Action Research, Reflection and Inquiry Learning

Context – The First Step in this Long Journey of New Knowledge Creation through Action Research 2017

This somewhat alternative looking post is the back story and early learning knowledge creation that lit the touch paper for wholedentalhealth.com. It was presented twice to professional audiences in Nelson and Auckland in 2017. It was the outcome of extensive nutritional research carried out over the previous months when the opportunity arose. This usually occurred during twice-daily dog walks and even during a 5-day cycle through Central Otago, I kid you not. The intention was to fill a vast knowledge gap regarding nutrition and dental health primarily. It, however, soon morphed into a far bigger project as more and more associated health-related material was discovered. What you see before is just a snippet, relevant though, of the presentation delivered on those days. The title really says it all, especially concerning the ongoing nature of learning that followed but also the contrary process of understanding the nutritional relationships between the mouth and the body. It revealed the politics, personalities and clashes between the ideologies of the time, and their effect upon the future of dentistry, and my dental landscape in particular.

The learning aims leant heavily on the available research gleaned from the internet from reliable sites like PubMed and Cochrane, but a lot came from books and news publications.  Some of these appeared in the public domain way before my birth. There seemed to be a massive disconnect between the established science and the voices of some very learned and passionate voices in the medical field. It also became very apparent that current thinking was very slowly unravelling, becoming less convincing and harder to justify within the new age of scepticism and scrutiny. The internet was acting as a courtroom, podcasts and publications contradicting and challenging the present status quo and beliefs. This wasn’t being done in some callous, half-hearted manner but within the bounds of scientific methods and criteria. The most prominent exponents of these were journalists using their talents at spotting a rotten apple and getting their teeth, so to speak, into the meat of the matter, finding obfuscation, contradiction and blatant misleading by the elements of the medical establishment, and the confounding of the public at large. Ego, money, power and persuasion appeared deeply rooted.

Take, for example, the very public journeys of one Ancel Benjamin Keys and a the lesser known, it seemed at the time, John Yudkin. One American, fresh from the nutritional fame of the World War 2 K ration design for US troops and a marked political influencer on one Dwight D. Eisenhower, American President and multiple heart attack sufferer. Key’s diet-heart hypothesis ran contrary to that of John Yudkin, a British scholarly and published Academic. His assertion was that sugar, refined carbohydrates, in particular, was the primary antagonist in the marked decline in modern health, associated with changing lifestyles and behaviours. Both men published books to back up their ideological and theoretical positions.

It was at this time that the scientific method of epidemiology saw its debut. It involved gathering data and assimilating findings into hard data, interpreted with graphs displaying mathematical statistics, revealing answers to scientific questions regarding the particular population being studied. It became a new feature to the public, demonstrating the significance, both colourfully and persuasively, of their research findings and advancing their theories into mainstream policy making. Yudkin, unfortunately, was the loser in this alternative scientific heavyweight contest. His reputation was besmirched by the darling of the medical and political establishment, Ancel Keys, with his subsequent funding for his important future research drying up, and his academic reputation in tatters. The legacy of which is now that of sugar laden processed diets of our modern society, an anathema to our ancestral dietary roots. The demonising of saturated fat continued until recently when investigative journalists sought to demonstrate Yudkin’s assertions and theories would have had a far more positive impact on global health.

The use of visual evidence to demonstrate the correlation of dietary behaviours to disease outcomes was in its infancy. Evidently too, it was also possible to “cherry pick” and select positive data to affirm a position or article of faith, in this case nutritionally. Data gathering on countries with diets that could have confounded the statistical charts was absent or ignored. Evidence was also presented in biased ways, focusing on men, of a specific age, not adjusting for cultural, religious, climatic or physical facts, information that could spoil the effect and positive power of the curve. These charts presented powerful arguments to those in positions of authority and influence. More funding and research would follow, and advice given to the politicians and people of the world, fearful of the negative health implications of fat in their diet, subsequently changed the food industry as we then knew it.

However, recent emerging evidence from critical investigation by determined journalists and medical specialists is challenging the gated medical establishments standpoint. This has been potentiated by the freedom offered by social media, the internet and activistic pressure groups. New research is reversing the belief that saturated fat is bad but is also demonstrating its potential health benefits.

The project made me consider me pre-existing beliefs, one specifically opened up a glaringly obvious omission, that sugar is was only implicated in dental caries. Low and behold the lightbulb moment when the penny dropped on that one. I was stunned, and somewhat crestfallen, some of these studies go back many years. Why wasn’t this part of my training way back  in the mid-eighties?

My critical deep dive into learning also drew my attention to nutritional changes beyond simple sugars. The micro-nutrient components of food, minerals and vitamins essential in the maintenance of good oral health and the development of the mouth, required my attention too. The presentation looked closely at essential fatty and amino acids, as well as, omega 3 and 6 levels, and their role in reducing systemic inflammation. It seemed strange but wholly appropriate to make the association between the mouth and the rest of the body. The paradox that both are separate and neither the twain shall meet now, in itself is plainly inappropriate. What and how we eat, the function of our teeth, their bony support, blood supply and innervation are all connected to the whole well-being and function of our bodies. This also brings into context the holistic approach to practice, more food for future investigation. Further to that it made me consider the endocrine system, chemical messengers, namely hormones, which are intrinsic to the health of our bodies, by regulating hunger or satiety, and chemical communication. But when imbalanced and influenced by poor nutritional choices, may promote addictive habit forming behaviours which can add significantly to the plethora of chronic diseases plaquing dental health like diabetes and obesity.

The experience of this process alerted me to the need to encompass nutrition as part of my workplace practice. It now plays an even larger role in improving oral health, both directly and indirectly. Having a greater general knowledge allows me to better understand client general nutritional behaviour and preferences. The understanding of individual health ideology, for example clients who are vegan, vegetarian or carnivore, allows me greater awareness of how best to adjust or adapt a tailored dental health message.

Future learning will be directed at the nutritional and behavioural role in maintaining and promoting healthy oral flora, our mouths ever present microbiome, part of our bigger, personal bacterial picture. What foods can support or imbalance this important and potentially beneficial ecology in our mouth? Which dietary choices can lower or elevate the mouths critical pH balance? Co-existing with our acquired oral and general bacteria can afford us benefits in health and well-being as much research is now demonstrating. Therefore promoting an environmental and ecological approach to oral health maintenance is the future direction of my personal practice.

Action Research – At the beginning

I was never really academic at school, much to my father’s consternation. He was Edwardian in his manner, distant, expecting but caring. I was very average at most things but enjoyed Art and Sport finding most core subjects totally dull and uninspiring. My school reports pay historic lip service to that fact. However, where I enjoyed or understood something I began to learn, with a passion and a hunger, as I still do today. I could smell the sweat,  carbon and oil in the pictures I drew for Mrs Edwards and she in turn gave me freedom to learn. Teach and preach at me meaninglessly and I will rebel, give me the freedom and method to learn on my own, in my own time and I will thrive and take up the mantle. interestingly I also find this particularly true with languages as when I lived in Germany or holidayed abroad, learning was alive and my very reality, it was all around me. This typifies another learning environment, my workplace.

“Mark appears to spend most of his time on the Eastern Front in the Spring of 1943”.

Mrs Edwards, Marks Art Teacher 4th Year, The Winston Churchill School

Learning

Russell, Ackoff and Greenberg (2008) point out in their book, Turning Learning Right Side Up: Putting Education Back on Track , that our education system is seriously flawed focusing on teaching rather than learning. “Why should children or adults be asked to do something computers and related equipment can do much better than they can?” Traditional education focuses on teaching, not learning. It incorrectly assumes that for every ounce of teaching there is an ounce of learning by those who are taught. Most of what is taught in classroom settings is forgotten, and much or what is remembered is irrelevant.

Carl Rogers (1969) famously described in Freedom to Learn learning as “insatiable curiosity.” He divides it significantly into two types, a meaningless “from the neck up” involving no “feelings or personal meanings” with no relevance for the “whole person.” and contrasting this with so-called “experimental learning”, one which brings personal significance and meaning which can proceed rapidly. Such significant learning he defines further as having  self-initiation and a sense of discovery and being pervasive changing “behaviour, the attitudes, and perhaps even the personality of the learner.” Controversially Rogers continues by conjecting that all teachers and educators would prefer to facilitate such experimental and meaningful learning rather than a nonsensical syllabus.

“Education is an admirable thing, but it is well to remember from time to time that nothing that is worth learning can be taught.” Oscar Wilde

Donald Schon (1963, 1967, 1973) linked the experience of living in a situation of an increasing change with the need for learning. He stated that “we must become adept at learning” and “be able not only to transform our institutions, in response to changing situations and requirements; we must invent and develop institutions which are ‘learning systems’, that is to say, systems capable of bringing about their own continuing transformation.” A  learning society culture has now been created as “education systems were no longer able to respond to the demands made upon them” ( Hutchins, 1968). Bring on the concept of lifelong learning.

Experimental Learning

There are many different ways of learning; teaching is only one of them. We learn a great deal on our own, in independent study or play. We learn a great deal interacting with others informally too, sharing what we are learning with others and vice versa. We learn a great deal by doing, through trial and error. Raj Ratten (2002) states that all dental professionals should pursue “personal and professional growth” and “acquire and refine skills.” He continues with a criteria for successful learning which is “led by the learner”, is “problem centred”  and demonstrates “active participation and the use of their own resources.”

Gray et al (2004) indicate, referring to Kolb and Fry’s Learning Cycle (1975), that learning “begins with an experience.” It involves observations and reflections which generate concepts which are then tested in practice. Honey and Mumford (1992) define individual learner styles as either activist, reflector, theorist or pragmatist in nature with experiences followed by reviewing, concluding and planning. It can be seen by both models that learning is reflective in nature too. They continue by attempting to define the meaningfulness of learning by making a distinction between it being deep or surface in nature. Some learners describe learning as “an increase in knowledge, memorisation  and increasing ability to apply knowledge.” Others think learning is “an increase in understanding, the seeing of things in different ways or change as a person.” One way of developing a practical, meaningful and deeper understanding of learning in the workplace is the egalitarian and democratic endeavour of action research.

Action Research

Action research is a value driven, powerful, collaborative and liberating form of enquiry based learning which begins simply with a question. Do I need to improve my practice? If so, how? It is inclusive in nature, there for everyone. McNiff and Whitehead (2011) plan a process that involves observation, reflection, acting, evaluating and modifying before moving on being framed as an action-reflection cycle.

The critical aspect of action research is that of the individual “I” being at the centre of the process, the “first person”. This puts you, your questions and experiences within your workplace into the centre of learning. It brings your thoughts, reflections, theories and actions into a personal living form. Your theories are not taken just from others, be they your peers or academics but also what is happening to you and is termed “living theory.” Thus we, as Dental Care Professionals can claim to be;

“Practitioner Researchers, First Person Living Theorists”

who “improve their understanding, develop their learning and influence others’ learning.”

Action researchers;

• Identify a research issue
• Identify research aims
• Design a research plan
• Gather data
• Establish a criteria and standards for judgement
• Generate evidence
• Make a claim to knowledge
• Submit the claim to critique
• Explain significance of work
• Disseminate findings
• Link new and old knowledge

McNiff and Whitehead, Action Research (2011, p.26)

My living contradiction – a reflection

There were many times when I  felt out of step with the direction of many a practice. I was a professionally conflicted  for years, as Whitehead (2006) relates “that you see yourself as a living contradiction, holding educational values whilst at the same time negating them” (http://www.actionresearch.net/writings/china/mllet10908.htm). I aimlessly attended annual symposia never seriously paying attention to or gaining from them. This typified my approach to learning at the time, a dull and meaningless process directed at me. I now have a super system driving and facilitating my desire to learn and earn. I am into my first action research project through the O’Hehir University that introspectively looks to improve my delivery of oral health in my workplace. It is simple in its construction, collaborative with my practices, the dental industry and patients ultimately benefiting the improvement of my practice. An experimental initial project undertaken earlier was supported by a dental supplies company and looked at implementing air polishing to improve my practice (http://mihygienist.wordpress.com/2012/09/17/experimental-learning-within-the-workplace-ems-air-flow-handy/).

