Dental patient education: a survey from the perspective of dental hygienists

Abstract

The aim of this study was to describe the current patient education practices of dental hygienists by exploring their views concerning their skills and knowledge related to patient education and by determining the implementation of patient education in their work, with regard to both method and content.
The target group consisted of 416 dental hygienists (n = 222, 53%) The research strategy used was a survey. The material was gathered using questionnaire.
According to the dental hygienists, their skills and knowledge about patient education were good. However, the implementation of education was not in line with these assessments. The content of the education given focused mostly on the functional dimension. Little use was made of various educational methods, and the dental hygienists felt that they were not in good enough command of the methods. The patient's expectations and learning were not assessed systematically. The education provided and the assessment of the need for education often focused on the professional him/herself and the standpoint of the patient empowerment was disregarded.
These results lay the foundation for additional research aimed at developing the patient education given by these professionals and making it support the empowerment of each patient.

Full text

M Rantanen
K Johansson
E Honkala
H Leino-Kilpi
M Saarinen
S Salantera
¨
Authors’ affiliations:
Mirkka Rantanen, Kirsi Johansson, Helena
Leino-Kilpi,Sanna Salantera
¨, Department
of Nursing Science,
University of Turku, Turku,
Finland
Eino Honkala, Department of Public Health
Dentistry,
University of Turku, Turku,
Finland
Maiju Saarinen, Research Center of Applied
and Preventive Cardiovascular Medicine,
University of Turku, Turku,
Finland
Correspondence to:
Mirkka Rantanen
Department of Nursing Science
University of Turku
20014 Turku
Finland
Tel.: +358 50 5872729
Fax: +358 2 333 8400
E-mail: miinra@utu.fi
Dates:
Accepted 21 April 2009
To cite this article:
Int J Dent Hygiene 8, 2010; 121–127
DOI: 10.1111/j.1601-5037.2009.00403.x
Rantanen M, Johansson K, Honkala E,
Leino-Kilpi H, Saarinen M, Salantera
¨S. Dental
patient education: A survey from the perspective
of dental hygienists.
2009 The Authors.
Journal compilation 2009 Blackwell Munksgaard
Dental patient education:
a survey from the perspective
of dental hygienists
Abstract: Objectives: The aim of this study was to describe
the current patient education practices of dental hygienists
by exploring their views concerning their skills and
knowledge related to patient education and by determining
the implementation of patient education in their work, with
regard to both method and content. Methods: The target
group consisted of 416 dental hygienists (n= 222, 53%) The
research strategy used was a survey. The material was
gathered using questionnaire. Results: According to the
dental hygienists, their skills and knowledge about patient
education were good. However, the implementation of
education was not in line with these assessments. The
content of the education given focused mostly on the
functional dimension. Little use was made of various
educational methods, and the dental hygienists felt that they
were not in good enough command of the methods. The
patient’s expectations and learning were not assessed
systematically. The education provided and the assessment
of the need for education often focused on the professional
him ⁄herself and the standpoint of the patient empowerment
was disregarded. Conclusions: These results lay the
foundation for additional research aimed at developing the
patient education given by these professionals and making it
support the empowerment of each patient.
Key words: dental hygienist; empowerment; patient
education
Introduction
Oral diseases (caries and periodontal diseases) are the most com-
mon health problems among people in industrialized societies;
ORIGINAL ARTICLE
Int J Dent Hygiene 8, 2010; 121–127 121

the majority of adults and 60–90% of children have caries (1).
For example, in Finland oral health has improved for the past
30 years; but recent studies have indicated that the positive
development of oral health has come to an end. Of the12-year
old children in Finland, 62% have at least one decay, missing,
filled (DMF index) surface (2) and 64% of Finnish adults have
gingival problems (3). Severe periodontal disease, which may
result in tooth loss, is found in 5–20% of middle-aged adults,
the rate varying across geographical regions (1). A link has been
shown between oral diseases and general health. Inflammations
in oral tissues are an integral part of heart and vascular diseases
(4, 5). In addition, some results even suggest that aggressive
forms of periodontitis attributed to Actinobacillus actinomycetem-
comitans and Porphyromonas gingivalis are associated with inci-
dence of stroke (6).
