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Cdho Portfolio Bibliography Meaning

A dental hygienist or oral hygienist is a licensed dental professional, registered with a dental association, or regulatory body within their country of practice. They are primary healthcare professionals who work independently of or alongside Dentists and other dental professionals to provide full oral health care. They have the training and education that focus on and specialize in the prevention and treatment of many oral disease. The dental hygienist is a primary resource for oral cancer screening and prevention. Most importantly, they spend a large amount of time at each patient visit looking at the soft tissues of the oral cavity, where the early manifestations of oral cancer occur.[1] They can choose to work in a range of dental settings from independent practice, private practice, and specialist practice to the public sector, and they can also work in residential aged care facilities.[2][3] Dental hygienists have a specific scope of clinical procedures they provide to their patients. They assess a patient's condition in order to offer patient-specific preventative and educational services to promote and maintain good oral health. The use of therapeutic methods assists their patients in controlling oral disease, while providing tailored treatment plans that emphasize the importance of behavioral changes .[4] In most jurisdictions, hygienists work for a dentist or dental specialist, and some are licensed to administer local anesthesia and perform dental radiography.[5] The major role of a dental hygienist is to perform periodontal therapy which includes things such periodontal charting, periodontal debridement (scaling and root planing), prophylaxis (preventing disease) for patients with periodontal disease. In addition dental hygienists are able to perform examinations, make diagnosis, take intraoral radiographs, dental sealants, administer fluoride, and provide patient specific oral hygiene instruction.[6] They are also able to work at an orthodontic clinic and can perform many tasks there such as selecting and sizing of orthodontic bands for dental braces, the removal of orthodontic appliances. They are also able to make dental impressions for the construction of study casts and mouthguards.[4]

Dental hygienists work together with other dental professionals, with a higher number working at general practices with Dentists, dental therapists and oral health therapists. A smaller number work at specialist practices alongside orthodontists and periodontists. They help with the contribution of an interdisciplinary approach, aiming to provide optimum oral health care to their patients. Dental hygienists also aim to work inter-professionally to provide holistic oral health care in the best interest of their patient. Dental hygienists also offer expertise in their field and can provide a dental hygiene diagnosis, which is an integral component of the comprehensive dental diagnosis.[7]

Dental Hygienists may also serve as researchers and as educators in dental hygiene programs.

Treatment phases of periodontal therapy[edit]

Periodontal therapy is a continuous cycle requiring regular evaluation and maintenance to optimise treatment outcomes. The treatment is normally carried out by a dental hygienist or oral health therapist, but involves all members of the dental team and can include specialists throughout the course of care. There are six phases undertaken by dental professionals when undertaking periodontal therapy, which are as follows;[8]

Systemic pre-phase[edit]

This includes, but is not limited to;

  • A full review of the patient's medical history to identify the patient's systemic health, as well as establishing a provisional diagnosis. The provisional diagnosis is generated following a comprehensive oral examination, data collection and radiographic interpretation.
  • An ASA physical status classification system is used to indicate future treatment options for the patient, whilst considering the implications of risk factors, such as medical conditions (i.e. endocarditis, diabetes, smoking). This also allows the dental clinician to begin planning all non-surgical therapy.
  • All emergency treatment should be addressed first, this includes emergency periodontal treatment;[8]
  • The patients compliance should be established during this phase as optimal oral hygiene practices need to be employed in order to assist with treatment planning and, long-term goals and results;[8]

Initial phase: non-surgical periodontal therapy[edit]

Non-surgical periodontal therapy is concerned primarily with disease prevention, and is accomplished through patient and clinician cooperative interaction. It is normally accomplished with the incorporation of patient education and motivational interviewing, and if appropriate may include discussions regarding nutrition and smoking cessation.[8] The various treatments involved in this phase include;

  • Debridement
  • Antimicrobial therapy
  • Correction of local risk factors
  • Fluoride therapy
  • Caries control and placement of temporary restorations
  • Occlusal therapy
  • Minor orthodontic treatment

If disease is present, secondary prevention may be necessary, the cause of disease should be identified and noted, and the relevant professional movement should be identified and patient instruction for dental plaque control established in an attempt to reinstate a healthy oral condition. Therefore, mechanical and chemical plaque control are involved in this phase. This may be via;

  • Plaque disclosing agents
  • Manual or electric toothbrushes
  • Tooth brushing techniques
  • Inter-dental aids
  • Dentifrices
  • Chemical plaque control (antimicrobial mouthwashes)

Re-evaluation of non-surgical periodontal therapy[edit]

This phase is continuous throughout treatment, allowing the dental professional along with the patient to monitor the patients oral health status and assists in recognizing the need for change or amendment to the previously formulated treatment plan, according to the patients specific needs.[8] Treatment is monitored using accurate periodontal charting and clinical observation of hard and soft tissues by the dental professional. The results of the periodontal charting and clinical observation dictates what follows the non-surgical periodontal phase. The three generalised outcomes that may result are essentially;

  • The patient progresses straight to the maintenance phase
  • The patient returns to the non-surgical periodontal therapy phase, until such a time as their periodontal status is satisfactory
  • The patent advances to the corrective phase

Corrective phase: surgical periodontal therapy[edit]

The corrective phase is not needed for all patients, but is dictated by the outcomes of the re-evaluation phase, encompassing all indicated;[8]

Supportive periodontal therapy and restorative therapy[edit]

As with the corrective phase, supportive periodontal therapy is not needed for all patients, but is too dictated by the outcomes of the re-evaluation phase. It includes all required;

A re-evaluation of the overall response to treatment should be conducted at the end of this phase before continuing onto the maintenance phase.