I am of the conclusion that traditional education partially qualified and equipped me personally and professionally. I am also still developing in both. I now believe I am a different living contradiction. Not one of clinical negation but more of being opposed to the culture of passive knowledge gain supported by endless corporate opportunists exploiting the crazy regulatory fixation in our professional environment and thus sadly in our workplace too. Attending meetings that don’t reflect our learning needs, mollified by free lunches or so-called “high profile” speakers might tick the boxes but no more than that. Action research is our future and I intend to do as much, if not all, of my future CPD cycle in that method. 

“Continuously review your knowledge, skills and professional performance. Reflect on them, and identify and understand your limits as well as your strengths. “
Professional Standards in Dentistry, GDC, UK

O’Hehir University Project Part 1: A DCP Pilgrims Progress – A Simple Journey into Dental Health Improvement

The term “journey” nowadays seems to be a noun guilty of gross overuse. However, I feel it’s very roots are founded in our great English literary past. John Bunyan, (28 November 1628 – 31 August 1688) an English Christian writer and preacher, wrote in allegorical terms about one such very famous journey. First published in 1678 and written whilst Bunyan was imprisoned in Bedford Jail it follows the journey of an everyman character called Christian. This “burdened” individual sought guidance and deliverance from his sin and guilt and along the way encounters both good and bad people and events including “the Slough of Despond”, a physical swamp of despair, only to be pulled out by Help. He is finally led to the “Place of Deliverance” where the shackles and straps of his many burdens are freed. Christian mirrors my own journey in many respects, one of continuous trials, occasional success, support and the odd moment of deep despair. I am now certain of one reality, I am nearing my proverbial place of deliverance. How do I know that? Professionally I have been, seen and done many things and feel am now completing my professional circle by returning to a simple, deconstructed and stripped back approach to dental health promotion. Perhaps this is where I should always have been (MIHygienist, 2012a).

Observation

People’s minds are changed through observation and not through argument. Will Rogers
I seek a new challenge, one which wants to deliver better simple dental health outcomes to my patients – but why? And more over, what is the best way to achieve it? My Strengths, Weaknesses, Opportunities and Threats (SWOT) assessment indicated to me the need to introspectively look at what I do in practice and affect or influence others to be like-minded. I can easily criticise other clinicians for delivering a poor and less focused dental health message but I need to examine myself too. An appraisal of this determined I was doing a good job but I still I know I can improve my performance further and would like to know how (MIHygienist 2012b &c).

What is Dental Health?

Is the pure message of dental health being diluted by less preventive and more lucrative treasures? Perhaps I am too cynical by half nowadays but worryingly I found no dental health definitions from our Professional major players and had to, instead, go straight to the top to finally discover one. The World Health Organisation (WHO) state the “Oral health is a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity”(WHO, 2013).The Department of Health (DoH) determine that Dental health is a “Standard of health of the oral and related tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being. Oral health is integral to general health and should not be considered in isolation (DoH, 2006).
In the UK regulators and professional bodies direct my continuing clinical journey. I am tasked to apply up-to-date knowledge, provide dental hygiene care and skills to a wide range of patients ethically (GDC, 2009). Additionally, clinical governance promotes criteria for successful learning that is founded on what is already familiar to the learner, is owner led and participated, problem-centred, self-resourced, built on previous experiences, and involves relevant and timely feedback and elements of self-assessment (Ratten et al, 2002). This linked to our professional standards which advocate providing a “good standard of care based on available up-to-date evidence and reliable guidance” and “putting patients’ interests before your own or those of any colleague, organisation or business” as well as “maintaining your professional knowledge and competence” (GDC, 2005) sets the legal framework for my project.

Critical Enquiry

Periodontal diseases and caries are both major acute and chronic diseases known to mankind and are of complex multifactorial bacterial, health and lifestyle origin. The 2009 Adult Dental Health Survey indicates that 31 per cent of adults had obvious tooth decay in either the crowns or roots of their teeth but the pattern of decay since 1998 has decreased from 46 per cent to 28 per cent. 45 per cent of adults had periodontal pocketing exceeding 4mm but only 17 per cent of dentate adults had very healthy periodontal tissues and no periodontal disease.

Disturbingly 75 per cent of adults claim to clean their teeth at least twice a day whereas 23 per cent of adults said that they cleaned their teeth once daily. A surprising 78 per cent said that they had been given advice by the dental team on cleaning their teeth and/or gums. 66 per cent of dentate adults had visible plaque on at least one tooth. The survey continues to claim, contradictorily in my opinion, that “Whilst twice-daily brushing is now a fact of life for three quarters of the population, there is still some room for improvements in the effectiveness of that cleaning” (DoH, 2011). I can only surmise that despite the great exposure to “the” dental health message more “smart” and “simple” targeted advice is required in at the “clinical coal face” and elsewhere besides.

“Simplicity is the ultimate sophistication”. Leonardo da Vinci

Action Research – The Vehicle

Action research commits the critically enquiring clinician to improve their individual practice by creating and measuring new knowledge, collaborating with others for social good in a personally accountable and value driven context (McNiff and Whitehead, 2011). Such projects are far removed from traditional methods of enquiry being centred in the individual workplace in a vital, living context, far removed from theory derived outside of the reality of clinical life. The action reflection model follows a logic course unravelling and structuring the activity of the individual. Reason and Bradbury (2008) identify such a project as “First – person research” (me) and is of a kind “that enables the researcher to foster an inquiring approach to his or her life, to act choice fully and with awareness and to assess effects in the outside world while acting.”

I had originally wanted to compare two patients groups in a blinded and controlled manner but after discussion with my mentor I changed from this pretext as it required unnecessary ethically approval with a time delay, complexity and was less driven by the values of action research. I can achieve my learning, discover truths, and by doing so improve and move my practice forward for professional and social benefit in action research.

Into Action

“Fortune Favours the Prepared Mind”. Pasteur

I want the project to focus on simple delivery of a focused dental health message which, I believe will contribute significantly to reducing “active disease” in the gums and teeth by more effectively reducing and deconstructing dental biofilm levels. I also want to demonstrate improving Basic Periodontal Examination (BPE) outcomes but more importantly changes in perception of dental health in my patients. Markman (2012) in his book “Smart Thinking” advocates the role of three in developing high quality knowledge and learning. My action plan will test this theory of a culture of smart by linking existing knowledge, in this case what they currently do as part of their dental hygiene activity, to remembering three things about their interaction with me, namely brushing, interdental cleaning and fluoride advice. (MIHygienist, 2012d) The VAK (aka VARK) learning model postulated by Fleming and Mills (2010) and states four types of learning styles. I am focusing on three listed below as the written (R) will be handed out to the patients in a leaflet.

1. Visual learners – Preference for learning by seeing
2. Auditory learners – Preference for Listening and learning
3. Kinaesthetic learners or tactile learners – Prefer learning by experience

I therefore want to use a role of three model that encapsulates all of the above.

1. The model – Visually demonstrated
2. My mouth – Visual and Auditory (and less threatening)
3. Their mouth – Kinaesthetic, tactile whilst confirming understanding

Protocol
The project form will be given to each patient, over 120 to make the results more meaningful, twice over a project period of 4 months. The design of the form is composed of 2 parts, an initial enquiry into the patient’s current dental health behaviour and a BPE probing and a simple question on how they feel they learn (MIHygienist, 2012e). The appraisal and reflective part concludes the process. I don’t think it will take too much time to complete but the real challenge is determining who to select as some people don’t use a Braun Oral B (most do however) . I have decided to focus on those who use Braun and Manual Brushes as the company have supplied me these products to aid the project. Floss picks I will supply myself. The BPE will measure whether dental health has improved individually and as a whole and the questions will be audited to determine potential behavioural change. I will reflect on those and myself professionally as a consequence of the project.

Conclusion

“Finally, from so little sleeping and so much reading, his brain dried up and he went completely out of his mind.” Don Quixote

I anticipate the need to modify certain aspects of my project upon evaluation will occur. I welcome this and am willingly intent on learning from the outcome and then move on to something else that needs a similar deconstruction job doing to it. I believe that by following action research that I fulfil my commitment to “Continuously review my knowledge, skills and professional performance. Reflect on them, and identify and understand my limits as well as my strengths.”

References

MIHygienist (2012a) O’Hehir in my 2013 Face – Accepting the past, Valuing the present, Embracing the future. Available at http://mihygienist.wordpress.com/2012/11/18/accepting-the-past-valuing-the-presenting-embracing-for-the-future-oherir-in-my-2013-face/ (Accessed 10 January 2013)

MIHygienist (2012b) O’Hehir University SWOT ANALYSIS | SISYLANA TOWS – A Reflection.Available at: http://mihygienist.wordpress.com/2012/12/12/swot-analysis-sisylana-tows-a-reflection/tp (Accessed 10 January 2013)

MIHygienist (2012c) O’Hehir University = Simply Putting Opinions into Action (Learning). Available at: http://mihygienist.wordpress.com/2012/12/29/ohehrir-university-simply-putting-opinions-into-action-learning/ (Accessed 10 January 2013)

World Health Organisation (2013) Definition of Dental Health Available at: http://www.who.int/topics/oral_health/en/(Accessed 10 January 2013)

Department of health (2006) Oral Health, Eastern Regional Public Health Observatory. Availableat:http://www.erpho.org.uk/Download/Public/13920/1/204082%20INPHO%2017.pdf (Accessed 10 January 2013)

Press. General Dental Council. (2009) Standards for Dental Professionals. London, GDC Publications. Available at: http://www.gdc-uk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf (Accessed 10 January 2013)

Rattan et al. (2002) Clinical governance in general practice. Oxford, Radcliffe Medical ltd, P49-53.
General Dental Council (2009) Scope of Practice, London, GDC Publications.

Availabkleat:http://www.bristol.ac.uk/dentalpg/dcp/scopeofpractice.pdf (Accessed 10 January 2013)
British Society of Periodontology (2011) Basic Periodontal Examination. Availableat:http://www.bsperio.org.uk/publications/downloads/39_143748_bpe2011.pdf (Accessed 10 January 2013)

Department of Health (2011) 2009 UK Dental Health Survey. Availableat:https://catalogue.ic.nhs.uk/publications/primary-care/dentistry/adul-dent-heal-surv-summ-rep-them-seri-2009/adul-dent-heal-surv-summ-them-exec-2009-rep2.pdf (Accessed 20 January 2013)

McNiff and Whitehead. (2011) All you need to know about action research, SAGE Publications, London.

Reason. and Bradbury. (2008) The SAGE handbook of action research: Participative Inquiry and Practice.

Markman, A (2012) Smart Thinking, Pilatus, UK. p.75-82.

MIHygienist (2012d) Air-Flow A Go-Go – The Role of Three as part of Smart Thinking.Available at: http://mihygienist.wordpress.com/2012/07/12/air-flow-a-go-go-the-rule-of-three-as-part-of-smart-thinking/ (Accessed 10 January 2013)

MIHygienist (2012e) O’Hehir University – My Assessment Tray – A Way Forward For My Practice? Available at: http://mihygienist.wordpress.com/2012/11/25/my-assessment-tray-a-way-forward-for-my-practice/ (Accessed 10 January 2013)

Fleming, N and Mills, C. (2010) “Not another Inventory, Rather a Catalyst or Reflection”, To Improve the Academy, Vol. 11, p.

Recently published in Dental Health I hope this can demonstrate a workplace action research journey that can demonstrate how to develop from research, problem solving, learning and knowledge creation.