The causes of oral diseases are known; two major factors are
poor hygiene and sugar consumption (7). In industrialized
countries, studies show that smoking is a key risk factor for
periodontal disease (1). Oral diseases are largely regarded as
being dependent on lifestyle and therefore individual adoption
of health habits plays an important role in their prevention.
Almost all dental diseases could be prevented or treated with
proper self-care, which includes healthy food habits and regu-
lar toothbrushing using fluoride toothpaste (7).
Proper self-care should also be fostered because traditional
curative dental care is a significant economic burden for many
high-income countries, where 5–10% of public health expendi-
ture is related to oral health (1). Therefore good oral health is
cost saving both for individuals and for the society.
The main task of the dental hygienist is to promote oral
health and to prevent oral diseases (8). According to earlier
studies dental hygienists provide more patient education than
other oral health care professionals do (9–11). In addition,
patients consider that of all the oral health care professionals,
dental hygienists are the ones who should implement patient
education (9). In view of these studies, it can be seen that
dental hygienists have the primary responsibility for educating
patients and promoting their oral health. However, in recent
years many structural and functional changes have taken place
in the Finnish system of public oral health care (2). The
development and consolidation needs of oral health care sys-
tems have required prioritization and allocation of the existing
limited resources (12). These changes may have affected the
work of oral health care professionals so that they have less
time for patient education.
In Finland, the content of patient education is, in part, gov-
erned by legislation: patients have the right to know their
health status and goals, alternatives and effects of their treat-
ment as well as issues concerning their care (13). Patient edu-
cation is also part of the ethical code for dental hygienists:
information about oral health, alternatives for treatment and
expenses should be explained to the patient in such a way that
he ⁄she understands them (14).
There are a variety of benefits from patient education, rang-
ing from reduced anxiety (15) and pain (16), increased motiva-
tion and knowledge about care (15) as well as improved ability
to cope with health problems and to participate in self-care
(17). When the objective is empowerment of the patient,
patient education can be perceived as a method that empha-
sizes the patient’s ability to manage his ⁄her health problems
(18).
The structure of patient education and the educational solu-
tions used generally vary from personal to group counselling
and from planned programmes of education to random ques-
tion-and-answer sessions (e.g. 19, 20). Patient education can
be seen as consisting of planning (assessing the patient’s
knowledge expectations and preferences, setting learning
objectives), implementation (methods, timing) and evaluation
of outcomes (18). In empowering patient education, the edu-
cational structure and methods are based on a patient-centred
approach and patient participation is considered important
(21). Current studies, however, show that the frequency and
content of oral health education (e.g. 22, 23) do not provide
evidence of the actual and interactive processes of patient
education (24). Unfortunately, existent patient education in
oral health care is more often professional-centred than
patient-centred (24, 25).
In view of these considerations, effective patient education
is particularly important, and research and further develop-
ment in this area are needed. The aim of this study was to
study current practices in patient education from the per-
spective of dental hygienists. In addition, we were interested
in exploring the relationship between demographic factors
pertaining to dental hygienists and patient education prac-
tices.
Research questions
1. How do dental hygienists assess their own educational skills
and knowledge about common oral health problems?
2. How do dental hygienists perceive the content, structure
and educational solutions (including assessment of knowledge
expectations, preferences, setting of learning objectives, use of
educational methods and evaluation of learning outcomes) in
current patient education?
3. Is there a relationship between demographic factors for
dental hygienists and the content, structure and educational
solutions of patient education?
