0.535 | ||
| Fear of losing teeth | GP vs. DH | 0.001 | 6.129 | 2.162 | 21.392 | ||
| Fear of losing teeth | P vs. DH | 0.011 | NE | ||||
| Fear of losing teeth | Ass+ vs. Ass− | 0.001 | 0.277 | 0.148 | 0.512 | ||
Results are presented as level of significance (P-value), odds ratio (OR) and confidence interval (95% CI for OR). Only statistically significant outcomes of the subgroups Qualification [general practitioner (GP vs. dental hygienist (DH); periodontist (P) vs. DH], Assistance (Ass+ vs. Ass−) and Age (<35 years vs. >54 years, 35–54 years vs. >54 years) are given. Bias corrected accelerated (BCa) bootstrapping (n = 1000) was applied to validate the model and avoid overfitting. P < 0.05. NE, not estimable because of quasi complete separation.
Discussion
In the present study, a questionnaire on oral-hygiene instructions and patient motivational actions was distributed among dental hygienists in the Netherlands and general practitioners and periodontists in Flanders in order to compare their attitudes toward preventive oral care. The results demonstrated significant differences in the provision of oral-hygiene instructions and patient motivational actions between dental hygienists and general practitioners, as well as between general practitioners and periodontists. Regarding patient motivational questions, no significant differences were noticed in the answers by dental hygienists and periodontists compared with general practitioners. Qualification and the presence/absence of chair-assistance were the most influential factors; age and area of practice had less impact; and workload did not affect the attitude towards oral-hygiene instructions or the performance of patient motivational actions.
The similarities in attitude about patient motivational actions between dental hygienists and periodontists might be explained by the fact that both are aware of the need for patient compliance as an essential prerequisite to succeed in the non-surgical and surgical treatments of periodontal disease17. Nevertheless, significantly different approaches to oral-hygiene instructions were found between both subgroups, suggesting a divergence in instruction techniques6.
The majority of general practitioners reported working without chair-assistance in comparison with a minor proportion of the participating periodontists and dental hygienists. According to Suga et al.18 general dental clinics are focussed to a greater extent on the financially more rewarding restorative treatments than on preventive oriented care. Both findings may explain why a higher proportion of general practitioners, than of periodontists and dental hygienists, indicated lack of time as a complicating factor for oral-hygiene instructions.
Additionally, national variations in reimbursement of oral care may also have influenced the differences in attitude of dental hygienists compared with those of general practitioners and periodontists. In the Netherlands, preventive care, including oral-hygiene instructions, patient counselling and even the follow-up sessions, is reimbursed and charged per unit of time19. In Belgium, oral-hygiene instructions are not reimbursed by the health insurance system because it is not considered as an autonomous activity. Patient motivational actions are supposed to be performed together with a general oral-health consultation, of which the remuneration under reimbursement is limited to once a year. No further specifications or minimum criteria are determined20. Consequently, oral-hygiene instructions and patient motivational actions are provided in the spare time between other clinical activities (e.g. while waiting for anaesthesia to infiltrate or at the end of a consultation).
General practitioners were significantly more inclined to report that their efforts to motivate patients did not correlate with the results obtained. The obvious difference between general practitioners and dental hygienists in addressing preventive care is their clinical focus. Whereas general practitioners have to focus on both preventive and curative aspects, the main focus of dental hygienists is preventive dentistry21. This single focus enables them to establish close engagements with their patients, thus creating optimal oral health. Both close engagement with patients and long-term follow-up have been reported by dental hygienists to enhance job satisfaction22.
In a dental-care system without dental hygienists, patients experiencing primary care complaints, such as plaque-related gingivitis, are directed to general practitioners and/or periodontists. Of these latter groups of dental professionals, both claim to spend enough time on patient counselling and guidance, but within the restricted time limits reserved for each patient23. Often counselling is insufficient and ineffective when patients are in need of special care or require a customised approach24. In addition, the demand for preventive care is increasing, as improved personal hygiene measures in ageing populations is enabling patients to keep their natural dentition for longer. In response, a need is emphasised for task enlargement and/or delegation within the oral sector25., 26..
In oral-health systems without dental hygienists, it is also interesting to consider the economic aspects of delegating preventive tasks, including the lower expenses for training of dental hygienists compared with training for dentists, the creation of new employment in economically hard times, increased access to preventive oral care27, lowered treatment costs and cost-saving reimbursement for health insurance systems and stakeholders28. Notwithstanding, the beneficial consequences for oral health, and by extension general health, as a result of the professionalization of preventive care, are difficult to estimate; they are most rewarding on a long-term basis29.
The present study investigated the attitude of dental hygienists, general practitioners and periodontists towards oral-hygiene instructions and patient motivational actions. A questionnaire was developed to retrieve personal opinions, reflections and ingrained habits starting from daily-practice situations. As a result, two questions (OHI5 and OHI6) were negatively formulated as described by patients in practice. This may have influenced the results owing to inattention or respondents reading the question too quickly.
A total of 965 dental professionals participated in the present study, representing, respectively, 8%, 16% and 36% of the population of dental hygienists, general practitioners and periodontists. Furthermore, the participants displayed an age pattern similar to that of the total population of dental professionals, and the study population was equally distributed as a result of collection of data from multiple locations within the Netherlands and Flanders. Consequently, the cohort analysed in the present study could be considered as representative. Nevertheless, the results of this study should be interpreted with caution. A self-reported questionnaire was used in this study and introduced the risk of bias as a result of socially desirable answers30. To counteract this potential problem, the anonymity of respondents was guaranteed.
Furthermore, despite the fact that Flanders and the Netherlands are neighbouring societies with a similar socio-economic breakdown, differences in health-care organization and reimbursements of preventive treatments could have affected the inflow of patients and provision of therapy. Hence, these factors should be considered when interpreting the results.
Future research could investigate the preventive therapy actually provided in the clinic and focus on the treatment outcome. To understand fully the relationship between the clinician, his/her attitude toward preventive dentistry and the treatment outcome, future studies should also address the patients' perspective, as the literature suggests the presence of a complex relationship between treatment approaches and patients' perceptions31., 32..
Conclusions
The present study has identified barriers to and divergence in the application and opinions about oral hygiene instructions and patient motivational actions between dental hygienists and general practitioners/periodontists working in a context without dental hygienists. In addition to qualification, the presence/absence of chair-assistance was also identified as affecting the attitude towards preventive oral care. In response to the reported barriers it is suggested that preventive orientated care may benefit from the deployment of dental hygienists to increase access to comprehensive preventive oral care.
Acknowledgements
The authors would like to express their gratitude to the Flemish Dental Association (V.V.T.), Proctor and Gamble Oral Health and Ms Joyce Baert for their support with data collection. Eric Thevissen received a scientific grant from the Flemish Dental Association.
Conflict of interest
None.
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