Action Research

O’Hehir University Action Research Reflection – A Positive Dental Health Message – The Worm that Turned

A comment recently struck me on an Oovoo classroom discussion, rather like those “ear worms” you get after listening to a song on the radio that just won’t get out of your head. It starts there, in your head, moving inexorably into a hum and finally manifesting itself into a badly sung chorus line and then, as quickly as it came, vanishes only to return at the most inexplicable moment once again. Then you download it and add it to the numerous other ear worms that had infected your senses on your iPod or MP3 player. This worm beckoned me to tune into “a positive dental health message” but subconsciously I elected to ignore its significance. However, it slowly buried itself within me.

Ear-Worms-Ear-Buds

As part of my project I am looking at a self-directed KISS philosophy, in intraspectical look at delivering better dental health outcomes in a “keeping it smart and simple” way. As I construct and pilot the premise into practice a few things now strike me.

1. Having time to deliver the message effectively could be a challenge.

2. Collaboration is a big word but fraught with complexity.

3. Can delivering a positive dental health message also be ethically profitable too?

I have discovered that timing, like in comedy, is critical to getting the best results. What do I mean by this? I used to use the bulk of a standard thirty minute appointment  in active treatment or instrumentation, after all, this was my training, my conditioning. I was taught to scale and debride perfectly and expect that as a consequence dental health would eventually prevail. Wrong. I soon discovered and now am more actively of the opinion that less is more and a focus on a positive dental health message is key. I now call it guided facilitation and is a much smarter way of achieving positive dental health messages with more time dedicated to oral hygiene instruction. But how do I sell this to the patient? After all they are used to and expect “The full Monty” of scrapping, rasping, with blood and guts with a cherry polish on top.

Most patients I suspect would like none of it, in fact I believe they would instead desire gentle and empathetic care ( note how I don’t mention “treatment”) which stems from a genuine concern for improvement by them in their dental health, leading to general health benefits ( the wow, wow factor) born of their efforts, facilitated indirectly by us. As a consequence I am now changing my care planning from less physical effort to a more listening and guiding approach with a huge upside. Interestingly too I now view, after assessment, mouths in percentages terms of health and disease and believe the positive health message that, in most cases the degree of health outweighs that of disease, is proving a powerful motivational tool.

As a result my “active” initial treatment focus is exactly that, the remove of plaque retention factors to improve dental health compliance and outcomes for the patient. Less time is used in active care and more in passive and fruitful facilitation. My hands hurt less, the patient hurts less and more over, the opportunity to ethical sell presents itself. “Passively” giving the patient choices based upon their own perceived learning styles and needs, directed by themselves will add an interesting dimension to the project. Will they buy more product as a perception of improving their dental health and if so where? From me, the shops or not at all?

Talking of “product” I now conclude with collaboration. I have had to change my project design to using Philips products – Electric toothbrushes ( Easy Clean/ Health White/ Flexcare Plus and Diamond Clean) as my P&G contact is ill and can’t help in its supply. This however has been a simple change and in fact could also help me understand better one thing that perplexes me still, why do patients still use manual toothbrushes when power brushes evidently are up to 25% more effective at plaque removal? This rare opportunity also allows me to give choice to the patient from the range of Philips brushes available and also still to demonstrate intra orally too, the critical key I feel to adding value and success to the “my mouth, model, their mouth” KISS model.

So to recap, I have changed my delivery of care, my collaboration and the premise that I will look also at how ethically profitable delivering KISS will be. As with most experimentation reviewing and appraising progress and changing accordingly isn’t a weakness or failure but a reflection of progress. No doubt further adaptations will follow but the main thing I hope to learn is that patients ultimately benefit with improved dental health outcomes as will I with less operator fatigue and answers to those questions that are like the proverbial ear worm that continually pop up in my head. Oh how the worm has turned.

Action Research within the Workplace – EMS Air-Flow Handy

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.2

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. 4, 5

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? 6

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. 7, 8

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, autoclaveable 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 Handys 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 renumerated 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 Gylcin 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. 9,10, 12
  • 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. 11, 12

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 polishing221583
I felt the procedure was comfortable and beneficial.003621
I would be willing to have the Airflow procedure again at future appointments001326
My mouth feels fresher and cleaner than I expected with Airflow.001524
I would be willing to pay an additional fee for Airflow.1012107

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 “Sherbert 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 suprisingly 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> Accessed (22 June 12).