Rantanen et al. Dental patient education
122 Int J Dent Hygiene 8, 2010; 121–127

Methods
Sample and data collection
The subjects who participated in this descriptive study were
dental hygienists who are members of the Finnish Dental
Hygiene Association (n= 832). A systematic sample was taken
so every second dental hygienist was included (n= 416).
The data were collected using a previously developed and
tested, mainly structured, questionnaire (26) which was modi-
fied for this study. The questionnaire was mailed to the dental
hygienists; they were asked to complete the questionnaire and
return it to the researcher in a stamped envelope. The
response rate was 53% (n= 222). As the anonymity of the
participants was protected, no reminders could be sent.
Ethical issues
Participation in this study was voluntary; those who returned
their questionnaires were considered to have given voluntary
consent. The basic principles of research ethics were followed
at all stages of the study and the data were confidential (27).
Instrument
The questionnaire included demographic variables (12 items)
and questions concerning the content (20 items, e.g. I provide
education on symptoms related to the patient’s illness, I pro-
vide education on costs and benefits, I provide education on
how to recognize feelings concerning to illness), structure and
educational solutions of patient education (a total of 23 items,
e.g. I provide education by showing, I provide education by
using computer, I assess patients educational needs by using a
questionnaire). In addition, the questionnaire included ques-
tions about patient education skills (six items, e.g. communica-
tion skills, mastering the content and skills in assessing
patients educational needs) and knowledge of basic oral health
care (15 items, e.g. knowledge of caries, malocclusion and hali-
tosis) The items were rated by the respondent on a four-point
scale (1 good – 4 poor, 1 all patients – 4 none of the patients)
(Table 1).
Validity and reliability of the instrument
The reliability in terms of the scale internal consistency was
estimated by Cronbach’s acoefficient, which was 0.74–0.89 for
the subscales, thus showing good reliability (28). The acoeffi-
cient was 0.76 for educational skills, 0.79 for knowledge about
common oral health problems (basic 0.79, generic health 0.89,
lifestyle 0.74) and 0.80 for the sum variables related to educa-
tion content (bio-physiological 0.83, cognitive 0.89, experiential
0.74 and ethical 0.77).
Data analysis
The data were analysed using spss for Windows (13.0) software
(SPSS Inc., Chicago, IL, USA). Descriptive statistics (frequencies,
percentages, means, standard deviations and range) were used to
summarize the demographic data and Fishers exact test was
used to examine demographic data and sum variables. The sum
variables related to content of patient education were formed
based on the theoretical framework of empowering knowledge
of Leino-Kilpi et al. (18). According to this theoretical frame-
work, patient education is viewed from six different dimensions.
The sum variables were bio-physiological (identification of the
Table 1. The questionnaire (26)
Question about Items Scale 1–4
Demographic factors 12 items (age, work experience, working environment)
Content of patient education 20 items formed into 6 sum variables: bio-physiological,
functional, cognitive, experiential, ethical, financial
The area considered with every
patient– none of the patients
Knowledge about oral care 15 items formed into 3 sum variables: basic,
generic health and way of life related knowledge
The area considered good – poor
Patient education skills 6 items (assessment, objectives, content, methods,
evaluation and communication)
Good – poor
Based on patient education
skills and practice
4 items (skills based on) and 6 items (practice based on) Very much – not at all
Assessing knowledge
expectations and preferences
5 items (how to assess patient’s knowledge
expectationss and preferences)
Every patient– none of the patients
Setting of learning objectives 5 items (how to set objectives) and 4 items (what objectives) Every patient – none of the patients
Use of educational methods 23 items Every patient – none of the patients
Evaluation of learning
outcomes
8 items (ways of confirming) Every patient – none of the patients
Rantanen et al. Dental patient education
Int J Dent Hygiene 8, 2010; 121–127 123

symptoms and signs), functional (activities of daily living), cog-
nitive (receiving enough knowledge and the ability to use it),
experiential (emotions and earlier experiences), ethical (feeling
of appreciation as an autonomous individual) and financial (costs
and benefits) (18). Sum variables related to basic dental care and
the dental hygienists’ assessments of their educational skills
were calculated. The differences between the demographic fac-
tors concerning sum variables and single items were analysed
using non-parametric tests. By convention, 0.05 was the
accepted level of significance (28).