Maintenance phase[edit]

The maintenance phase involves continuous care, which varies anywhere from two to six-month intervals. This maintenance phase involves both the patient and the dental hygienist to stop the disease from re-occurring, with the objective of keeping the dentition functioning for as long as possible in the oral cavity.[8]

History of dental hygienist[edit]

  • In the late 1800s dental disease prevention methods became popular amongst dentists and dental nurses, with dentists being trained to perform routine prophylaxis treatment in the fight against dental disease. During this period D. D. Smith of Philadelphia demonstrated the prophylactic methods to his colleagues and patients and the acceptance of his theories become increasingly popular.[9]
  • In 1898 Smith presented a lecture on his system of periodic oral prophylaxis, which required patients to attend regular visits for prophylactic treatment and education sessions around oral home care.[9]
  • In 1906 one of his followers Alferd C. Fones took a great interest into Smith’s theories and began to train his cousin, Irene Newman, to act as an apprentice, scaling and polishing teeth as well as giving instructions on how to keep their mouths clean with daily home care practices. She was then to become the first recognized dental hygienist.[9]
  • In 1910 the Ohio College of Dental Surgery offered a formal course for dental nurses. However, dentists in Ohio strongly opposed the formal training school, and those who completed the coursework were never allowed to practice. The course was soon to be discontinued in 1914 due to the backlash from the dental community.[9]
  • In 1913 the term dental hygienist was devised and Alfred Fones began the first school for dental hygienists in Connecticut[9]
  • 1914 the first legal dental hygienists graduated from Dr. Fones’ dental hygiene program and legally allowed to provide patients with prophylaxis treatment.
  • In 1915 Connecticut amended the dental practice act to include the regulation of dental hygienists and other states followed amending dental hygiene regulations outlining the scope of practice of a dental hygienist.[9]
  • 1923 the first meeting of the American Dental Hygienist Association took place [9]
  • 1939 There were 8,000 dental hygienists in the USA[10]
  • 1950 Dental hygienists were recogni[z]ed in Canada and the University of Toronto established the first dental hygiene program in the country.[11]
  • 1965 The first male Jack Orio graduated from The University of New Mexico [10]
  • 1965 over 15,400 dental hygienists were working in America [9]
  • 1974 Dental hygienists were employed by the government of New Zealand to treat members of the New Zealand army.[12]
  • 1975 Dental hygiene profession was introduced in Australia.[13]
  • 1980 There were 204 dental hygiene programs across America[14]
  • 1988 The Journal of Dental Hygiene celebrates 75 years of commitment to care[15]
  • 1994 dental hygienists in New Zealand to work publicly and privately.[12]
  • 2006 Auckland University of Technology Bachelor of Health Science (Oral Health):3years (dual-degree in Dental Hygiene and Dental Therapy)[12]

Global oral hygiene education and legislation timeline[edit]

First Year of TrainingFirst Year of Legislation of PracticeNo. of programs in 2001
USA19131907ȸ 1917†234
Canada19511947ȸ 1952†27
Japan1948‡ 19511948125
United Kingdom1954195419
R. of Korea1965197327
The Netherlands196819744
South Africa197219696
Switzerland19731975§ 1991§4
IcelandEduc. Abroad1978none
China (Hong19961
India (भारत)19721972NA
  • ȸLegal recognition of profession in first State or Province.
  • †First license issued.
  • ‡First training at US Allied Headquarters.
  • §For selected cantons first; in 1991 for all cantons.




See also: Dental therapist

Dental hygienists in Australia must be graduates from a dental hygiene program, with either an advanced diploma (TAFE), associate degree, or more commonly a bachelor's degree from a dental hygiene school that is accredited by the Australian Dental Council (ADC).[18]

In Australia it is a legal requirement for dental hygienists/ oral health therapist graduates to be registered with the Dental Board of Australia before practising their scope in periodontology in any state or territory in Australia.[19]

The Dental Hygienists’ Association of Australia (DHAA) Inc., established in 1975, is the peak body representing registered dental hygiene service providers in Australia. A dental hygienist does not need to be employed by a dentist but can independently assess patients and make treatment plans within their scope of practice whilst working in the community. Practising as an autonomous decision maker, and working within the scope of only what they are "formally" trained in. The National Law requires the same level of professional responsibility from dental hygienists, oral health therapists and dental therapists as it does from dentists, dental specialists and dental prosthetists in that all practitioners must have their own professional indemnity insurance and radiation licences. They are also required to complete 60 hours of mandatory continuing professional development in a three-year cycle.[20][21]

A Bachelor of Oral Health is the most common degree program. Students entering a bachelor's degree program are required to have a high school diploma or equivalent. Most Bachelor of Oral Health programs now qualify students as both dental hygienists and dental therapists, collectively known as oral health therapists.[22]


Dental hygienists in Canada must have completed a diploma program, this can be 19 months to 3 years. All dental hygiene students must pass a NDHCB (NDHCB) examination after graduation. This examination is offered three times per year, January, May and September. Three universities in Canada offer Bachelor of Science degrees in Dental Hygiene: Dalhousie University, University of Alberta, University of British Columbia.[3][4][5]