Mark James BSc RDH

O’Hehir University Project Part 2: A DCP Pilgrims Progress – A Simple Journey into Dental Health Improvement

“Listen to patients and give them the information they need, in a way they can use, so they can make decisions.”

2.4 Professional Standards in Dentistry, GDC, UK 1

Introduction

I qualified as a Dental Hygienist in 1988 and continue this journey today after nearly a quarter of a century still intent of learning how I can improve my practice, enjoy my work and meaningfully add to society. I currently work between five practices, a personal choice born of economic reality and have found the additional challenge of O’Hehir University at times daunting as a consequence. More daunting however is the reality of dental health in Britain today. It appears to me a World where real truths are hidden with smoke and mirrors to promote a picture of continuing improvements and reductions in dental disease and risk, where smart advertising influences the public in their dental habits and where the reality of true dental health improvement appears to have been diluted in political correctness and dogma. Added to this is a smattering of cynical commercial imperatives for less functional and dental health related care. What had happened to dental health and how could I make a difference in my practice and, if I succeeded, to a bigger dental and general audience? Having learned during mentorship training about learning styles I wondered after so many disappointments at patient reviews and follow ups if I had missed something blindingly obvious, essential and indeed simple? How would I facilitate this investigation and where would it end, if at all? I started where every good narrative in born, at the beginning.

What was my concern?

The Department of Health (DoH) in 2007 published an evidence based preventive toolkit for dental professionals appropriately named “Delivering Better Dental Health.”2 Updated since, it gives a meagre one side of A4 with an understated introduction claiming that the “major dental conditions of caries and periodontal disease can both be reduced by regular toothbrushing and fluoride toothpaste.” The National Health Services (NHS) Dental Epidemiological Programme for England report (2010) stated more resoundingly that “Oral health is an important indicator of a population.” 3 If these are true should we be proud or satisfied of our achievements or crest fallen with despair at the reality? What have we achieved thus far and where are we going? Are we improving dental health and, if so, where is the evidence to prove it?

Why was I concerned?

In 1968 the Adult Dental health Survey (ADHS) began, less the thirty years after the Second World War ended, three years after I was born. The fifth and latest survey, 2009, was published with the additional intention of obtaining “knowledge about and attitudes towards dental care and oral hygiene” and changes over time in dental health, attitudes and behaviour. It demonstrated interesting and sombre reading. 4

In dental health terms;

• 9 per cent of adults reported current pain.
• 8 per cent of adults had one or more untreated teeth with unrestorable decay.
• Untreated and unrestorable decay was present in 23 per cent of those with current dental pain.
• 66 per cent of dentate adults had visible plaque on at least one tooth averaging nearly 23 percent of all teeth.
• 68 per cent had calculus in at least one sextant of the mouth.
• 17 per cent of dentate adults had no evidence of periodontal disease.

The public perception was that;

• 81 per cent of adults said that their dental health was good or very good.

The ADHS perception was that;

• The importance of toothbrushing twice a day is a message that appears to have been taken on board by the MAJORITY of dentate adults.
• Modern dentistry is centred on a “Preventive philosophy.”

If these figures and facts about the nation’s dental health are to be believed and are reflected in our practice environment are we satisfied that Britain’s dental health practice is built upon firm foundations or are there still important questions to be asked? Surely there is a massive discrepancy to what the public believe and their reality as a whole? Moreover, are the academics and politicians who sanction such findings deluded to state that modern dentistry is preventive centred and improving?

A famous British general once reflected upon the dramatic initial events after D-day on the 6^th June 1944, where the enemy prevented his advance. He commented that “There is no such thing as an ordinary battle” and that leaders at all levels must “adapt their actions to the particular problems confronting them.” Montgomery clearly was frustrated and aware of the human cost of employing failing tried and tested formulas, predictable and too rigid, which were being defeated by a determined foe. 5

Could a simple dental health strategy, supported now with better direct public access, being affordable and patient centric improve those statistics and more over change attitudes and perceptions of professionals and the public too? I believe we too, are fighting a battle against the causes of dental disease and by approaching the foe with predictable, rigid and unimaginative strategies we too are prevented in making a vital and dramatic breakthrough. Where did I start this process?

“Action research should be seen as not simply about problem solving but also learning and creating knowledge”. McNiff and Whitehead

The vehicle, evidence and data

There are many ways of getting from A to B, of achieving our aims and goals but as a clinical hygienist I had never been trained to think and challenge myself beyond the bounds of my training. This was an attitude that has denied me advancement until I discovered Action Research (AR).

AR is designed to reappraise or affirm old or current knowledge and theory. It is morally and value driven, related to our workplace and is set within a social context (the dental health of our patients and the nation), challenging us to improve our “workplace practice through improving learning”. Its egalitarianism and social context puts the benefit of our learning to the patient first but further more can advocate our newly discovered theory and knowledge gain to a bigger professional audience too. It is first person centred (you and me), living theorist (our workplace learning), collaborative (involving others both public and the profession), and “actively” reflective by improving our practice through experiencing, questioning, researching and finding new knowledge and understanding. 6

Action research aspires the practitioner researcher to be open ended developmentally, allowing them to continue their projects flexibility and within a learning and developmental framework. We never stop learning but through AR we understand that what we do is provisional, not set in concrete, but will grow and change with new knowledge and feedback from our peers and patients alike due to its reflective, unfolding nature.

“Change is the end result of all true learning”. Leo Buscaglia

The evidence

I began the project and started gathering evidence from the beginning of February and intended to complete as many of the second parts of the process as possible. Ideally it would have been more interesting and perhaps convincing to have over a hundred participants in the end but circumstance and poor health only allowed me 21 with 8 completing both parts 1 and 2. As the project began I became aware of a couple of issues that needed addressing, one directly and the other indirectly.

AR allows us the opportunity to change our process reflectively. This happened to me when I began the data gathering. I hadn’t considered stamping an ethical statement on the form initially but upon further reading and research I changed tack and evolved my form (MI Hygienist, 2013a). 7 This I feel was critical in the respect of potential peer validation beyond O’Hehir University and possible future publication to a bigger audience. I also felt that I had intrinsically missed out another important question and asked one that wasn’t so weighted in value. Thus my form evolved further to incorporate a patient value section whilst omitting detailed oral hygiene advice (see forms below). I was more concerned about understanding how the patient thought about their dental status rather than how many times a day they flossed as the later could be addressed through the learning and motivational phase. Knowing where they stood in terms of dental health priority was vital. Did they value their dental health more than function and appearance?

All participating patients, whether they completed part 2 or not, received routine active instrumentation and prophylaxis within the confines of a thirty minute appointment. They were initially asked to answer part of the form and then complete it afterwards in private and give feedback if desired.

Initial Dental Health Improvement Project Form – Mark James RDH

Name                                                         Date                                                    Visit

Do you use a manual or an electric toothbrush or both?

Manual

Electric

Both

Do you clean between your teeth?

Floss/interdental brush

Both

No

How often do you use them? More than twice, twice or once daily or never?

Toothbrush     ________   Floss/ Interdental  _________

How best do you think you learn?

Seeing

Listening

Doing

Combo

Marking scale is 1 to 5 [5 being the highest]

1

2

3

4

5

How do you rate your mouths present health?

Do you feel this dental appointment will help you improve your dental health?

How do you rate your Dental Hygienists performance in delivering your dental health message?

BPE Examination   Additional Comments/Feedback

Adapted Dental Health Improvement Project Form – Mark James RDH

Name                                                         Date                                                    Visit

Do you use a manual or an electric toothbrush or both?

Manual

Electric

Both

Do you clean between your teeth?

Floss/interdental brush

Both

No

How best do you think you learn?

Seeing

Listening

Doing

Reading

Where would you place these in order of importance to you?

Health

Function

Aesthetics

Marking scale is 1 to 5 [5 being the highest]

1

2

3

4

5

How do you rate your mouths present health?

Do you feel this dental appointment will help you improve your dental health?

How do you rate your Dental Hygienists performance in delivering your dental health message?

Additional Comments/Feedback                                    BPE

Ethical Statement

I am undertaking action research in how to improve the outcome of dental health through improved communication with and feedback from you. I will give priority to your interests at all times, protect your identity unless you express otherwise. You are free to withdraw from this research at any time and all data will be destroyed. If made public I will check all data related to you.  Mark James RDH  

I hereby give permission to be included in the research.

——————————

The data

The first set of data compiled the evidence gathered in total, divided by the 21 participants. The second combined both parts 1 and 2 of the 8 patients who completed the project.

The 21

Those who allowed me to begin the project were from two of my five practices. The overall impression I got from feedback was a genuine surprise and satisfaction that they felt included, involved and empowered within this process. Most were keen to spend time after the appointment to give feedback and comments. Some feedback proved very useful and most supportive. I learnt the important lessons of time management regarding the questioning and oral hygiene phase. I kept it brief, hence an attraction to a “quick brief” approach which evolved into a motivational interviewing style linked to their preference for learning.

“Came out of today with good solid information on how to progress and improve my oral health, delivered in a professional and friendly manner, many thanks”.

“Expected only a routine clean before fillings, but was advised about other problems. Given information and demonstration about what I need to do moving forwards (very impressive!) and told next steps, which is exactly how I like to be told. He helped me understand instead of being told off as per previous”.

The data told me that;

         Over half, 57 per cent, were using a variety of powered toothbrushes.

         38 per cent didn’t interdentally clean.

         71 per cent viewed themselves primarily as kinaesthetic or “doing” learners.

         73 per cent considered their dental health more important than function or aesthetics.

         57 per cent rated their mouths as average.

         81 per cent felt they’d benefit from and improve their dental health with 85 per cent very satisfied with my performance.

Gathering initial data is great in getting a snap shot of a group with base line records. The most compelling aspect of moving beyond this was to discover whether my concept of delivering a different oral hygiene message would succeed. Would this and the additional benefit of using an oral hygiene product (supplied free) to demonstrate techniques intra orally, based upon their perceived learning style be conducive to behavioural change and improved results and outcomes? Part 2 would be the key phase of the project.

Dental Health Improvement Project – Data Drop Box 1

Do you use a manual or an electric toothbrush or both?	Manual  7			Electric 12					Both 2
Do you clean between your teeth?	Floss/interdental brush 8				Both 5				No 8
How best do you think you learn?	Seeing 2		Listen  1				Doing 15			Reading 3
Where would you place these in order of importance to you? (15 completed )	Health 11					Function 0				Aesthetics 4
Marking scale is 1 to 5 [5 being the highest]	1	2				3		4			5
How do you rate your mouths present health?	4	4				12		1
Do you feel this dental appointment will help you improve your dental health?	1							3			17
How do you rate your Dental Hygienists performance in delivering your dental health message?	1							2			18
3.2          (67)   2.9    (60)   3.2     (67) 2.9   (62)  2.6     (55)   3.1     (65)   Average BPE combined scores in brackets

The 8 of 21

Parts 1 and 2 combined – Dental Health Improvement Project – Data Drop Box 2

The figure before the/is the first appointment, the figure after is the second

Do you use a manual or an electric toothbrush or both?

Manual 1/0

Electric 7/8

Both

Do you clean between your teeth?

Floss/interdental brush 4/7

Both        1/1

No  3/0

How best do you think you learn?

Seeing   1/3

Listening

Doing   5/4

Reading   2/1

Where would you place these in order of importance to you? 4 out of 8 completed

Health            3/8

Function

Aesthetics 1/0

Marking scale is 1 to 5 [5 being the highest]

1

2

3

4

5

How do you rate your mouths present health?

1/1

6/1

1/5

0/1

Do you feel this dental appointment will help you improve your dental health?

1/0

7/8

How do you rate your Dental Hygienists performance in delivering your dental health message?