Results
Demographic data
The mean age of the dental hygienists was 43 years (range
23–64, SD 10.2). After graduating as dental hygienists, they
had worked an average of 14.1 years (range 1–34, SD 9.3)
and at the same workplace 10.7 years (range 1–37, SD 9.3).
Most of them (82%) had a permanent job and over half
(64%) worked in public dental health care. Most of them
(93%) give education to all patients. Of all dental hygienist,
89% assessed patient education as very important and 11%
as important. A majority of the dental hygienists experience
their work as physically (78%) and mentally (62%) very
stressful and 70% reported that the need for speed interferes
with their work.
Dental hygienist assessment of their educational skills
The dental hygienists were asked to assess their own skills in
assessing patient’s knowledge expectations, setting learning
objectives, mastering the content of patient education, using dif-
ferent educational methods, evaluating learning outcomes and
mastering the interaction with the patient. All dental hygienists
assessed their skills on the whole as fairly good (median for the
items 1.7, inter quartile range 1.3–2.0, scale 1 good – 4 poor).
The highest ratings were for competence in the content (99%)
and in communication skills (99%). The lowest rating was given
for use of different educational methods (88%).
The educational skills of these hygienists were based mainly
on experience (98%), slightly less often on independent study
(85%), pre-registration training (82%) or additional post-
registration courses (75%). Patient education practices were
also found to be based most often on work experience (99%)
and on professional publications (93%), while databases (24%)
and data from international scientific journals (20%) played no
role.
Dental hygienists assessment of their knowledge
on common oral health problems
The knowledge of the dental hygienists concerning common
problems in oral health was perceived as quite good (medians
of the sum variable 1.3–2.0, scale 1 good – 4 poor). The high-
est rated section of knowledge was basic knowledge, i.e. how
to prevent and care for caries (100%) and periodontal diseases
(100%) or knowledge about self-care instruments and products
(99%). The lowest rated knowledge was about cessation of
smoking (65%) and oral piercing (45%). Dental hygienists who
treated mainly children assessed their level of knowledge as
good (100%); where as only 44% of those who treated mainly
adults assessed their level of knowledge as good (P< 0.001).
Dental hygienists’ perceptions of the content
of patient education
Questions concerning the content of patient education were
asked. Here the dental hygienists were asked to indicate how
large a portion of patients they counsel in each area (one all
patients – four none of the patients). Dental hygienists
revealed that the education they gave consisted of mainly
issues concerning functional matters, for example, toothbrush-
ing and flossing, followed by the cognitive aspects, such as
knowledge about oral illness and care (Table 2).
Dental hygienists’ perception of the structure
and educational solutions of patient education
The main areas of structural and educational solutions that
were identified were: knowledge expectations and preferences,
setting of learning objectives, use of different educational
methods and evaluation of learning outcomes. Almost all of
the dental hygienists (99%) reported that they assessed all or
many of the knowledge expectations of the patients. The
assessments were most commonly made during the informal
Table 2. The content of patient education. The rank order
of dealing with content by areas (medians)
Area q
1
md q
2
Functional 1.00 1.00 2.00
Cognitive 1.44 1.67 2.00
Bio-physiological 1.33 2.00 2.00
Ethical 2.00 2.00 2.50
Experiential 1.75 2.25 2.50
Financial 2.00 3.00 3.00
md, median; q
1
, lower quartile; q
2
, upper quartile.
Scale, every patient (1) – none of the patients (4).
Rantanen et al. Dental patient education
124 Int J Dent Hygiene 8, 2010; 121–127

interviews (95%) and less often according to a plan prepared in
advance (35%).