Dental hygiene across Canada is a well-respected career with many opportunities. These possibilities include working in clinical, administration, education, research and public health positions. The wages vary throughout the country; from approximately $32 per hour in some areas to as high as $55 per hour in others. A surplus of new dental hygiene graduates in recent years has resulted in a decrease in wages in some regions.[citation needed]

Some of the downfalls to practicing in different provinces are the different regulations. For instance, in BC, the hygienist cannot provide treatment without the patient receiving a dental exam in the previous 365 days unless the practicing hygienist has an extended duty module (resident-care module). In AB, BC, MB and SK, hygienists also administer local anesthesia if qualified to do so.[6][7][8][9] In Ontario, dental hygienists may take further training to become a restorative dental hygienist. Registered dental hygienists must register every year by December 31. Ontario dental hygienists must also prove continuing competence by maintaining a professional portfolio yearly. In Ontario, dental hygienists are registered with the College of Dental Hygienists of Ontario (CDHO). [23]

Dental hygienists in BC, ON, NS and AB are able to open their own private clinics and practice without a dentist on staff.

New Zealand[edit]

Since 2006,[12]New Zealand dental hygienists are trained at either University of Otago in Dunedin (at the country's only Dental School) or at Auckland University of Technology.[24] The qualifications (Bachelor of Oral Health at Otago, Bachelor of Health Science in Oral Health at AUT) enable graduates to register and practise as both a dental hygienist and a dental therapist.[12]

Prior to this, dental hygienists were first domestically trained in 1974 for use in the New Zealand Defence Force. The one-year course was taught by the Royal New Zealand Dental Corp at the Burnham army base outside Christchurch.[12] Hygiene training was briefly offered at the Wellington School for Dental Nurses in 1990 as 2 week a supplement to Dental Therapy students training.[12] However, this was quickly discontinued.[12]

The first independent non-military training began in 1994.[12]Otago Polytechnic began offering a 15-month Certificate in Dental Hygiene in Dunedin.[12] In 1998, the programme was modified to be a 2-year Diploma.[12] Otago Polytech stopped offering the course in 2000.[12] The following year, University of Otago began offering a 2-year Diploma in Dental Hygiene qualification.[12] In 2002, the university added a 3-year Bachelor of Health Sciences (endorsed in Dental Hygiene) degree alongside the Diploma.[12] This course was discontinued in 2007, when the current 3 year Bachelor of Oral Health commenced.[12]

In order to practise, all hygienists must annually register with the Dental Council.[25] For the 2014-2015 cycle, the cost of this is $669.07.[26] One hygienist is represented on the Council for a three-year term.[27]

Dental hygienists can become members of the New Zealand Dental Hygienists' Association.[28] The association was founded in 1993,[29] and is affiliated with the International Federation of Dental Hygienists.[30]

United States[edit]

Dental hygienists in the United States must be graduates from a dental hygiene program, with either an associate degree (most common), a certificate, a bachelor's degree or a master's degree from a dental hygienist school that is accredited by the American Dental Association (ADA).[31]

All dental hygienists in the United States must be licensed by the state in which they practice, after completing a minimum of two years of school and passing a written board known as the National Board Dental Hygiene Examination as well as a clinical board exam. After completing these exams and licenses, dental hygienists may use "R.D.H" after their names to signify that they are a registered dental hygienist.[32][33] Dental hygienists also have to become licensed in the state in which they intend to practice. State licensure requirements vary, however most states require an associate degree in Dental Hygiene, successful completion of a state licensure examination, as well as a clinical examination also typically administered by the state.

Dental hygienists school programs usually require both general education courses and courses specific to the field of dental hygiene. General education courses important to dental hygiene degrees include college level algebra, biology, and chemistry. Courses specific to dental hygiene may include anatomy, oral anatomy, materials science, pharmacology, radiography, periodontology, nutrition, and clinical skills.[citation needed]

A Bachelor of Science in Dental Hygiene is typically a four-year program. Students entering a bachelor's degree program are required to have a high school diploma or equivalent, but many dental hygienists with an associate degree or certification enter the bachelor's degree programs to expand their clinical expertise and help advance their careers.[citation needed]

Graduate degrees in the field of dental hygiene are typically two-year programs and are completed after the bachelor's degree. Common graduate courses in dental hygiene include Healthcare Management, Lab Instruction, and Clinical Instruction.[citation needed]

In addition, the American Dental Hygienists' Association has defined a more advanced level of dental hygiene, the Advanced Dental Hygiene Practitioner otherwise known as a dental therapist.

Dental hygienist students perform practical oral examinations free of charge at some institutions which have expressed a shortage in recent years.[34]

Direct access to care with a dental hygienist[edit]

The dental hygienists in some parts of North America can provide oral hygiene treatment based on the assessment of a patient’s needs without the authorization of a dentist, treat the patient in absence of a dentist, and also maintain a provider-patient relationship.


The Dental Hygienist Course in India is a full-time 2-year diploma course. The Dental Hygienist course is regulated and controlled by the Dental Council of India. After completion of the course a dental hygienist should be register with a state dental council. Any person who is a registered dental hygienist in a one state may practice as such in any other. The Federation of Indian Dental Hygienists Association (FIDHA)is the primary national body representing the dental hygienist profession in India, however some state dental hygienist associations also work at state level. In India, dental hygienists do not need to be employed by a dentist but can have their own clinic.