2/0

6/8

3.5 (28)    2.6 (21) 3.3 (26)   1.8 (14) 3.5 (28)    2.8 (23) 3.4 (27)   2.3 (18) 3.1 (25)   1.6 (13) 3.4 (27)   2.5 (20)   BPE combined in brackets Parts 1 (above) and 2 (below) Average BPE of Parts 1 and 2 in front of bracketed figure

 

I was initially concerned about the small number who completed part 2 and had hoped to get a bigger snap shot of the group. The time period between the two was between 3 and 4 months but I was content that I would see evidence of behaviour change and dental health improvement. Essentially I wanted to discover whether the VARK learning, intra oral product use and collaborative questioning combined with an evolving motivational interviewing (MI) technique would significantly show progress.

The data told me that;

• All changed to powered toothbrushes under advisement.
• All began flossing or interdental cleaning or both.
• Some of the group reflected upon their learning styles and changed their learning preference to better suit success in the future.
• All 4 of the group who completed the value section confirmed that their dental health was priority.
• 75 per cent of the group’s attitude to their mouth had changed and rated positively towards scores of 4 and 5. Previously it had been 25 percent for the same scores and individuals.
• The entire group now believed they had benefited from the process and rated me also a score of 5.
•  BPE data analysis indicated an improvement over all of 33.9 percent across the group.

Appraising and evaluating my evidence

Having now completed the data gathering and reflecting upon the evidence I am convinced that my oral hygiene phase of treatment needs to take on greater importance to ensure more effective and beneficial dental health outcomes. I have found that simply “showing, telling and doing” isn’t as effective as developing an action research based strategy that involves determining, understanding and combining;

1. Patient values and perceptions.

A good starting point is to better understand the patient’s needs by better understanding their present oral hygiene behaviours and values. This has helped me lose the general assumptions and conclusions I draw from the first patient contact or their previous clinical history and further guides the next strategy – that of developing a learning plan, based upon their current status and after BPE (similar to CPITN) is completed.

1. Tailored patient learning styles

Learning has been a one dimensional process historically in my practice, where I had imposed by beliefs and styles upon the patient. I hadn’t considered that most had developed their own style or a combination of throughout their life, creating barriers to many including mine. Carl Rogers (1969) asserts that people’s ambivalence is deeply routed by their experiences. The learner needs to believe that the information has relevance and purpose to themselves and can be managed in their time. Removing barriers to learning, a reality to those anxious or fearful patients, and creating an environment that allows them freedom to learn is essential as many perceive or expect pain, humiliation and ridicule born of their experiences. Giving the patient responsibility for their learning and self-evaluating their progress through a guided process of facilitation can create an appropriate and effective patient centred learning process. 8

Flemings VARK questionnaire was developed in New Zealand for teachers after its creator noticed “excellent teachers who did not reach some learners and poor teachers who did” and drew me to conclude that perhaps we have taught our patients in our preference rather than theirs. Interestingly too, over half of the participants of the project expressed more than one preference for learning which led me to believe that within our practice of teaching we can adapt different styles to meet their needs or, alternatively, review the styles on follow up and change direction with learning if necessary. I also feel that VAK would be a better format to adopt born of the particular environment we work in. Creating literature that can be taken away by the patient to read negates its usefulness in the clinical environment but still remains a tool to be used for those who see it as a preference after oral hygiene instruction or those requiring additional time to consider change. However I feel that seeing, doing and listening combine well or individually in the workplace. 9

1. Behavioural Support Intervention

I had never really paid much attention to behavioural change in the preventive dental sense in the past but since the project began I have begun to listen more intently but also critically. Rattan et al (2002) when discussing changing behaviour in terms of clinical governance allude to its use in drug, alcohol and smoking rehabilitation quoting classic examples of its success but where is there similar evidence in improving dental health? 10 Renz and Newton (2009) looked at the express purpose of changing patients’ behaviour with a view to improving periodontal outcomes and explored various psychological models. They could only conclude, however, that despite” several promising targets for interventions” that “critical importance be placed in the field of motivation, volition and self-efficacy. “11 Carr and Ebbert (2012) interestingly put smoking cessation in a dental setting with advice offered by oral health professionals. They concluded that “typically brief” behavioural counselling may reduce tobacco use.  12 Sgan-Cohen (2008) links the dichotomy between the profession and public regarding changing dental health behaviour citing “incorrect assumptions” in dental health promotion. I agree with him. He states that “Dentistry needs to be flexible in accepting new evidence based modalities of oral health promotion.” and continues that “applied prevention is not always easy” requiring the “optimal cooperation and motivation of the public.”13

Frencken et al (2012) in a report from the FDI group linking minimal intervention dentistry (MID) get nearer to a solution by declaring success in dental prevention, in this case caries, be considered not an infectious but instead a “behavioural disease with a bacterial component.”14 Could this be linked to periodontal diseases too? If so, how? In 2013 Brand et al published online a study investigating the impact of single session Motivational Interviewing (MI) in the context of periodontal maintenance therapy. They aligned them to the same principles in smoking, diabetes control and medication adherence to find emerging evidence suggesting the “utility of MI to improve oral health”. The study sampled 56 previously treated periodontal patients in a single blind, randomised control trial. Regardless of their optimism and statistically significant decreases in plaque, pocket depth and bleeding at baseline, 6 and 12 weeks, there were no differences in clinical parameters between the two groups. They surmised that a one- time MI session was insufficient for improving oral hygiene in the study group.15 This runs against the conclusion of Godard et al (2011) who used Leventhal’s theory in improving compliance with plaque control amongst a similar risk group. They determined that the MI group demonstrated greater “satisfaction” scores to those in the control group and deemed MI a promising approach. 16

Leventhal’s self-regulation model defines how an individual goes about identifying they are sick and what they do to get better, involving understanding, acting and appraising their progress. This model relies on the individual’s ability to reflect on their actions and subsequent consequences.

Self-confidence or self-efficacy according to Bandura (1977) is important in an individual’s ability to “perform a particular behaviour regardless of circumstances or contexts linked to expectations of outcome.” Motivation is determined by reasons for action, in this case, dental health improvement. The popular Health Belief Model, developed in the 1950’s in the USA, implies that people are motivated to change by understanding the benefits of them related to their health. 17

Within the short time frame and additional pressures of a hygiene appointment the best method for behavioural support is MI as it is “client centred and collaborative” in exploring and attempting to resolve “ambivalence” (Miller and Rollnick, 2002). It focuses on the process of building motivation for change and strengthening commitment to it. 18 The professionals, us, engage so called “change talk” with the patient focusing on;

• Reasons for change.
• Disadvantages of staying as they are.
• Advantages of change.

Interestingly, in my opinion and born of my experiences too, the professional also needs to ask the patient what they are going to do about it. This can lead to shared goal setting, planning and eventually commitment. I am also aware now that reviewing change, much like we review dental health status, is a key element in this. The belief we can elicit change purely from physically acting in someone’s mouth is now far from the truth and leads me finally to the conclusion that as well as being a “First Person, Living Theorist and Collaborative Practitioner Researcher” I can also claim to be a “Behavioural Support Interventionist” (BSI) in the making too.

Modifying and monitoring my practice

By modifying my practice in the light of my research, evaluation and experience I strongly believe in the effectiveness of a one to one approach which determines;

1. Their current dental health behaviour and values.
2. Their preferred learning style(s).
3. Their commitment to change.
4. The use of oral hygiene products intra orally to enhance the kinaesthetic or visual benefit of learning.

The support of the dental health industry, in particular Philips Health and Well-Being who supplied me products to facilitate this as well as the purchase of others by myself has also been a critical factor in the success of my project. I will continue to promote their use in this way and hope that the costs incurred by me will be met by a small increase in appointment fees. Additionally, there is an opportunity for me to develop greater in house sales of dental products ethically but also construct an online store that can deliver a similar process as the workplace. This is the theme of my next project through O’Hehir University in New Zealand.

Proposed New Dental Health Improvement Project Form – Mark James RDH

Do you use a manual or an electric toothbrush or both?

Manual

Electric

Both

Do you clean between your teeth?

Floss/interdental brush

Both

No

How best do you think you learn?

Seeing

Listening

Doing

Reading

Where would you place these in order of importance to you?

Health

Function

Aesthetics

Marking scale is 1 to 5 [5 being the highest]

1

2

3

4

5

How do you rate your present dental health?

Do you want to improve your dental health?

Could you change your current behaviour to benefit your dental and general health?

Additional Comments/Feedback /Action Plan                                       BPE

Conclusion

“A good traveller has no fixed plans, and is not intent on arriving.” Lao Tzu 

Have I made a contribution to new theory of practice and can I make a claim to knowledge? Action research is opened ended in its final position and for good reason. New knowledge and theory comes from the past and the present and to not learn from it, adapt, review, reflect and subsequently change accordingly would be fallacious.

McNiff and Whitehead (2011) describe a situation familiar to most professionals in practice as being a “living contradiction,” a situation in their workplace where ideologies conflict and where compromise needs to be sought. 19 Ironically I have been supported by both teams and more over by my patients whilst undertaking this project and for this I am very grateful. However, my living contradiction appears to be with the established view of where we are as a society regarding the state of dental health in the UK (MI Hygienist, 2013b). 20 There are steps afoot with truly preventive minds, I believe, intent on improving dental and general health. This gives me hope that on a national level and with greater patient access to dedicated Dental Care Professionals (DCP) the public and society will be better served. My dilemma remains that would we as DCPs continue to develop ourselves professionally not just in the fashionable and lucrative aspects of our scope of practice but to reappraise and seek ways in which we can improve better dental health?

My claim to knowledge, albeit provisionally, is thus – I have developed a simple strategy that combines assessment with a focus not only on traditional scoring but behaviours and values. Also developed is a teaching approach that collaborates with and complements the learning strengths of the individual enhanced with patient centred confidence building, motivational and ongoing support. I will continue to review improvements in my performance and the dental health of my patients and, if other mindful clinicians  develop similar developmental and learning strategies perhaps  our  communities, society and nation alike will benefit too.

References

1. General Dental Council (2009). Standards for Dental Professionals. London, GDC Publications
2. Delivering Better Oral Health (2007). An evidence based toolkit for prevention, Department of Health. Part 2.
3. Rooney (2010). NHS Dental epidemiological Programme for England. http://www.nwph.net/dentalhealth/reports/NHS_Dental_Epidemiology_Programme_for_England_Report_June_2010.pdf

4. Adult Dental Health Survey (2009).http://www.dhsspsni.gov.uk/adultdentalhealthsurvey_2009_firstrelease.pdf 
5. Max Hastings (1984). Overlord: D-Day and the Battle for Normandy, Simon & Schuster.  New York
6. McNiff,J and Whitehead,J. (2011). All you need to know about action research, SAGE Publications, London. 10-39.
7. MIHygienist(2013a)http://mihygienist.wordpress.com/2013/03/06/ohehir-university-the-shifting-sands-of-action-research-ethics-a-reflection/
8. Carl Rogers (1969). Freedom to learn. Merrill, Columbus, Ohio, 157-166.
9. Fleming, N and Mills, C. (1992). Not Another Inventory, Rather a Catalyst for Reflection. To Improve the Academy, 11, 137-155.
10. Rattan et al. (2002). Clinical governance in general practice. Oxford, Radcliffe Medical ltd, 126-127.
11. Renz, A and Newton, J. (2009). Changing the behaviour of patients with periodontitis. Periodontology 2000, vol.51,252-268.
12. Carr, A and Ebbert, J. (2012). Interventions for tobacco cessation in the dental setting. http://www.asat.org.ar/images/comunidad/biblioteca/ib_odontologos_2007.pdf
13. Sgan-Cohen. H. (2008). Oral hygiene improvement: a pragmatic approach based upon risk and motivation. http://www.biomedcentral.com/1472-6831/8/31
14. Frencken et al. (2012). Minimal intervention dentistry for managing dental caries-a review: report of a FDI task group, Int Dent J, Oct; 62(5):223-43.
15. Brand et al. (2012). Impact of single-session motivational interviewing on clinical outcomes following periodontal therapy. International Journal of Dental Hygiene, 11(2): 143-141.
16. Goddard et al. (2011). Application of self-regulation theory and motivational interview for improving oral hygiene: a randomized controlled trial. Journal of Clinical Periodontology, Dec; 38(12): 1099-105.
17. The Kings Fund (2008). Motivation and confidence, kicking bad habits. http://www.kingsfund.org.uk/sites/files/kf/field/field_document/motivation-confidence-health-behavious-kicking-bad-habits-supporting-papers-anna-dixon.pdf
18. Bandura, A. (1977). “Self-efficacy: toward a unifying theory of behavioural change”. Psychological Review, 84(2): 191-215.
19. Miller, W and Rollnick, S. (2002). Motivational interviewing: preparing people for change. New York: Guilford Press.
20. McNiff,J and Whitehead,J. (2011). All you need to know about action research, SAGE Publications, London. 57-8.
21. MIHygienist(2013b) A Reflection.http://mihygienist.wordpress.com/2013/02/09/ohehir-university-learning-and-living-with-my-contraditions-as-a-dental-hygienist/