Dental hygienists indicated that they set learning objectives
for all or many of their patients (87%). In most cases (89%)
the objectives were set in discussions with the patients. Almost
as often (87%) the objectives were set primarily by the dental
hygienists, who then explained these objectives to their
patients.
Questions concerning the use of different educational meth-
ods were also included. The dental hygienists used mostly per-
sonal education sessions (99%); group sessions were used
rarely (16%). Talking (99%), demonstrating (98%) and advising
(97%) were commonly used rather than computers (17%) and
videos (4%), both of which were used rarely. Patient education
was usually given at the same time as treatment (93%).
A majority (82%) of the dental hygienists used less than half
of their working time for education. One patient education
session usually lasted 5–10 min or less (58%).
According to most of the dental hygienists (91%) learning
outcomes were assessed in informal interviews. In addition,
80% of the dental hygienists checked the outcome by asking
the patient to show how to do something or by asking the
patient to self-evaluate his or her learning outcomes (67%).
Relationship between demographic factors
and the content of patient education
Relationships between the demographic factors for the dental
hygienist and issues concerning patient education were stud-
ied. The demographic factors were dental hygienist’s age,
work experience, working environment, employment status
and age distribution of patients (children, adults or both).
Issues concerning the patient education were the content of
patient education, the structure and educational solutions of
the patient education.
The employment status of the dental hygienists was associ-
ated with the content of patient education: dental hygienists
who worked in private practice more often implemented edu-
cation about bio-physiological (P= 0.003) and economical
(P= 0.028) issues than other dental hygienists did. Those who
worked mainly with children implemented education more
often on bio-physiological (P= 0.021), ethical (P= 0.047) and
economical (P= 0.019) issues than did dental hygienists who
worked mainly with adults or with both adults and children.
Age and years of working as a dental hygienist were associ-
ated with the content of patient education. Younger (<36 years
old) dental hygienists implemented less education on recogni-
tion of emotions (P= 0.007), symptoms (P= 0.024), different
treatments (P= 0.028), costs and benefits (P= 0.030) and deal-
ing with emotions (P= 0.042) than did older dental hygienists.
Associations between demographic factors for dental
hygienists and structure and the educational solutions
of patient education
Some of the associations between the demographic factors of
the dental hygienists and the structure and the educational
solutions of patient education were significant. The dental
hygienists who were 37–45 years old based their patient educa-
tion on data from international scientific journals more often
than the other age groups did (P= 0.019). Those dental
hygienists who had worked for the longest period of time in
the same workplace based their education on the results of the
domestic studies more often than the other dental hygienists
did (P= 0.038).
Dental hygienists who worked in public dental care imple-
mented group counselling more often than those who worked in
private practice (P= 0.006). In addition, those who treated
mainly children preferred patient education in groups more often
than other dental hygienists did (P= 0.001). The same relation-
ship was found between the use of computer in education and
demographic factors: computers were used more often in public
dental health care (P= 0.001) and with children (P= 0.001).
Discussion
The main new outcome of this study is that the dental hygien-
ists’ assessment of their skills, knowledge and functions are not
in line with how the skills are implemented in practice. The
dental hygienists assessed their own educational skills in assess-
ing patient’s knowledge expectations, setting learning objec-
tives, evaluating learning outcomes, mastering the content of
patient education, using different educational methods and mas-
tering the interaction with the patient as fairly good. However,
the results of our study indicate that although patients’ knowl-
edge expectations and preferences were assessed with almost all
patients, the assessments were usually made during the informal
interviews. Therefore some relevant information may have been
missed. A structured, well-planned framework for the interviews
could be useful for assessing knowledge expectations. It has
been shown that patients can evaluate their own knowledge
expectations and anticipate what information they require (26)
and that valuable information should be taken into consideration
when patient education is planned.