British Columbia[edit]

1995 - A client must have seen a dentist within the previous 365 days in order for the hygienist to provide dental hygiene treatment.

2012 - New bylaws offers an exemption from the 365-day rule if hygienists are registered in the Full Registration (365 Day Rule Exempt) class.[35]


2006 - Dental hygienists are able to offer their services in many practice settings including independent practice.[36]


2008 - If the dental hygienist has practiced for more than 3000 hours, and the client does not have a complex medical condition then the hygienists do not require the supervision of a dentist. [37]


2007 - Registered dental hygienists in Ontario who have been approved by the College of Dental Hygienists of Ontario can practice independently.[38]

United States[edit]


1998 - Registered dental hygienist in alternative practice (RDHAP): RDHAPs may provide services for homebound persons or at residential facilities, schools, institutions and in dental health professional shortage areas without the supervision of a dentist. RDHAPs can provide patient care for up to 18 months and longer if the patient obtains a prescription for additional oral treatment from a dentist or physician .[39]


1987 - Unsupervised practice: Hygienists may have their own dental hygiene practice; there are no requirement for the authorization or supervision of a dentist for most services. Colorado is currently the only state where this is approved. Case was won by JoAnn Grant, a dental hygienist from Fort Collins, CO. [40]


1999 - Public health dental hygienist: dental hygienists may practice without supervision in institutions, public health facilities, group homes, and schools as long as they have two years of work experience.[41]


2008 - Independent practice dental hygienist: A dental hygienist licensed with an independent practice may work without the supervision of a dentist, providing that the dental hygienist has to complete 2,000 work hours of clinical practice during the two years prior to applying for an independent license, as well as a bachelor's degree from a CODA accredited dental hygiene program or complete 6,000 work hours of clinical practice during the six years prior to applying for an independent license, as well as an associate degree from a CODA accredited dental hygiene program. [42]


2005 - PA 161 Dental hygienist: hygienists with grantee status can work in a public or nonprofit environment, a school or nursing home that administers dental care to a low-income population. Dentists collaborating with dental hygienists do not need to be present to authorize or administer treatment. However, dental hygienists must have the availability to communicate with a dentist in order to review patient records and establish emergency protocols. Hygienists need to apply to the state department of community health for grantee status.[43]


1984 - Unsupervised practice: dental hygienist practice without the supervision of a dentist is allowed in hospitals, group homes, nursing homes, home health agencies, Health and Human Service state institutions, jails, and public health facilities as long as the hygienist refers their patients to a dentist for treatment. Hygienists must have at least two years of work experience within the last 5 years.[44]

Notable dental hygienist[edit]

See also[edit]

Further reading[edit]