Unorthodoxy in Learning. Testing a Workplace Concept – Carl R. Rogers –  Supporting Authentic Online Learning at O’Hehir University – A Narrative Account

My whole world, both personal and professional, is in an evolving state of healing as a consequence of the global pandemic. It feels like I’m in a recovering state of COVID decompression akin to a deep-sea diver in a planned act of readjusting to normality after being to the deepest, darkest depths. This imbalance has been emotionally unsettling, for several weeks of lockdown and uncertainty, not knowing whether PPE would be required, the very nature of new practice, and when we were to return to it. It did, however, allow me to drive, undistracted, and determined to complete my self-directed learning project which began the previous June. The reams of printed studies this project generated had been sitting on the bookcase, gathering dust, and tested my resolve to meet its critical challenge. All but one post is now done, so this will be the final piece of the puzzle with just an introduction and ending to conclude it. Let us to it proceed. 

“Educated! We are not even born as far as our feelings are concerned.” D.H. Lawrence

The High-Speed Train (HST) was introduced into service in Britain in the mid-’70s. The idea of this highly modern express train was speed and comfort. I can remember walking into Paddington Station, in West London, in my youth, smelling the scent of diesel, the atmosphere of the Victorian structures surrounding the platforms, and many parked trains. The cacophony of noise, the hustle and bustle of everyday events, door shutting, breaks screeching, and the low drone of the spoken word was omnipresent. The train itself was what is called a “push, and pull” system, state of the art coaches sandwiched between two cutting edge locomotives. The energy created by both pushing and pulling created higher speed. They are still in service today. This analogy reflects the determination required to a more effective learner, the coaches reflect the workplace, where you sit, meet and treat. Still, the locomotives are the intent and motivation of that journey, the drivers of what happens between them.

The addition of that second “pushing” engine creates more energy, more purpose, juxtaposed against having one where you are being pulled towards a destination, unknowingly. The second unit metaphorically pushes you towards a destination of your design, perhaps to answer questions appropriate to the environment in which you operate or those which may determine the way to move your practice forward. Imagine being the driver of that necessity, being in control of the whole process, being accountable for its design, making sense of the research and data, analysing the outcomes, disseminating the results, and evidence of it to others. Consider the strategy and structure that can facilitate that, having confidence in its processes and being able to gather, assimilate, and make sense of the information.

“What thrills me about trains is not their size or their equipment but the fact that they are moving, that they embody a connection between unseen places.” Marianne Wiggins

The two arenas in this story are Quin Dental, Nelson, Tasman, New Zealand, and O’Hehir University, a global action research and self-developmental learning hub created in the USA in 2013. Quin is my place of work, a practice combining general practice, orthotropics, and orthodontics supported by oromyofacial therapy. Quin Dental’s leader details their mission as one of “excellence and innovation in dental health while aiming to make a positive impact on staff and community”. The vision encompasses providing clients with a “holistic dental experience aimed at providing the best dental preventive care” as well as, at all times, “respecting client views” and “providing individualised treatment.” The values of this practice include “dignity, compassion, empathy, warmth, and respect.”

Quin Dental, in the spring of September 2019, become my new professional home. Initially, my focus was to familiarise myself with the nuances and nature of the clinical environment, its people, and clients. The equipment and instruments, infection control procedures, and the history of oral healthcare delivered by previous oral health care professionals all added context to and set the scene of the message spoken and how it was instrumentally delivered. I was aware the wedded ideology lent heavily on EMS piezo and airflow systems and the associated system was available for its delivery. I had an in-depth knowledge of the equipment and the scientific basis of guided biofilm therapy (GBT) having trained with it at the company headquarters at Nyon in Switzerland.

The disruption of dysbiotic biofilms with a variety of powders and processes had featured prominently in my previous practice, for several years. The advantage of GBT has become a phenomenon in dental hygiene circles globally, and its promotion and popularity was increasing until the COVID crisis put the proverbial headlock on it due to aerosol and droplet generation. I, however, began to limit its use almost the moment I arrived at the practice and had an awkward conversation with the practice owner about my devolving view on its clinical application. I explained that based upon my empirical and observational experience, the feedback from clients I treated, and an altering viewpoint as a consequence of directed and self-directed study, I had re-evaluated how I used it. This was linked to a growing environmental and sustainable awareness, born of my odyssey experiences, of the need to sustain altered and more beneficial biofilms. Accordingly, I would be more selective and discriminate in its use. My boss was understanding, cautiously listened to my concerns but stressed its importance and efficacy in superficial stain removal in which we both wholeheartedly agreed. Progress from my perspective had been made.

“Live in each season as it passes, breathe the air, drink the drink, taste the fruit, and resign yourself to the influence of the earth.” Henry David Thoreau

GBT is very much indicated in active cases where the ecological imbalance is negatively sustainable, unstable bleeding on probing is observed, and potential or active loss of periodontal attachment is uncontrollable. In its strictest context, GBT is a local biofilm reset mechanism, especially interproximally and sub gingivally. It is also supremely indicated with gross staining or where a client requests or desires it based upon previous positive experiences. However, the GBT model is one that goes beyond the active phase and has become king in the maintenance realm. My push back relates to an ecological imperative of preserving and allowing balanced biofilm, created as a consequence of careful active clinical and facilitative oral health adaptation to abide and thrive within our oral biofilm. Regular monitoring and reviews are as crucial as COVID isolation is at New Zealand borders at present, the onus of care switching to one of less active intervention, timely reviews maintained self-care and personal oral health sustainability and responsibility.

This leads to the challenge of moving my philosophical change into the Quin oral health arena related to its core mission values. I felt the need to get a perspective from the client base of the practice and created a survey questionnaire that would essentially take a snapshot of their thoughts and feelings. This led to questions regarding expectations of treatment and inquiries about our service. 100 people participated, 93(%) would recommend us to their friends and family, over a third alluded to orthodontics being the primary attraction to the practice and 10% were attracted to its holistic branding. One comment in response to the survey, written with care, stood out to me. “What about your approach is natural?” It was a salient question, and it indicated that although we were marketing ourselves as natural, the practice was growing as a consequence of its reputation of arch expansion and tooth straightening, and not necessarily upon its oral health credentials. I began to feel an additional set of questions requiring answers being centred explicitly around the preventive message of Quin. My curiosity was fuelled by further feedback I felt was relevant when in discourse with clients. The new survey reflected them but also my growing hypothesis born of a notion that my practice was becoming increasingly environmentally and sustainably influenced and orientated.

“Every great idea comes with the minority of one.” Eric Weinstein

Survey two began with my new clinical approach, one of mutual co-existence when stable and in balance and whole intervention when dysbiosis is present. It is born of research undertaken before, during, and since returning from my learning odyssey, published at wholedentalhealth.com;

“Dental diseases are driven by imbalances in oral bacteria and pH (acidity and alkalinity) and saliva function being further mediated by negative dietary and lifestyle choices, our age and health status, and, to a certain extent, our genetics.”

“promoting natural oral health requires sustainable behaviours that reduce the risk of inflammation and disease, promotion of beneficial bacteria, active and functional saliva flow, proper tongue posture, effective breathing, and tooth strengthening strategies tailored to the individual. This, in turn, has the potential to support and promote our general health and well-being.” Mark James RDH NZ

Q1. Do you view your mouth environmentally and/or ecologically? Upon reflection, I think I should have described this less starkly and more in the vein of seeing the bacteria in the mouth environmentally and ecologically. 55% Yes, most upon reflection of the question.

Q2. Do you believe there are links between your general health and your mouth?  100% Yes.

Q3. Do you follow a specific nutritional approach to your health? 95% Yes most whole food or low carb BUT 15% gluten and dairy-free.

Q4. Do you have an opinion regarding fluoridation? I should have said water fluoridation and perhaps differentiated between topical and systemic modalities. 75% Yes – against water fluoridation – 15% of this group said they’d use it in toothpaste.

Surprising responses revolved around questions 1 and 4. Both 2 and 3 were predictable when considering the type of client seen at Quin, being professional, engaged with health and well-being topics, and informed. The age demography between those supporting fluoridation and those not was interesting. The younger the client it seemed, the less supportive of it they were. I’m curious to understand this better, though. Is it due to the nature of modern communication and the omnipresence of social media platforms that support the anti-fluoride pressure groups? Or are more of the younger population less trusting of authority, more critically educated, or concerned about the perceived health impact to fluoride on children? There were forthright and vocal opinions on the effects of fluoride with regards to brain health, and less it seemed to democratic choice and dosage. Question 1 had a curious initial silence before being answered, I got the sense that they had never heard oral bacteria put in the context of environmental, ecological, or sustainable perspectives. After consideration, I felt it required refinement, and I changed the wording to include bacteria in the sentence. Question 3 brought the most variety of responses, but interestingly all were aware of the threat posed dentally by sugar. Less understanding was afforded to pH lowering activities at mealtimes. The erosive potential of health-related options like apple cider vinegar, lemon in water, kombucha, and carbonated water wasn’t considered either.

This survey has helped me dive into client opinions of key issues that present themselves in modern oral health promotion and give credence to a tailored approach to care, looking specifically at individual needs and perceptions, guiding care planning. This process marries well, I feel, with the Quin mission statements that highlight the “holistic dental experience aimed at providing the best dental preventive care”, “respecting client views” and “providing individualised treatment.” Q.E.D, Qoud erat demonstrandum.

“It is in fact nothing short of a miracle that the modern methods of instruction have not yet entirely strangled the holy curiosity of inquiry; for this delicate little plant, aside from stimulation, stands mainly in the need for freedom; without this, it goes to wrack and ruin without fail.” Albert Einstein

Questioning in this format also afforded additional benefits of which I hadn’t foreseen. The opportunity presented itself to enhanced general discourse, encouraging the clients to demonstrate their opinions, allowing active discussion and, I feel, bringing a sense of greater respect for their points of view and mutual trust within the process. I felt it added weight and rigour to the importance of their perception of their mouths being compared to the specific everyday habitats and environments we live in and benefit from. The comparative and similar natures of both explained I hope will bear fruit in oral health outcomes with my co-existing ecological approach to improving oral health outcomes.

Moving forward to early April this year and into the second week of lockdown, I was contacted by a colleague and friend who I’d worked with as a Key Opinion Leader in the UK in the past. I had assisted by being part of a Beta learning group in the infancy of his collaborative online university learning hub, O’Hehir University (OHU). I hadn’t seriously considered involvement with OHU, and, if I’m honest, had avoided it as I couldn’t see a way in which my character and unorthodoxy in practice would lend to it. I didn’t see it being a comfortable fit, and my time up until the lockdown was at a premium. That was soon to change, seeing an end in sight with my wholedentalhealth.com project and deciding upon a change in professional direction brought about a change of heart, the opportunity to observe OHU in motion. I was welcomed to observe and offer support in their online classrooms. I found an engaged, curious and excited community, at first almost shy and timid, perhaps initially fearful, uncertain as to how to proceed in this new environment. Within a matter of a few meetings, the shackles were loosening as the students began to exchange ideas, thoughts, and opinions. It was as if a breakout had occurred, the shell of convention broken and the budding shoots of new discovery and knowledge appearing.

