Randomized trial of two e-learning programs for oral health students on secondary prevention of eating disorders

The purpose of this study was to test whether an interactive, web-based training program is more effective than an existing, flat-text, e-learning program at improving oral health students' knowledge, motivation, and self-efficacy to address signs of disordered eating behaviors with patients. Eighteen oral health classes of dental and dental hygiene students were randomized to either the Intervention (interactive program; n=259) or Alternative (existing program; n=58) conditions. Hierarchical linear modeling assessed for posttest differences between groups while controlling for baseline measures. Improvement among Intervention participants was superior to those who completed the Alternative program for three of the six outcomes: benefits/barriers, self-efficacy, and skills-based knowledge (effect sizes ranging from 0.43 to 0.87). This study thus suggests that interactive training programs may be better than flat-text e-learning programs for improving the skills-based knowledge and self-efficacy necessary for behavior change.

Evaluation of a theory-driven e-learning intervention for future oral healthcare providers on secondary prevention of disordered eating behaviors

Oral healthcare providers have a clinical opportunity for early detection of disordered eating behaviors because they are often the first health professionals to observe overt oral and physical signs. Curricula regarding early recognition of this oral/systemic medical condition are limited in oral health educational programs. Web-based learning can supplement and reinforce traditional learning and has the potential to develop skills. The study purpose was to determine the efficacy of a theory-driven Web-based training program to increase the capacity of oral health students to perform behaviors related to the secondary prevention of disordered eating behaviors. Using the Reach, Effectiveness, Adoption, Implementation and Maintenance evaluation framework, a longitudinal group-randomized controlled trial involving 27 oral health classes from 12 oral health education programs in the United States was implemented to assess the efficacy of the Web-based training on attitudes, knowledge, self-efficacy and skills related to the secondary prevention of disordered eating behaviors. Mixed-model analysis of covariance indicated substantial improvements among students in the intervention group (effect sizes: 0.51-0.83) on all six outcomes of interest. Results suggest that the Web-based training program may increase the capacity of oral healthcare providers to deliver secondary prevention of disordered eating behaviors. Implications and value of using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework are discussed.

Evaluate, assess, treat: development and evaluation of the EAT framework to increase effective communication regarding sensitive oral-systemic health issues

Oral healthcare providers are likely to encounter a number of sensitive oral/systemic health issues whilst interacting with patients. The purpose of the current study was to develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of eating disorders (i.e. early detection of oral manifestations of disordered eating behaviours, patient approach and communication, patient-specific oral treatment, and referral to care) for patients presenting with signs of disordered eating behaviours. The EAT Framework was developed based on the Brief Motivational Interviewing (B-MI) conceptual framework and comprises three continuous steps: Evaluating, Assessing, and Treating. Using a group-randomized control design, 11 dental hygiene (DH) and seven dental (D) classes from eight institutions were randomized to either the intervention or control conditions. Both groups completed pre- and post-intervention assessments. Hierarchical linear models were conducted to measure the effects of the intervention whilst controlling for baseline levels. Statistically significant improvements from pre- to post-intervention were observed in the Intervention group compared with the Control group on knowledge of eating disorders and oral findings, skills-based knowledge, and self-efficacy (all P < 0.01). Effect sizes ranged from 0.57 to 0.95. No statistically significant differences in outcomes were observed by type of student. Although the EAT Framework was developed as part of a larger study on secondary prevention of eating disorders, the procedures and skills presented can be applied to other sensitive oral/systemic health issues. Because the EAT Framework was developed by translating B-MI principles and procedures, the framework can be easily adopted as a non-confrontational method for patient communication.

Developing and pretesting case studies in dental and dental hygiene education: using the diffusion of innovations model

Case-based learning offers exposure to clinical situations that health professions students may not encounter in their training. The purposes of this study were to apply the Diffusion of Innovations conceptual framework to 1) identify characteristics of case studies that would increase their adoption among dental and dental hygiene faculty members and 2) develop and pretest interactive web-based case studies on sensitive oral-systemic health issues. The formative study spanned two phases using mixed methods (Phase 1: eight focus groups and four interviews; Phase 2: ten interviews and satisfaction surveys). Triangulation of quantitative and qualitative data revealed the following positive attributes of the developed case studies: relative advantage of active learning and modeling; compatibility with a variety of courses; observability of case-related knowledge and skills; independent learning; and modifiability for use with other oral-systemic health issues. These positive attributes are expected to increase the likelihood that dental and dental hygiene faculty members will adopt the developed case study once it is available for use. The themes identified in this study could be applied to the development of future case studies and may provide broader insight that might prove useful for exploring differences in case study use across dental and dental hygiene curricula.