Dental hygienist holding a scaler
A dental hygienist at work
  1. ^"Be part of the change". Oral Cancer Foundation. Oral Cancer Foundation. Retrieved 27 September 2017. 
  2. ^Australian Dental Association. "Dental Hygienist". Australian Dental Association. Archived from the original on 25 February 2014. Retrieved 16 March 2014. 
  3. ^"Dental Hygienist". American Dental Association. Retrieved 16 March 2014. 
  4. ^ abDental Hygienists' Association of Australia Inc. (1999). A professional Body Addressing Training, Uniformity of Practice and Growth of the Dental Hygienist Profession. Retrieved from "Archived copy". Archived from the original on 2014-05-18. Retrieved 2014-05-17.  Print. Local dental regulations determine the scope of practice of dental hygienists respectively
  5. ^"Response to the Dental Board of Australia's Preliminary Consultation on the Draft Scope of Practice Registration Standard and Guidelines". Retrieved 24 May 2014. 
  6. ^"American Dental Association-Dental Hygienist- Job Description". Retrieved 24 May 2014. 
  7. ^American Dental Hygienists' Association - Standards of PracticeArchived 2012-11-07 at the Wayback Machine.
  8. ^ abcdefg, J. and D. Willmann, Eds. (2008). Foundations of Periodontics for the Dental Hygienist.
  9. ^ abcdefghiDanner, V. "Looking back at 75 years of the Journal; former editors reflect on their time with the Journal". Journal of Dental Hygiene. Retrieved 16 March 2014. 
  10. ^ abMarsh, Lynn. "Dimensions of Dental Hygiene". The Journal of Professional Excellent Dimensions of Dental Hygiene. Mrs Lynn Marsh. Retrieved 7 July 2015. 
  11. ^Johnson, Patricia M. "International profiles of dental hygiene 1987 to 2006: a 21-nation comparative study"(PDF). International Dental Journal. Retrieved 16 March 2014. 
  12. ^ abcdefghijklmnopCoats, Dawn E. "Dental Therapists and Dental Hygienists Educated for the New Zealand Environment"(PDF). International Dental Journal. Retrieved 16 March 2014. 
  13. ^"Dental Board of Australia - Registration Standards". Retrieved 23 May 2014. 
  14. ^Burt and Eklund, Brian and Steven. Dentistry, Dental Practice, and the Community (6 ed.). Brian A. Burt, Steven A. Eklund. 
  15. ^Danner, Valerie. "Journal of Dental Hygiene". Retrieved 7 July 2015. 
  16. ^Johnson, D.L.; Karkut, R.T. (October 1994). "Performance by gender in a stop-smoking program combining hypnosis and aversion". Psychological reports. 75 (2): 851–7. doi:10.2466/pr0.1994.75.2.851. PMID 7862796. 
  17. ^"Dental Board of Australia - Registration Standards". Retrieved 25 May 2014. 
  18. ^"Australian Health Practitioner Regulation Agency - Approved Programs of study". Retrieved 25 May 2014. 
  19. ^"Australian Health Practitioner Regulation Agency - Accreditation Standards". Retrieved 25 May 2014. 
  20. ^"Dental Board of Australia - Guidelines on continuing professional development". Retrieved 23 May 2014. 
  21. ^[1][permanent dead link], The Dental Hygienists’ Association of Australia Inc. June 2013 ‘’’Response to the Dental Board of Australia’s Preliminary Consultation on the Draft Scope of Practice Registration Standard and Guidelines.’’’ Pages 2-12
  22. ^"Dental Board of Australia - Oral Health Therapist". Retrieved 23 May 2014. 
  23. ^CDH BCArchived 2014-05-18 at the Wayback Machine.
  24. ^"Careers NZ: Dental Hygienist: How to enter the job". 25 Jun 2013. Archived from the original on 2014-10-23. Retrieved 24 Oct 2014. 
  25. ^"Dental Council of New Zealand: Apply for an annual practising certificate". 2014. Retrieved 24 Oct 2014. 
  26. ^"Dental Council of New Zealand: Fees for dental hygienists". 2014. Retrieved 24 Oct 2014. 
  27. ^"Dental Council of New Zealand: Council members". 2014. Retrieved 24 Oct 2014. 
  28. ^"New Zealand Dental Hygienists' Association: About us". Retrieved 24 Oct 2014. 
  29. ^"New Zealand Dental Hygienists' Association: Welcome to NZDHA". Retrieved 24 Oct 2014. 
  30. ^"International Federation of Dental Hygienists: Association Members". 2014. Retrieved 24 Oct 2014. 
  31. ^American Dental Hygienists' Association - Education
  32. ^Dental Hygienist License Information
  33. ^[2]
  34. ^
  35. ^"Dental Hygiene". Retrieved 1 April 2014. 
  36. ^"Dental Hygienists Profession Regulation". Alberta Queen's Printer. Retrieved 1 April 2014. 
  37. ^"The Dental Hygienists Act". Statutory Publications. Retrieved 1 April 2014. 
  38. ^"Health Professions Regulatory Advisory Council"(PDF). Retrieved 1 April 2014. 
  39. ^"RDHAP Application Instructions". Retrieved 1 April 2014. 
  40. ^"Direct Access States"(PDF). ADHA. Retrieved 1 April 2014. 
  41. ^
  • © 2006 American Dental Education Association

The Impact of Quality Assurance Programming: A Comparison of Two Canadian Dental Hygienist Programs

  1. Joanna Asadoorian, A.A.S. (DH), B.Sc.D. (DH), M.Sc. and
  2. David Locker, B.D.S., Ph.D.
  1. School of Dental Hygiene, Faculty of Dentistry, University of Manitoba
  1. Direct correspondence and requests for reprints to Prof. Joanna Asadoorian, School of Dental Hygiene, Faculty of Dentistry, University of Manitoba, D35-780 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W2 Canada; 204-789-3574 phone; 204-789-3948 fax; Joanna_Asadoorian{at}
  • Received July 25, 2005.
  • Accepted May 25, 2006.


Quality assurance (QA) and continuing competence (CC) programs aim to ensure acceptable levels of health care provider competence, but it is unknown which program methods most successfully achieve this goal. The objectives of the study reported in this article were to compare two distinct QA/CC programs of Canadian dental hygienists and assess the impact of these two programs on practice behavior change, a proxy measure for quality. British Columbia (BC) and Ontario (ON) were compared because the former mandates continuing education (CE) time requirements. A two-group comparison survey design using a self-administered questionnaire was implemented in randomly selected samples from two jurisdictions. No statistical differences were found in total activity, change opportunities, or change implementation, but ON study subjects participated in significantly more activities that yielded change opportunities and more activities that generated appropriate change implementation, meaning positive and correct approaches to providing care, than BC dental hygienists. Both groups reported implementing change to a similarly high degree. The findings suggest that ON dental hygienists participated in more learning activities that had relevancy to their practice and learning needs than did BC subjects. The findings indicate that the QA program in ON may allow for greater efficiency in professional learning.


Continuing competence (CC), quality assurance (QA), and quality improvement programs are strategies designed to ensure that the public receives not only appropriate and technically sound care, but also that health care delivery improves over time. The structure of these programs has become a contentious issue because requirements for registrants vary considerably between professions and jurisdictions and are resource-intensive. Program developers are increasingly obligated to validate CC requirements.