OHU is founded upon action research, an opened ended form of self-reflective first person, inquiry learning, and problem-solving. It is self-directed, workplace-based, and collaborative. The central beating heart is the online classroom with a google classroom suite where students can submit assignments for collective rigour and peer review, the instructors and leaders gently over watching and supporting expressive, creative, and curious learning.

Students at OHU enrol for a six-month odyssey in which professional and personal values are examined, challenged, and potentially altered. They complete a project related to their clinical or professional role and are submitted to scrutiny by their tutors, instructors, and peers. Becoming a small part in the machinery of OHU has become a weekly habit, I’m lubricating my cogs of mentorship, gently participating in the verbal and visual dialogue of the student journey, remembering my pathway through OHU back in 2013. Action research has been a tool that has seen me change, evolve and grow from a face value instrumentalist to a critical, observational, and evidence guided minimal interventionist, with a healthy side order of sustainability and ecologically orientation on the side. Here is an example of a part of the artistic and creative bend of OHU, where the student is asked to reflect on a piece of work which is supported by art, of their choosing, in a way that defines them. This is my example, inspired by them.

“Come forth into the light of things, let nature be your teacher.” William Wordsworth

“The humble tree is emblematic of many things, longevity, wisdom, life, and much more.  Trees are deeply rooted, withstanding the elements, time, and the seasons. They, to me, signify what is right about the environment and, conversely, what might be wrong. They are structures of nurturing, communicating, and protection. Especially for me as a forager, they symbolise community and connectivity, their vast root systems are intertwined by subterranean mycelial networks, huge neurological pathways that support, guide, and nurture the less strong and needy.” Mark James RDH NZ

The inspiration and influencer of OHU is Carl R. Rogers, a humanist psychologist, world-renown author, and keen observer of education, and a proponent of responsible, and participatory student-centred learning. His motivation in the field of education is facilitation rather than pure education, advocating practical and student-centric methods of achieving its effective agency. Rogers sees change in education as creating a real developmental journey, using powerful sentiments, feelings, the risk of sharing ideas, being authentic, and community-driven engagement to drive its purpose. The sense of freedom pervades his written work strengthening the argument that those involved should follow their own goals, be invested in them, and by doing so putting more of themselves, their passion, energies, and efforts into working harder. This, in turn, he opines promotes retention of knowledge and allows more of what they learn to be more meaningful to them, greater than that of established education. The standard of knowledge created has to be tested, just as it is in the conventional system, but the reviewers of it are not only teachers but the peer group of fellow students too. All outcomes and accomplishments are the fruiting bodies of one, very simple question the Rogers clearly defines, “what is the single, most important, unsettled value issue for you right now?”

“There is direction, but there is no destination.” Carl R. Rogers

In effect, my year-long odyssey has reinforced commitment to my social and professional principles. The curious nature of finding evidence that supports or detracts from my journey, allowing new light to be shed upon established values, challenging them to the point of change, or certainty in them, is what endears authentic and genuine learning to me. My future appears now not to lie in clinical dentistry though, as I am beginning now to see the light at the end of the proverbial tunnel. Change is now on the horizon. With no more fruit-bearing branches to climb upon I anticipate, with the supportive help and insight of others, the trunk dividing, one travelling in the direction of my choosing, the other sustaining it, and keeping my experiences and knowledge in dental health alive albeit online and in learning.

Airflow Action Research – Product into practice

An article in the dental press recently caught my eye and made me think more about the direction of my learning journey. It discussed issues regarding our present Continuing Professional Development (CPD) system and the debate around meaningfully improving it. The text raised issues that inferred a need for change from the present “input” based system to a clinically relevant outcome based “output system” where learning evolves by demonstrating its effect on individual professional life and everyday practice.1 This, in my opinion, marries well to our present evidence based practice culture. Many educationalists advocate “learning within the workplace” which is informal, reflective and involves acquiring new knowledge and problem solving. Three important stages in this approach advocated by Gray et al (2004) are technical, interpretive and strategic.

Technical – Acquisition of specific skills or knowledge.

Interpretive – Understanding experiences and making judgements on them.

Strategic – Critical evaluation where technical and interpretive ideas and opinions are discussed and ideas exchanged.

Rattan et al (2003) state that evidence based cultures link science and clinical practice by integrating literature, patient preferences, scientific knowledge, clinical judgement and personal experiences. Our current clinical governance culture promotes adopting proven methods and techniques and replacing those less effective and more costly.3 The four questions he asks are;

Are we doing things the right way?

What is the evidence relating to our practice?

How can we ensure that the necessary changes are implemented into practice?

How do we know that the changes being made are sustainable and, in addition, produce efficacious and cost effective benefits to patients in practice?

So, when introducing new materials and methods clinically we need to measure the extent to which they produce a beneficial result under “ideal conditions”. It also provides an ideal opportunity to begin experimental and developmental learning journey associated with Care Quality Commission regulations as well as the British Dental Association’s advice on clinical governance which advocates communication and consultation with patients that enhance practice relationships and clinical decision making.

My First Step

I wanted to introduce a new polishing system into an established practice that I believe would benefit both patients and practice alike by giving patients more choice and the practice a more effective polishing system. I also hoped to discover more about myself professionally in undertaking this new experimental learning. I have been struck historically by the lack of literature that sets out how an ordinary dental care professional can apply these principles into practice whilst being a busy clinician. How can I implement change within my surgery, demonstrate it to my colleagues and more importantly, deliver it safely, beneficially and effectively to my patients in conjunction with professional standards?

A Critically Reflective Practice Approach to Implementing Air-Flow Handy

Critically reflective practice draws distinction from reflective practice by linking learning within our practice and not just a “pause” for thought. Pure reflection deals with how we feel aspects or events in our professional day to day life went, whether it was good or not so good, and where it could have been improved. Critically reflective practice requires deeper questioning and not taking things at face value, involves self-awareness and turning thought processes into relevant learning. Such a process can be individual or collaborative but leads onto planning and potential change. It links our thinking to doing, thus learning from our experiences and crucially assimilating evidence based practice knowledge and research to make a positive difference in what we do clinically.

The Product

The EMS Air-flow Handy is a portable air polishing unit that uses specially produced bicarbonate of soda powder to remove stain, pellicle and biofilm from tooth surfaces. It has a detachable, autoclavable nozzle that directs the powder and water in a focused spray onto the tooth surface. Care has to be taken to ensure that the root surface is avoided and that patient selection is considered regarding contra indications and their preferences.

Historically I have used Air-Flow units and have heard that some clinicians have found that the nozzle blocks frequently, that some patients found the procedure tastes unpleasant and that the Hendy’s operating procedure and initial and running costs are prohibitive. Having undertaken previous product trials with EMS products through Optident I asked if I could trial this unit free within a practice in which the patient base that have never encountered this product and service before. In undertaking this I asked not to be remunerated which I hope has afforded me better objectivity and critical independence.

Implementation

Having agreed with Optident about the evaluation and article I set about constructing the process. I read the technical aspects of the equipment, research data, how it worked, how to use it, when not to etc. I wanted to focus on the patients experience and preferences as this I feel is under represented in literature. Therefore it involved;

• Reviewing the research available from EMS and other sources. It was evident from online evidence that most appear dated and refer to the abrasiveness of the bi-carbonate powder on the tooth surface, especially exposed dentine surfaces. The instructions from Air – Flow strongly recommend techniques that avoid this. Current EMS literature discuss the sub gingival benefits of lighter and less abrasive Glycine based powders in Perio-Flow units but these can also be used in Air-Flow Handy units but alas aren’t flavoured yet. Interestingly there is a paucity of literature examining the dental health benefits of conventional polishing. The best research evidence is inconclusive regarding the beneficial and adverse effects of routine (scaling and) polishing for periodontal health.
• Finding a group of patients who had, within the last 6 to 12 months, been seen by me for conventional polishing treatment. I sought permission of the practice owner and briefed him about the process.
• Determining the cost benefit analysis by asking my patients to complete a very simple feedback form and the reviewing the cost of the equipment. The sample size is important but I was constrained by only working in the practice 2 to 3 sessions a week and have minimal support.
• Explaining the benefits of both methods comparatively before using Airflow Handy and seek patient consent. No additional fee would be charged to the patient.
• Afterwards asking them to complete the form.
• After two months correlating the data and analysing the results.
• Evaluating the data.

Airflow Patient Feedback Form

Marking grid: 5=Strongly Agree; 4=Agree; 3=Unsure; 2=Disagree Agree; 1=Strongly Disagree
Airflow Questions	1	2	3	4	5
I was uncertain that airflow would be as effective as conventional polishing
I felt the procedure was comfortable and beneficial.
I would be willing to have the Airflow procedure again at future appointments
My mouth feels fresher and cleaner than I expected with Airflow.
I would be willing to pay an additional fee for Airflow.

Process

American Philosopher Henry David Thoreau stated “It takes two to speak the truth – one to speak and one to hear”. Feedback is a peculiar experience and I have been uncomfortable with it historically. It always seemed to me to allude to negative criticism, judgement and poor performance. However, feedback itself is learning and developmental tool, when carefully and simply designed it can objectively focus on delivering improvement. The Collins Dictionary describes its purposes well, stating it as “information in response to an inquiry or experiment.” Interestingly an initial positive from using feedback is the surprise and satisfaction from the patient’s perspective that their experiences and opinions are valued and their input can a make a difference as well as benefitting them in the future too.

I wanted to set out the questions in a statement format as it felt less ambiguous and simpler in addressing Rattan’s four questions. After constructing the form I spent a week getting proficient in operating the Handy as well as ironing out any gremlins likely to cause issues once the feedback process had begun. I discovered that the nozzles need to be purged immediately after use to prevent blockage, how to adjust the water pressure on the dental unit and how, if blocked, to simply remove it effectively. I also needed to make sure that I could use it safely with or without nursing support. This transpired to be not as difficult as anticipated.

Once the survey began I gradually lost any anxiety about asking my patients to participate and feedback to me. I wanted them to be honest and sincere in their responses. This got easier to ask for with experience. Some were very keen to add value to the form by giving measured and mindful comments whereas others were simply keen to tick the boxes and leave. I eventually completed thirty forms and analysed the data.

Air-Flow Patient Feedback

Marking grid: 5=Strongly Agree; 4=Agree; 3=Unsure; 2=Disagree Agree; 1=Strongly Disagree

Air-Flow Question Responses (Data Drop Box)	1	2	3	4	5
I was uncertain that airflow would be as effective as conventional polishing	2	2	15	8	3
I felt the procedure was comfortable and beneficial.	0	0	3	6	21
I would be willing to have the Airflow procedure again at future appointments	0	0	1	3	26
My mouth feels fresher and cleaner than I expected with Airflow.	0	0	1	5	24
I would be willing to pay an additional fee for Airflow.	1	0	12	10	7

The participants voiced many feelings and opinions after the procedure. Comments included;

• “Much better result than traditional polishing.”
• “Brilliant and good experience”
• “A more pleasant experience than before.”
• Several commented on the taste being “unpleasant” and “initial feeling of cold.”
• It felt “cold but not uncomfortable” and reminded them of “Sherbet Dabs.”
• A “towel” rather than tissues would be useful and “warn people that the spray could ruin their make-up.”
• “My mouth feels really clean” and many commented on the “Fresh” feeling afterwards.