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. Available from:http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf > Accessed (22 June 2012).

BDA Clinical Governance Kit, version 2. Available from:http://www.bda.org/dentists/advice/practice-mgt/laws/qs/clinical-gov/implementing/clinical-gov-in-practice.aspx> Accessed (22 June 12).

General Dental Council, Standards for Dental Professionals. London, GDC Publications, 2005.

Availablefrom:

http://www.gdcuk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf > Accessed (22 June 2012).

Published in Dental Health in 2013

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 meager 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 somber 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 6th 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  7Electric 12Both 2 
Do you clean between your teeth?Floss/interdental brush 8Both 5No 8 
How best do you think you learn?Seeing 2Listen  1Doing 15Reading 3
Where would you place these in order of importance to you? (15 completed ) Health 11 Function 0Aesthetics 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 1/0Electric 7/8Both 
Do you clean between your teeth?Floss/interdental brush 4/7Both        1/1No  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            3/8FunctionAesthetics 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 behavioral 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 kinesthetic 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. Available at: http://www.gdc-uk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf (Accessed 10 May 2013).
  1. Delivering Better Oral Health (2007). An evidence based toolkit for prevention, Department of Health. Part 2.
  2. Rooney (2010). NHS Dental epidemiological Programme for England. Available at:http://www.nwph.net/dentalhealth/reports/NHS_Dental_Epidemiology_Programme_for_England_Report_June_2010.pdf (Accessed 12 May 2013).
  3. Adult Dental Health Survey (2009). Available at:http://www.dhsspsni.gov.uk/adultdentalhealthsurvey_2009_firstrelease.pdf (Accessed 12 May 2013).
  4. Max Hastings (1984). Overlord: D-Day and the Battle for Normandy, Simon & Schuster.  New York.
  5. McNiff,J and Whitehead,J. (2011). All you need to know about action research, SAGE Publications, London. 10-39.
  1. MI Hygienist (2013a). A Reflection.  Available at:http://mihygienist.wordpress.com/2013/03/06/ohehir-university-the-shifting-sands-of-action-research-ethics-a-reflection/ (Accessed 13 May 2013)
  2. Carl Rogers (1969). Freedom to learn. Merrill, Columbus, Ohio, 157-166.
  1. Fleming, N and Mills, C. (1992). Not Another Inventory, Rather a Catalyst for Reflection. To Improve the Academy, 11, 137-155.
  2. Rattan et al. (2002). Clinical governance in general practice. Oxford, Radcliffe Medical ltd, 126-127.
  3. Carr, A and Ebbert, J. (2012). Interventions for tobacco cessation in the dental setting. Available at:http://www.asat.org.ar/images/comunidad/biblioteca/ib_odontologos_2007.pdf (Accessed 13 May 2013).
  4. Sgan-Cohen. H. (2008). Oral hygiene improvement: a pragmatic approach based upon risk and motivation. Available at:http://www.biomedcentral.com/1472-6831/8/31 (accessed 13 May 2013).
  5. 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.
  6. 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.
  7. 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.
  8. The Kings Fund (2008). Motivation and confidence, kicking bad habits. Available at: http://www.kingsfund.org.uk/sites/files/kf/field/field_document/motivation-confidence-health-behavious-kicking-bad-habits-supporting-papers-anna-dixon.pdf (Accessed 13 May 2013).
  9. Bandura, A. (1977). “Self-efficacy: toward a unifying theory of behavioural change”. Psychological Review, 84(2): 191-215.
  10. Miller, W and Rollnick, S. (2002). Motivational interviewing: preparing people for change. New York: Guilford Press.
  11. McNiff,J and Whitehead,J. (2011). All you need to know about action research, SAGE Publications, London. 57-8.
  1. MI Hygienist (2013b) A Reflection. Available at:http://mihygienist.wordpress.com/2013/02/09/ohehir-university-learning-and-living-with-my-contraditions-as-a-dental-hygienist/ (Accessed 13 May 2013).
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