Canadian dental hygiene provincial QA/CC programs range in format from traditional mandatory continuing education (CE)-based programming, such as that occurring in British Columbia (BC) and other provinces, to more unique portfolio-based schemes, like that implemented in Ontario (ON). A full review of Canadian dental hygiene QA program requirements has been previously published.1

This article reports the findings of a survey-based study that compared the impact of the BC and ON dental hygiene QA programs on positive practice behavior change, a necessary prerequisite for practice improvements. These two Canadian self-regulated jurisdictions were selected because of their dissimilar QA/CC program requirements and because both have a sufficiently large population of dental hygienists to allow for statistical analysis. A previous article reported on the fulfillment of program requirements by study participants.2

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While keeping up-to-date with current research is foundational to providing quality care, it is the application of recent findings to practice that has the potential to improve practice.35 There is a considerable lag time between new research findings and their general application into the majority of practice settings,4,69 which has helped generate debate surrounding the best way to encourage current research utility in practice. Because the delivery of competent care requires the application of new knowledge and skills into practice, measurement of change in practice behaviors has been used as a proxy to measure quality and improvement.3,10,11

The idea that mandatory CE as an isolated mechanism, especially when passively disseminated, ensures CC of providers or quality in practice has not been empirically demonstrated.4,10,1215 New initiatives in QA programming have been partly fuelled by research demonstrating that learning based on individual needs and practice environment does lead to practice change.10,13,15,16 The College of Dental Hygienists of Ontario (CDHO), a provincial regulatory body, implemented such an innovation in QA programming in 1999.1

The ON program requires registrants to self-direct their learning, guided by ongoing self-assessment comparing individual practice behaviors to practice standards.17 Through the self-assessment, learning goals and a plan are established, the plan is implemented, and, finally, the plan is evaluated for the attainment of goals.17 Regardless of the learning resources selected or their quantity, the critical element is that activities are based on the predetermined learning goals. In contrast, the BC program requires seventy-five credit hours of formally recognized CE within a three-year cycle.1 While self-assessment is recommended, it is not an enforced component of the CE program in BC.

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Materials and Methods

This study utilized an observational, cross-sectional two-group comparison survey design. Data was collected with self-administered, mailed questionnaires primarily composed of closed-response items. The research proposal and survey instrument were validated based on face, content, consensual, criterion, and construct validity.18,19 A four-step approach was used to develop the survey instrument. First, knowledge acquired through previous research was applied.1 Second, an extensive literature review of QA, CE, Quality Improvement, CC, behavior change theory, adult learning theory, and the principles of health survey design was conducted. Next, several consultations with experts in QA, dental hygiene, survey methods and design, behavioral sciences, and psychometrics were carried out. Finally, pre-testing of the survey instrument was conducted with a convenience sample of practicing dental hygienists, and appropriate revisions were made.

The sample size was calculated based on a formula for two-group comparisons.18 While no comparable research was available within this specific population to base predicted values, Aday states that assumptions may be made based on knowledge of the group and previous research.18 We estimated a 50 percent difference between the two groups because self-assessment is a requirement within the ON QA program whereas, in BC, self-assessment is a recommendation. Based on this estimation, we calculated that each group required 860 cases to detect a difference between the group proportions for the main outcome variable: implementation of appropriate behavior change in professional practice. Appropriateness was defined for study subjects within the survey as “what you believe to be a positive and correct approach to your work and to be consistent with your knowledge, skill, and professional standards.”

While positive health care outcomes have been described as the most robust method for testing the impact of continuing medical education3 and are considered to be the “gold standard” for the study of QA in health care, outcomes can be complicated to measure and may be influenced by factors outside of the delivery of care, such as lack of patient compliance and the nature of the disease process.10,11 Greco and Eisenberg say that a less stringent test is whether health care providers (physicians) change their practice.3 Measuring change in practitioner behavior is based on the premise that improvements in health care delivery, specifically structure and process elements, will increase the likelihood of positive health care outcomes.11 The measurement of practice behavior change has been used as a proxy measure in other studies.3 In this study, the primary outcome measure was behavior change reported as occurring as a direct result of selected learning activities, such as continuing education, within a two-year period. As professional health care providers with legal and ethical responsibilities, we assert that dental hygienists are expected to be able to distinguish between appropriate and inappropriate care within their own scope of practice, knowledge, and level of expertise. Subsequent to reading a journal article or attending a course on an innovation in periodontal maintenance therapy, for example, the dental hygienist would implement this innovation into practice.

We used a 0.05 significance level of precision. In less complicated study designs such as the systematic random sampling used in this investigation, Aday states it is unnecessary to estimate and adjust for an anticipated design effect.18 Adjustments for an expected response rate of 75 percent were made.

Survey procedures were based, where feasible, on criteria from Dillman’s “Mail and Other Self-Administered Questionnaires” and Aday’s Designing and Conducting Health Surveys.18,20 Standardized survey procedures were exactingly followed to ensure reliability of the results. The study was ethically and scientifically approved by the University of Toronto and the Faculty of Dentistry respectively. Strict privacy and confidentiality were ensured throughout the study, and no risks to participants were expected. Sample subjects were disproportionately drawn from the two jurisdictions, BC and ON, of registered, active dental hygienists. Exclusion criteria included registrants with less than two years registration in BC or ON, those registered in more than one province, and those not actively registered in either BC or ON at the time of the survey.

The survey was divided into two components: Part I requested demographic data and QA activities and has been previously reported on,2 and Part II examined appropriate professional behavior change. This article presents the results of Part II. The survey instrument is available by contacting the first author.