Appraisal and Planning

Most participants preferred the Handy to routine polishing and were surprisingly satisfied with its freshness. I was initially concerned more about patient comfort and determining whether they would pay an additional fee for future its application as part of treatment. It transpired this was less contentious than I thought. When questioned the majority thought that a fee of more than £5 to £10 would be excessive. Only a few considered that it would be inappropriate to charge more than polishing.

Given the opportunity of adding further value to my patients’ polishing preferences with Air-Flow, considering its portability, reliability and clinical benefits I will now begin to use the system in all four of my present practices. This will be made easier through this experience and I will now confidently demonstrate and advocate it to individual practice teams. In future clinical equipment evaluations I will continue to listen, through feedback, to the patient’s perceptions and preferences. I hope that feedback questioning would continue to accurately guide clinical decision making and back up the changes consequently made.

Cost Benefit to the DCP and practice – income and expense

Despite the initial price of the product and ongoing purchasing of powder I can see many pluses to using the Air-Flow Handy from the clinical perspective through to providing additional income. A simplified route map in terms of approximate cost and expenditure is;

Cost of Air-Flow Handy, 1 additional nozzle and 4 boxes (16 bottles) of Air-Flow powder in a year.

£ 2100.00 inc VAT – less if discounts and special offers apply

46 weeks of clinical work using Air-Flow Handy on 8 patients a day @£5 or £10 per patient.

£9,200 @ £5 per patient over a year

£18,400 @£10 per patient over a year

Summing up

Completing this critically reflective experience has to provide answers to the original four questions posed by Rattan;

Are we doing things the right way?

What is the evidence relating to our practice?

How can we ensure that the necessary changes are implemented into practice?

Were changes being made sustainable and, in addition, producing efficacious and cost effective benefits to patients in practice?

By putting the Air-Flow Handy into practice I believe my patients benefit from its stain and biofilm removal efficacy, especially interproximally. Improving my skill with it through experience and feedback has benefitted my personal and professional development.

Gathering evidence from my patients demonstrates approval and positive responses to the Handy. Where it was negative or indifferent opinion was sought to improve future experiences with it.

The changes needed to facilitate Air-Flow have been achieved but will be re-evaluated frequently. The key to its future success is maintaining its serviceability and buying additional Air– Flow powder by charging extra for its use.

The final question is the most critical as Air-Flow needs to be determined by the patient to be beneficial and by the operator to have cost effective benefits. Cost benefit analysis determines all the collated positive factors. These are the benefits. Then it identifies, quantifies, and subtracts all the negatives, the costs. The difference between the two indicates whether the planned action is advisable.

Conclusion

Patient feedback indicates a positive cost benefit result and that an increase in treatment fees would be accepted by most surveyed. Whether to introduce Air-Flow Handy is for the individual clinician to decide but I will continue to promote it a part of my preventive care regimes. Air-Flow Handy can also be used in other treatments, such as preparation for fissure sealants, in fresh breath therapy, periodontal and caries risk management programmes. Furthermore I would recommend all Dental Care Professionals continue their clinical development through evidence based critical reflective practice within their workplace. This allies to our professional duty of care, working in the best interests of patients, but also benefits our practice and ourselves by linking to companies like Optident who can help facilitate this opportunity.

References

Big Conversation on CPD continues. The Probe, May 2012. Available from:http://www.dentalrepublic.co.uk/the-probe/news/detail/big-conversation-on-cpd-continues

Gray, D. Cundell, S Hay, H & O’Neill, J. Learning through the workplace – a guide to work based learning, Nelson Thornes, 2004: pp 1-5.　

Rattan et al. Clinical governance in general practice. Radcliffe Medical Press, Oxford. 2002: P 99-107.

Care Quality Commission. Guidance about Compliance; Essential Standards for Quality and Safety, 2010. :http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf

BDA Clinical Governance Kit, version 2.:http://www.bda.org/dentists/advice/practice-mgt/laws/qs/clinical-gov/implementing/clinical-gov-in-practice.aspx>

General Dental Council, Standards for Dental Professionals. London, GDC Publications, 2005.http://www.gdcuk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf

Thompson, S & Thompson, N. The critically reflective practitioner. Palgrave MacMillan, Basingstoke, UK. 2008: pp. 26-28.

Cottrell S. Critical thinking skills. Palgrave study guides, Basingstoke, UK, 2008: pp.1-12.

The influence of air polishers on tooth enamel. An in-vitro study. 1998;59(1):1-16.:http://www.ncbi.nlm.nih.gov/pubmed/9505051

Changes in the surface microrelief and the loss of dental enamel after the use of an abrasive spray of sodium bicarbonate,1990;33(2):77-82. :http://www.ncbi.nlm.nih.gov/pubmed/1964618

Routine scale and polish for periodontal health in adults. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004625.pub3/abstract

Pocket Mentor Giving feedback. Harvard Business School Press, Boston, USA. 2006: pp.4-8.

Collins Online Dictionaries :http://www.collinsdictionary.com/dictionary/english/feedback

Mentoring – Guiding the learning journey

Once qualified the DCPs learning journey alters radically to autonomous accountable practitioners working within unknown teams and clinical environments where expectations from employers and patients have to be met in that important first year. 1 Can “novice” hygienists and therapists gain valuable skills and expertise from trained and experienced DCP mentors and is there now a need for an embedded culture of mentoring like our colleague dentists and fellow health care professionals? 2

Standards and Regulations

Professional standards define the DCP as an individual who accepts responsibility for the effective safe care of their patients with underpinning ethical guidance promoting the co-operation with members of the dental team and other health care professionals in the interests of the patient. 3 The Nursing and Midwifery Council (NMC) have established standards that support learning in practice with post graduate professionals being guided within this structure, after training for their first “preceptorship” year and beyond with competencies being validated annually by a supervising “sign off” mentor. 4 Comparable mentoring activities within dental hygiene and therapy have yet to be fully realised by the profession despite greater regulations in place to protect the patient and increased professional standards from authorities like the General Dental Council and the Care Quality Commission 5, 6

Mentoring within our current dental culture

In 2009 a revalidation linked feasibility study undertaken for dentists by Costley identified that many practitioners in the dental sector were not meeting the minimum standards of “operational” competency with a perceived need for face-to-face assessment with all, or a selection, of dentists throughout the UK. 7 Revalidation builds on current standards to protect patients by asking dental professionals to demonstrate their suitability to remain on dental registers. The study made no mention of co-operation, collaboration with or comparison to other health care professionals or mentoring in addressing this serious issue. A rapid response to this was a change to dentist vocational training that extends the course from one to two years and encompasses a new title, Dental Foundation Training (DFT). Participants need to log clinical experiences, assessments, education, continuing professional development (CPD) and personal development with reflective practice required weekly for the first eight weeks then monthly for the duration of training.

The General Dental Council (GDC) currently refers the issue of mentoring activities and training for DCPs to educational and CPD services provided by the Committee of Postgraduate Deans and Directors and have commissioned the Centre for Medical and Dental Education to develop post graduate dental and medical education for dental practitioners. 8The fifteen UK Deaneries are tasked to develop and quality assure opportunities for trainers in Primary and Secondary Care Services and to ensure that sufficient training places are available to meet the future needs of the NHS. Other providers include the Faculty of General Dental Practice, the University of Lancashire and Kings College London. 9, 10, 11 The development of mentoring services from the Deaneries appear very limited varying from a general lack of any training or guidance to a few, like the Northern Deanery, offering training and a mentoring service similar to that of the NMC. Other providers offer level 3 study varying in length and cost which might, to many DCPs, appear prohibitive and distant.

This appears to bode well for struggling or newly graduated dentists but what about the DCP? We too are registered and accountable, regulated by the same body, working within the same standards and guidelines, and are advised, like our dentist colleagues, to evidence base practice whilst viewing our annual retention fees and indemnity costs increasing with incredulity. However, DCPs appear be less served in comparison despite facing increasing risks of negligence claims against us for malpractice or poor performance. Surely there is a need to develop mentorship and guided support, irrespective of costs, which brings parity to dentists and healthcare colleagues, and continues to raise standards, quality of care and safety for patients.

 Mentorship training

 The initial challenge of the team professionally qualifying as mentors was addressed by training at the University of Surrey.13 The tutoring team were very approachable, experienced and flexible providing an established programme over twelve weeks at level three with several mixed professional cohort groups in each academic year. The five day course is divided into two learning sessions with reading and course work set which includes a teaching and assessment session and a fifteen hundred word reflective submission about the teams learning journey in mentoring. Learning with other healthcare workers allows a unique insight into their environment, knowledge and experiences and gave us a good academic foundation helping us to evolve the support programme design with the knowledge and experiences acquired.

The course explored in detail individual learning styles, domains and theories to complement broader mentoring subjects and debate. Knowledge learned was evaluated when we all undertook individual teaching and learning sessions as part of the module. Being able to put our learning into practical use and understanding the underpinning elements of individual learning has better equipped us to structure and deliver the programme more focused upon the individual using their input and feedback to deliver clinical shadowing, online interaction and peer event elements more effectively.

Organised Peer Events and Learning Programme

The programme is designed around three organised peer events throughout the initial pilot year. The events will be heavily influenced by feedback received from several “about to graduate” hygienist and hygiene therapist student cohorts from universities across England. The team ensured that the groups had the opportunity to debate the challenges that the current dental health environment now presents and focused on the opportunities to develop their professional skills and voices. Great weight was given to listening to what they perceived their challenges would be in the coming years and how these may affect or benefit them. Most were concerned about finding appropriate employment after training and losing skills as therapists when only employed as hygienists. With these views considered the course will guide the DCP in designing their aims and goals, to be involved in a reflective process of learning with awards and prizes given for development linked to the promotion of the professional, dental health and their clinical environment. The programme will also use pre and post course feedback to benefit the participant and the team, its future development and quality control.

Shadowing

Skills gained by the mentor during the course can enhance a one to one learning experience with participants potentially benefiting from time with a colleague or co-worker who is further on in their career or has a skill set or experiences the learner values. Being able to observe clinical activities set in different environments, to question the professional directly, absorb the work culture and procedures but also give and receive feedback with that expert provides an opportunity for a unique learning process, from which both can develop. 15, 16

Conclusion

Providing hygienists and hygiene therapists the opportunity to actively participate in a supporting learning culture will benefit the DCP, the professional body and the safety and care provided to the patient. Price (2004) believes mentoring is pivotal in setting goals, socialising learners in the practice culture and understanding their anxieties and needs but goes much further by challenging the mentor to demonstrate and maintain an active interest in learning whilst continuing to create learning opportunities. 17 Other health care environments have and continue to provide opportunities to promote best practice and develop competencies through clinical based mentoring within their professional culture.

Sources

1. James, M. Ives, T. Dickinson, J and Rawsthorne, P. The Transitional Support Programme for Hygienists and Therapists, A Pilot Study. Dental Health 2011, 50 (3): 20-22.
2. Benner, P. From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley,1984.
3. General Dental Council. Developing the Dental Team, 2004.

http://www.gdc-uk.org/NR/rdonlyres/3029D7DD-81AE-41C6-973A-F39FE7287BF8/15135/developing_dental_team2004.pdf

4. Nursing and Midwifery Council. Standards to support learning in practice: NMC Publications, 2006.
5. General Dental Council. Standards for Dental Professionals. London, GDC Publications, 2005.
6. Care Quality Commission. Guidance about Compliance; Essential Standards for Quality and Safety, 2010.

http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf

7. Costley, N. Revalidation Stage 1 Feasibility Study Final Report, General Dental Council, 2009.
8. The Committee of Postgraduate Deans and Directors.

http://www.copdend.org.uk/

9. Faculty of General Dental Practice (UK). Certificate in Mentoring in Dentistry.

:http://www.fgdp.org.uk/professionaldevelopment/dentists/mentoring.ashx

10. University of Central Lancashire. Mentoring in Dental Practice.

http://www.uclan.ac.uk/schools/dentistry_at_uclan/postgraduate_medical_dental_education/adv_cert_ment_dental_prac.php

11. Kings College Hospital. Mentoring in the Workplace (online).

http://dnetc.kch.nhs.uk/mentoring-in-the-workplace.html

12. Philips UK. Dental Professionals, Education and Resources.

http://www.sonicare.com/professional/dp/DP/Default.aspx

13.  University of Surrey. Health and Social Care, Mentorship. http://www.surrey.ac.uk/healthandsocialcare/study/CPD/mentorship/
14. Meggison, D & Whitaker, D. Continuing Professional Development. CIPD, 2008;122-123.
15. Gray, D. Cundell, S. Hay, H & O’Neill, J. Learning through the workplace – a guide to work based learning, Nelson Thornes, 2004;182-183.
16. Price, R. Mentoring Learners in Practice, Nursing Standard. 2004;18 (52).