The perception of dental hygienists concerning learning
objectives was that they set learning objectives for the majority
Rantanen et al. Dental patient education
Int J Dent Hygiene 8, 2010; 121–127 125

of their patients, but in most cases these objectives were set
by the dental hygienist alone. In addition, the learning out-
comes were usually assessed by the dental hygienists, although
self-evaluation by the patient might be more empowering to
the patient. An earlier study (24) also shows that one-way com-
munication was common even when the transtheoretical model
was explained to the dental hygienists beforehand.
Dental hygienists reported that they mastered the educa-
tional content. However, it seems that dental hygienists should
have a more holistic view of their patients. The perceptions of
the dental hygienists concerning the content of patient educa-
tion showed that the functional and cognitive areas had been
dealt with most adequately. The dental hygienists set great
store by these areas, including, e.g. knowledge about self-care
or where to search for more information. This is not surprising
in view of the need for oral health self-care, which requires
considerable commitment from the patient. The areas that
received least attention were the ethical, experiential and
financial areas. However, it would be important to provide
more information about treatment effects and potential prob-
lems and to take into consideration ethical considerations, such
as patients’ rights, financial matters and patients’ experiences
and expectations related to their care, all of which are impor-
tant issues in patient education.
As assessed by the dental hygienists, there was room for
improvement in the use of different educational methods. The
educational methods most commonly used were personal dis-
cussion, demonstration and instructions. However, in many
cases dental hygienists provided this kind of education while
they were treating the patient. For the patient, it is hard to
participate in conversation or put a question to the dental
hygienist at the same time as treatment. Of the various educa-
tional methods, computers and videos were used least. New
methods should be included in patient education because
today people are familiar with PC’s, the internet and other
information technology. These methods would allow education
to continue in places other than the treatment room. For
example, patient education material on the internet can be
used before and after the dental visit whenever patients would
feel a need for it.
The educational skills and patient education practices of the
dental hygienists were based mainly on experience but rarely
on research evidence from scientific journals or databases.
Dental hygienists must be encouraged to make use of research
data and to put evidence-based oral health care into practice.
This should be noted in education of the dental hygienists. In
addition, to update dental hygienists on these matters, contin-
uing education courses should be required.
Dental hygienists seem to have the knowledge and skills for
patient education in theory, but some improvements should be
made so that patient education could become more effective,
more patient-centred and more empowering. It is important
for dental hygienists to note that merely providing information
for the patient does not produce long-term changes in behav-
iour (29), but when individual’s ability to learn is known, it is
possible to place emphasis on patient empowerment. Viewed
from the perspective of empowerment, patients can be seen as
collaborators in their care (17, 21). Their expectations, knowl-
edge, experiences, motivation, perceptions, preferences and
participation should therefore be taken into consideration more
because these affect the patients learning.
Efforts were made to ensure the validity and reliability of this
study, however, there are limitations to this study. The response
rate was 53%. Despite that, response rate was considered satisfac-
tory and it was calculated to be representative. We have no infor-
mation of the reasons for non-participation, because a drop-out
analysis was not performed. However, the dental hygienists who
participated in the study might have been more interested in
patient education than those who did not. Furthermore, the con-
tact information for dental hygienists was taken from the mem-
bership list of the Finnish Dental Hygienist Association and it is
possible that not all information was correct and that perhaps not
everyone in the target group received the questionnaire.
The main purpose of this study was to clarify the current
state of patient education in a dental hygiene setting in Fin-
land. The results of the study are based on the perceptions of
the dental hygienists themselves. This study provides a lim-
ited perspective on the current state of patient education by
dental hygienists. The perspective of the patients should also
be analysed, and in that way the picture of current patient
education would be complemented. A study from different
standpoints and with different research methods is needed to
complete the picture of current practices and development
needs. A study of new educational methods and the effective-
ness of those methods should also be conducted. Overall
patient education in oral health care should be studied to
reveal the main challenges of and solutions for patient educa-
tion and to develop it in a direction that is more empowering
for patients. However, the present results will allow further
development of patient education in a dental hygiene setting.
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