In order to measure change in practice, study subjects were asked to report on their participation in seventeen specified dental hygiene and related learning activities (Table 1⇓) and, in addition, any other learning activities not included in the seventeen specified activities within the previous two-year period (see example in Figure 1⇓). Study subjects were asked to report on all learning activities undertaken during the previous two years including informal (e.g., journal reading, literature searches) and formal (e.g., continuing education lectures, study clubs) methods. Examples were provided within the survey of formal and informal activities. While respondents were asked in Part I of the questionnaire to report on the number of hours/days of informal and formal learning activities participated in,2 they were not asked to provide details on specific activities in relation to changes in behavior in Part II of the study. Opportunities were defined as “appropriate behavior change suggested and applicable for your work setting,” keeping in mind that the term “appropriate” had been defined earlier in the survey instrument. Three scores were calculated as presented in Table 2⇓. Three subsequent ratio scores were formulated for each respondent to present more accurate reflections of appropriate change implementation (Table 3⇓). This was necessary because the primary objective of the study was to measure behavior change as an outcome of learning activity; therefore, it is necessary to measure change as a proportion of opportunities rather than just total change as there may have been variation between the total activity scores.

Figure 1.

Example of specified dental hygiene learning activity

We interpreted the last score, implementation from activity, as a measure of learning efficiency.

Finally, a self-directed learning score was calculated as a reflection of the degree to which the respondents implemented the components of self-directed learning within practice, which theoretically guided their learning and change. Self-directed learning, as described originally by Knowles in 1975,21 involves several steps to guide learning and make it more relevant for the individual. The steps included in self-directed learning for the purposes of this study are:

  • self-assessment to determine professional weaknesses,

  • establishment of personal learning goals,

  • development of a plan for action,

  • implementation of a plan for action, and

  • re-evaluation to determine whether one’s goals were attained.

Self-directed learning scores were analyzed to determine if a significant relationship was evident between the self-directed learning score and the outcome measure, which reported appropriate behavior change implementation. Respondents were asked if they always, sometimes/occasionally, or never performed these self-directed learning steps and were allocated 2, 1, or 0 points, respectively, for a possible score out of 10.

Table 1.

Specified dental hygiene and related learning activities

Table 2.

Description of total scores

Table 3.

Description of ratio scores

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A total of 1,750 study subjects were randomly drawn from the two provincial registries (nBC=875, nON=875). A response rate of 49.5 percent of eligible subjects was achieved through two mailings. Of the eligible respondents, 46.6 percent (nON=404) and 53.4 percent (nBC=463) were from ON and BC, respectively.

Representativeness of the sample to the population was determined through comparisons of demographic and educational background data from this survey and that of a large Canadian study conducted in 2001 with a near 80 percent response rate.22 No statistically significant differences were demonstrated between the data, with the exception of a significantly greater proportion of ON respondents in the present study (13.4 percent) who obtained their dental hygiene education within a university setting as compared to those from the 2001 study (7.1 percent) (p=0.005).

Calculation of the activity score resulted in a range of zero to nineteen activities reported for both groups. Means for each of these three scores were calculated (Table 4⇓), and t-tests showed no significant difference between the two groups (activity score p=0.08; opportunity score p=0.27; implementation score p=0.42).

While not significant, these means show that while BC study subjects reported participating in slightly more total activities in the two-year period, ON dental hygienists demonstrated more total opportunities for practice behavior change.

A t-test of mean ratio scores demonstrated ON dental hygienists participated in significantly more professional learning activities that yielded relevant opportunities for change (opportunity from activity ratio score) than BC respondents (p<0.05) (Table 5⇓). The results indicated no significant difference between the BC and ON respondents’ implementation from opportunity scores. Therefore, when appropriate suggestions for change were presented, both groups implemented them to a similarly high degree. While the means revealed that both groups implemented much less change in relation to total activity (implementation from opportunity score) than in relation to total opportunities, respondents from ON showed a significantly greater proportion (p<0.05), suggesting more efficient learning strategies.

Previously reported findings demonstrated that ON participants reported significantly higher SDL scores than those in BC, which we believe is at least partially a result of the ON QA program requirements.2 The mean self-directed learning score in ON was 6.98 (s=2.40) and in BC was 6.14 (s=2.89) out of 10 (p<0.05).2

We tested for correlations between self-directed learning scores and the three ratio change scores. We believe that, of these scores, the best indicator of appropriate change is the implementation from opportunity score because no implementation of change would be expected in those activities participated in that did not yield appropriate suggestions for change. Using the Spearman’s rho correlation test for non-parametric data, a small (see Cohen, as cited in Hopkins for interpretation of correlation coefficients23) positive, significant correlation coefficient (rs=0.14, p<0.01) was demonstrated between self-directed learning score and implementation from opportunity score.

Correlations were also calculated for the SDL score and both the implementation from activity score and the opportunity within activity score. Again, small, positive, significant correlation coefficients were revealed (implementation from activity score rs=0.16, p<0.01; opportunity within activity score rs=0.11, p<0.01).

More moderate correlations were demonstrated for self-directed learning scores and the total scores: activity score rs=0.30 (p<0.01), opportunity score rs=0.32 (p<0.01), and implementation score rs=0.34 (p<0.01). These correlation coefficients indicate that as the self-directed learning score increases, so do the total amount of activity, total opportunities for practice change, and total implementation of practice change.