Designing hygiene intervention protocols for my practice – whole dental health – part’s 1 and 2

It has been almost a year since I arrived at my new practice in Nelson, time has passed rapidly in an eventful period for us all. Little would I have known that at this very moment I’m typing this nearly a half of my fellow countrymen and women are experiencing a level 3 COVID lockdown. This was the case for us all in New Zealand from the very end of March to the end of May. A few months of near normality followed this to where we are now, awaiting a national reduction to level 1 again. The degree of apprehension and uncertainty has evoked recent memories but the these feel more measured and less existential, for me at least. Despite this the need for normality in the workplace, even progress, has to be engaged, perhaps as a distraction but more so to meet the needs of clients here.

It was during this moment, last week, that my boss, Gerry, approached me to generate a protocol to link hygiene appointments to the treatment planning designed with the orthodontic auxiliaries. It was made clear that there needed to be a differentiation between age groups, youth, youth adult and adult as well as a plan for 12 or 18 month treatment patterns.

I am also mindful of the nature of the practice, it’s desire to be as natural as achievable in its treatment approach and empathetic in its guidance, tolerant by embracing differences of opinion regarding product and lifestyle ideologies. This could originate from objections or concerns regarding contents or perceived toxicity within products that are indicated in controlling and balancing biofilm and pH, strengthening or demineralising tooth substance through to nutritional, habitual or economic realities, even ideologies, that oppose or conflict with mainstream and established approaches to oral health development or management. This can be seen in the debates that rage around fluoride, additional materials found in dentifrices, allergies to components in toothpastes and diets rich in fermentable carbohydrates, acids or dehydrating effects. Consideration required for a dry mouth status emanating from poor tongue posture or arch form, or both is not in my present scope of practice but can be engaged with by our practice oral myo functional therapist and orthotropist.

My aim is to collaboratively design a protocol and consider a linked oral health process complementary to and in symmetry with the treatment planning of orthodontic clients including guided and considerate product recommendation, appropriate linked appointments for team reviews and timely interventions as deemed necessary on reassessment. This I began by designing an provisional flow chart, based upon guidance from the clinical team, aware that it is a prototype and will be changed and challenged. That’s fine by me.

Historic concerns have been raised with specific ortho cases of late, either due to poor oral health compliance, plaque and calculus accumulation linked to an increased risk of poor oral heath outcomes. The demineralisation of young enamel tooth substance, due to caries risk increase has been another subject of growing concern. The management of appropriate and sustainable oral health behaviours, conducive to stabilising and maintaining gingival and tooth integrity is as importance, in my opinion, as the process of arch expansion and tooth realignment. In addition to that, a post treatment phase be  considered, especially where retainers, either fixed and removeable, are utilised.

The instruction in cleaning appliances, currently undertaken by auxiliaries needs to be continued and promoted at fit appointment. Where compliance cannot be demonstrated or achieved during care, despite interventions will be guided back to Gerry for determination.

                                                                      Option 1

1. 30 minutes 3 x 12 months

$125 each

Cost for OH phase + review @ 4/52 and 3 x rev follow up and final visit = $640

2. 30 minutes 5 x 18 months

$125 each

Cost for OH phase + review @ 4/52 and 5 x rev follow up and final visit = $890

 

                                                                            Option 2 ( flat Rate not individual )

 

1. 30 minutes 3 x 12 months

 

Cost for OH phase + review @ 4/52 and 3 x rev follow up and final visit = $500

2. 30 minutes 5 x 18 months

 

Cost for OH phase + review @ 4/52 and 5 x rev follow up and final visit = $750

 

OH Phase – 45 minutes

• Disclose – Pictures – Intra Oral Hygiene Focus
• Debride calculus – Airflow Plus Biofilm Reset – Polish
• Nutritional behaviours – pH imbalance, dehydration, carbohydrates, carbonated and acidic foods, fluoride & non-fluoride toothpastes, Calcium Phosphate Based toothpastes, pre and probiotics before and during with at risk cases.

Review Phase – 30 minutes

• Disclose – Pictures if required – Adjust Oral Hygiene
• Debride calculus – Airflow Plus Biofilm Reset – Polish

Focus and Strategy

• Medical status – dry mouth linked to mouth breathing – medication
• Plaque control – manual or electric – Interstitial cleaning when brackets, bands and wires placed
• Hydration when dry mouth – regulation of carbohydrates, especially fermentable, to mealtimes – clear with water/milk after and before brushing at night time
• Nutrition – Regulation, reduction and cessation of fermentable carbohydrates and starches – carbonated and acidic drinks and foods
• Remineralisation/mineralisation – fluoride where parents accept – with calcium based products or alone if parents not accepting of fluoride intervention – no rinsing after spitting out
• Antimicrobial intervention with poor compliance or increased risk – pre and probiotics
• Motivation through visual means and positive affirmation. And demonstrating understanding
• Intervention – Full debride and polish post treatment/complete or removal of appliances

Products

General ecological balance (pH balance) and hydration/ saliva stimulation

• Prebiotics – Xylitol and Erythritol – granulated form – 5gms for xylitol diluted in water – or 1 gm per kilo body weight as a maximum – sipped throughout the day or in gum until flavour gone  or lozenges after meals
• Probiotics – BLIS M18 at night after brushing

Mineral integrity, sensitivity management and ecological balance (pH balance)

• Fluoride – Stannous Fluoride with Arginine or ACFP – brush spit no rinsing after – hydrate before – determine age for correct amount of fluoride and use of ACP
• Topical fluoride
• ACP – non fluoride options – as above

Physical intervention and ecological balance

• Manual and electric toothbrushes – Interproximal, interdental brushes – WaterPik
• Fissure sealants

Instruction – Information Sheet

 

Quin Dental Guidance Form

Disclosing/ Plaque

Positive nutrition

Negative nutrition 

Brushing

Tooth strengthening

Oral environment and pH

 Additional

Part 2

I work in two practices in Nelson and am fortunate in one to work with another Hygienist. This hasn’t been the case for a lot of my career so I’m grateful for this and also that they are collaborative and are happy to be part of, contribute to, and help implement change, if sound.

My challenge is that the cost of current treatment is the same whatever the status of dental health. That means that complex care is charged at the same rate as a well-managed and stable mouths. This is irrespective of whether a local anaesthetic is required, additional instrumentation with ultrasonic or airflow polishing and biofilm debriding systems are required. The additional labour, skill level and equipment requirement isn’t reflected by the flat rate being charged. How can we move this situation forward and bring a process that rewards oral health improvement, requiring fewer additional visits but can also demonstrate money well spent, and less costs incurred in the future?

Being employed, but having previously experienced self-employed I can appreciate the disconnect between the two as a dental hygienist. The self-employed hygienist is motivated in the same way as the employed, by their efficacy in line with standards and scope of practice responsibilities but are more likely, from my experience, to be more proactive and inclined to be aware of their efficiency, be it time management or economics. This has its downsides too, with the potential to be time constrained, less client care focused as the employed individual, from my experience. I have found, subjectively, that moving to employed status took a while to adjust to being less time pressured and production focused. The imperative is quality care, delivered safely and effectively, in partnership and with the consent of the client. The quandary being employed is to see a different way, in the relative safety of a system that is established but doesn’t appear fair. If we can marry both ways, the need for sufficient treatment time, bringing the best outcome, delivered ethically, meeting and rewarding the needs of the client and the clinician, then I’m a believer.

The way forward with routine care has been at the forefront of my enquiring mind of late. I have experimented at my previous practice adapting a traffic light system that marries the time and cost required based upon the need demonstrated by assessment prior to treatment commencing. It follows a red green and amber protocol with the fees being set that reflects the need and complexity of care as well as the stage the client’s oral health represents at that moment in time. A code score, linked to recently updated periodontal guidelines, is added as an alternative option. The benefit is with both clinician and client. They now know their status, it has been measured. They can determine the efforts required to either remain where they are if stable or the processes necessary to achieve better oral health and a shorter less costly next visit, determined by the recall recommended by the clinician after.

The original idea was as a consequence of a discussion with a client who challenged the cost of advance care. I indicated the best way to get to routine care would be to achieve oral stability and remission from their periodontal condition. I then considered standard care broken down into three parts to follow this rationale. I separated the advanced care as a different process as it requires more time, use of equipment, materials and skill. I tested it with a colleague and found it to be achievable. This was further approved by the practice owner and with all the team briefed it proceeded successfully into action.

For the purposes of this project we will spend a month doing a trial run, annotating the clinical day sheets with the code/colour and additional costs hypothetically. We will then gather the data, see how many would have been whichever code/colour and additional costs that would have been levied. We will also ascertain whether the idea works or needs modifying. This will guide whether we precede with the action plan. It can also be a useful aid to the practice management team regarding improving our hourly rate or linked to a novel bonus system, so everyone, both clients and the hygiene team benefit from improved dental health.

Dental Centre Hygiene Experimental Guideline Protocol

Routine

Code 0    < 10% BOP  Stable or just Phrophy   30 – 45  minutes     $100/125      GREEN

No risk                                                                      recall 12/12

Code 1    10-30% BOP  Unstable/localised       45 minutes              $110/140       AMBER

Low – Medium risk                                                 recall 6-12/12

Code 2     >30% BOP    Active /generalised      45 – 60 minutes      $120/155       RED

High risk  – possible two visit appointment       recall 3,4-6/12

ALL CODE 3 & 4 CLIENTS NEED CODE 2 Appointment at 45 or 60 minute appointment, dependent on need, for assessment and ORAL HYGIENE PHASE before COMPLEX CARE

 Complex

Clients seen as code 2 before –  5/10 minute review – consider OH review before to determine compliance, reassess need or whether interested in undergoing additional treatment

Code 3    Perio unstable         advanced             60 – 90 minutes      $200 – $300 per appt

per appt                                                                    quadrant or half mouth

Code 4    Perio unstable+       Complex               Combination therapy as above or refer

Or refer                                                                      as above              

Code 2P  Perio stable             Maintenance        45 minutes               $120/155    

Remission                                                                  recall to be determined

Codes 3/4 to be determined by Mark/Kelsey or referred to Periodontist

Based on modified fee structure and 2017 Classification  of Periodontal Diseases to Reach a Diagnosis in Clinical Practice www. Bsperio.ork.uk

 Patient Information Form

Environmental /Ecological – Plaque

pH balance

Caries risk

Perio risk

 Recession and sensitivity

 Products

 Fresh breath/ Tongue cleansing

 Dry mouth

 Erosion/ Wear/ Abrasion

In conclusion, the need to consider costs of care related to need conflicts with the assumption that all treatment should be charged at the same rate and that recall lengths are the alternative. This assumes that the recall will be met, that the clinician isn’t factoring in the additional effort professionally, physically, emotionally and mentally required to facilitate change and an achievable, beneficial outcome. My experiences demonstrate it is at least worth attempting, getting feedback from colleagues and measuring the benefits, quantitively and qualitatively, reflecting on them and making changes if required.