Dental education and changing oral health care needs: disparities and demands

The population of the United States has changed dramatically over recent decades and, with it, the oral health care needs of the nation. Most notably, the racial/ethnic composition of the population has shifted from a European American majority to what is now a much more diverse population, comprising a variety of racial/ethnic groups that, taken together, will become the majority by mid-century. The proportion of children from minority racial groups will represent more than half of all U.S. children by 2025. These groups are overrepresented among those living below the poverty level and have higher levels of oral disease and are less likely to have access to care than the European American segment of the U.S. population. Most of the population needing dental care in the future will be comprised of these now underserved groups, along with other groups who can be described in terms of the health and social challenges of aging, disabilities, or other special health care conditions. This article provides an overview of these various needs and what they will mean for the dental practitioners of tomorrow and suggests that dental education has not adapted to the changing population and its oral health needs as quickly as it should. As a result, we identify major gaps in current dental curricula and make some recommendations for change. Research has shown that dental education has a crucial influence on future providers' professional attitudes and behavior related to providing care for patients from underserved patient groups. Acknowledging the specific needs of patients and ensuring that future providers are optimally prepared to respond to these challenges must be a major goal of dental education in the twenty-first century. The Journal of Dental Education will continue to play a critical role in informing readers about innovative approaches and best practices that ensure this goal can be met.

Factors for increasing adoption of e-courses among dental and dental hygiene faculty members

The incorporation of web-based learning into the dental curriculum has been consistently recommended in the literature on reform in dental education. There has been growing support for web-based learning in dental and dental hygiene education as demonstrated by deans' identifying this as a planned curricular innovation. The purpose of our study was to explore characteristics of e-courses that may serve to increase adoption among dental and dental hygiene faculty members. Eight ninety-minute focus groups (three dental; five dental hygiene) were conducted with dental (n=27) and dental hygiene (n=23) faculty members from six academic institutions. The resulting data were analyzed to identify two overarching themes and associated subthemes with regard to benefits and barriers influencing adoption of e-courses. A working conceptual framework, based on the Diffusion of Innovations, was developed from these themes to understand the characteristics that may influence the rate of adoption of e-courses among dental and dental hygiene faculty members. Analysis of the data revealed four main adoption barriers: 1) low perceived relative advantage to faculty members; 2) low compatibility with current curriculum; 3) high perceived time commitment; and 4) complexity of e-course development. This exploratory assessment identifies leverage points for facilitating the adoption and sustainability of e-courses in dental and dental hygiene education.

Underrepresented minority dental student recruitment and enrollment programs: an overview from the dental Pipeline program

By now, all dental schools should understand the need to increase the enrollment of underrepresented minority (URM) students. While there has been a major increase in the number of Hispanic/Latino, African American/Black, and Native American applicants to dental schools over the past decade, there has not been a major percent increase in the enrollment of URM students except in the schools participating in the Pipeline, Profession, and Practice: Community-Based Dental Education program, which have far exceeded the percent increase in enrollment of URM students in other U.S. dental schools during Phase I of the program (2002-07). Assuming that all dental schools wish to improve the diversity of their student bodies, chapters 9-12 of this report--for which this chapter serves as an introduction--provide strategies learned from the Pipeline schools to increase the applications and enrollment of URM students. Some of the changes that the Pipeline schools put into place were the result of two focus group studies of college and dental students of color. These studies provided guidance on some of the barriers and challenges students of color face when considering dentistry as a career. New accreditation standards make it clear that the field of dentistry expects dental schools to re-energize their commitment to diversity.

Development and evaluation of a web-based training program for oral health care providers on secondary prevention of eating disorders

Although oral health care providers (OHP) are key in the secondary prevention of eating disorders (ED), the majority are not engaged in assessment, referral, and case management. This innovative pilot project developed and evaluated a web-based training program for dental and dental hygiene students and providers on the secondary prevention of ED. The intervention combined didactic and skill-based objectives to train OHP on ED and its oral health effects, OHP roles, skills in identifying the oral signs of ED, communication, treatment, and referral. Using a convenience sample of OHP (n=66), a pre-/post-test evaluated short-term outcomes and user satisfaction. Results revealed statistically significant improvements in self-efficacy (p<.001); knowledge of oral manifestations from restrictive behaviors (p<.001) and purging behaviors (p<.001); knowledge of oral treatment options (p<.001); and attitudes towards the secondary prevention of ED (p<.001). Most participants strongly agreed or agreed that the program provided more information (89 percent) and resources (89 percent) about the secondary prevention of ED than were currently available; 91 percent strongly agreed or agreed that they would access this program for information regarding the secondary prevention of ED. This pilot project provides unique training in the clinical evaluation, patient approach, referral, and oral treatment that takes a multidisciplinary approach to address ED.