Correlation coefficients were also calculated to test for associations between demographic data and the implementation from opportunity score. Only age and experience showed very small positive correlations rs=0.12 for both (p<0.01).

Table 4.

Comparison of mean total scores

Table 5.

Comparison of mean ratio scores

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No statistical differences were found between the two groups in any of the total scores (activity, opportunities, or implementation), but the ON respondents participated in significantly more activities that yielded change opportunities and more activities that generated appropriate change implementation than did dental hygienists in BC. Both groups implemented change to a similarly high degree when presented with an appropriate opportunity. These findings suggest greater efficiency in professional learning strategies for the ON subjects.

Several reasons may explain this phenomenon. First, a significantly higher level of adherence to the self-directed learning process may result in a higher acuity for ON respondents to select appropriate learning activities. However, the small correlation coefficient calculations of self-directed learning and ratio change scores did not support this rationale. Second, CE time requirements imposed in BC coupled with more limited access to formal learning resources2 may impose barriers to selecting appropriate learning interventions that have a greater likelihood for presenting relevant suggestions for change suitable for implementation. Third, the ON QA program removes the preceding barrier and permits autonomous selection of learning activities. We believe a combination of these factors is responsible.

Only small but significant positive correlations were found between self-directed learning scores and the three ratio scores. More moderate, significant positive correlations were demonstrated between self-directed learning scores and the three total scores. This suggests that the self-directed learning process, in its entirety, appears to be positively related to all aspects of learning: participation in activity, opportunities for change encountered, and implementation of change. Had the self-directed learning scores been more highly correlated with change opportunities and change implementation, but not with activity participation, it may have been rationalized that the self-directed learning process is associated with appropriate choice and subsequent implementation. However, this distinction was not evident.

It is our assertion that dental hygienists in BC will need to participate in more learning activities in order to encounter similar quantities of appropriate learning opportunities for change than do dental hygienists in ON. This point raises very important questions regarding the validity and legitimacy of the imposition of CE time requirements on registrants within professional colleges. We recommend further scrutiny of QA and CC program requirements, especially where CE time requirements are imposed, as they may be inappropriate and inhibit efficiency in learning.

We have identified four main weaknesses to the study. First, only the final stage of the change process, implementation, was measured and was not sensitive to the stages of change. Slotnick has stated that research needs to incorporate the movement from one stage to the next when evaluating the success of an intervention on change.24 Second, the study was based on the utility of somewhat discretionary self-reported data versus observed data, and it is therefore subject to reporting inaccuracies. Social desirability bias occurs when an individual does not adhere to a social norm but reports doing so when questioned.25 Despite a suspected overreporting of activity and change, these influences are believed to be reasonably equal between these groups. This means that comparisons between groups can be made, correlations calculated, and conclusions drawn. However, caution must be emphasized when examining the total scores because these results are based on subjective and individual interpretations. Third, the generalizations made from the literature review presented in this article, especially references 10–16, may be somewhat unjustified because most of the research has been conducted on physicians. Bero remarks that the generalizability of the findings from the physician studies to other settings is uncertain, because of educational differences, structure of health care systems, and different barriers to change.14 Finally, the study design did not incorporate a control group. Including a province where no formal QA program is in place may have yielded useful comparative data. While a small follow-up study in another province is conceivable, it may be argued that more traditional programming based on mandated CE time requirements provide the control as very few jurisdictions, particularly those that are self-regulated, have no QA/CC programming in place.

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No statistical differences were found between BC and ON study subjects participating in QA/CC programs based on mandatory CE and SDL in any of the total scores (activity, opportunities, or implementation). However, the ON respondents reported participating in significantly more activities yielding change opportunities and generating appropriate change implementation than dental hygienists in BC. When presented with an appropriate opportunity, respondents from both groups implemented change to a similarly high degree. Small but significant positive correlations were found between self-directed learning scores and the three ratio scores, but more moderate, significant positive correlations were demonstrated between self-directed learning scores and the three total scores.

This study has generated important hypotheses worthy of investigation, including how the SDL process can be enhanced to provide more accurate and meaningful reflections of individual learning needs, examination of how and why the change process may collapse specifically in dental hygiene among other health professions, and, finally, a determination of how QA policy and programming can best facilitate appropriate learning strategies and the positive practice changes required for CC.

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The authors thank the Community Dental Health Services Research Unit, Faculty of Dentistry at the University of Toronto for the generous financial support provided for this project. In addition, we appreciate Dentistry Canada Fund in the awarding of the DCF/Warner Lambert Fellowship for Dental Hygienists Community/Special Interest Project also used to help finance this study. Finally, we thank the College of Dental Hygienists of British Columbia and the College of Dental Hygienists of Ontario for the provision of their respective provincial registries for study sampling procedures.

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  • Prof. Asadoorian is Assistant Professor and First-Year Clinical Coordinator, School of Dental Hygiene, Faculty of Dentistry, University of Manitoba; Dr. Locker is Professor and Director, Community Dental Health Services Research Unit, Faculty of Dentistry, University of Toronto. Direct correspondence and requests for reprints to Prof. Joanna Asadoorian, School of Dental Hygiene, Faculty of Dentistry, University of Manitoba, D35-780 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W2 Canada; 204-789-3574 phone; 204-789-3948 fax; Joanna_Asadoorian{at}


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