Willing, ready, and able? How we must exercise leadership for needed change in dental education

For over twenty-five years, dental education has had the benefit of environmental analyses and institutional planning for change. Strong programs for leadership development have emerged to give direction to these efforts. Leading and thriving, not merely surviving, are universal aspirations, yet we remain vexed by finances, structures, and traditions. This article takes a look at change and examines the difference between technical frameworks for leadership and adaptive leadership. Leadership for change is viewed as an activity, not as a position of formal authority. The skills necessary to address the beliefs, attitudes, and culture that place limiting boundaries on adaptive leadership are described. Using the work of Heifetz and Linsky, the relationship between authority and adaptive leadership is defined. Resistance to change is presented as reaction to loss, which needs to be addressed in a fundamental way, through leadership activity and engagement. If change and innovation are to be sustained, leadership must be less accidental, less technical, and more adaptive.

Evolution of dental school clinics as patient care delivery centers

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

Financing clinical dental education

Many reports have documented the growing financial challenges faced by dental schools. This article examines the financial implications of two new models of dental education: 1) seniors spend 70 percent of their time in community clinics and practices, providing general dental care to underserved patients, and 2) schools develop patient-centered clinics where teams of faculty, residents, and senior students provide care to patients. We estimate that the average dental school will generate new net revenues of about $2.7 million per year from the community-based educational programs for senior students and about $14 million per year from patient-centered care clinics. These are upper boundary estimates and vary greatly by school. The organizational and financial challenges of moving to these new educational models are discussed.

U.S. state-supported dental schools: financial projections and implications

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

Does faculty development enhance teaching effectiveness?

Academic dentists and members of the practice community have been hearing, for more than a decade, that our educational system is in trouble and that the profession has lost its vision and may be wavering in the achievement of its goals. A core of consistently recommended reforms has framed the discussion of future directions for dental education, but as yet, most schools report little movement toward implementation of these reforms in spite of persistent advocacy. Provision of faculty development related to teaching and assessment strategies is widely perceived to be the essential ingredient in efforts to introduce new curricular approaches and modify the educational environment in academic dentistry. Analyses of the outcomes of efforts to revise health professions curricula have identified the availability and effectiveness of faculty development as a predictor of the success or failure of reform initiatives. This article will address faculty development for purposes of enhancing teaching effectiveness and preparing instructors for potential new roles associated with curriculum changes. Its overall purpose is to provide information and insights about faculty development that may be useful to dental schools in designing professional growth opportunities for their faculty. Seven questions are addressed: 1) What is faculty development? 2) How is faculty development accomplished? 3) Why is faculty development particularly important in dental education? 4) What happens when faculty development does not accompany educational reform? 5) Why are teaching attitudes and behaviors so difficult to change? 6) What outcomes can be expected from faculty development? and 7) What does the available evidence tell us about the design of faculty development programs? Evidence from systematic reviews pertaining to the teaching of evidence-based dentistry, strategies for continuing professional education, and the Best Evidence in Medical Education review of faculty development outcomes are presented to answer this question: does faculty development enhance teaching effectiveness? Characteristics consistently associated with effective faculty development are described.

Eating disorders in the oral health curriculum

Due to the oral/systemic nature of eating disorders, this serious health issue requires comprehensive patient assessment and coordinated health treatment. The purpose of this study was to assess the breadth and depth of eating disorder and comprehensive care within the dental and dental hygiene curriculum. Survey data were collected from deans of U.S. dental programs (n=24) and dental hygiene program directors (n=94). Statistically significant differences were observed between dental programs (DP) and dental hygiene programs (DHP) as more DHP reported including anorexia nervosa (p<.001), bulimia nervosa (p<.001), and oral manifestations of eating disorders (p=.003) within their curricula. Clock hours dedicated to these topics ranged from seventeen to thirty-five minutes, with no statistically significant differences observed between DP and DHP. Only 58 percent of DP and 56 percent of DHP included patient communication skills specific to eating disorders. Moreover, DHP were observed dedicating more instruction time for this skill (p=.011). As greater emphasis is placed on oral/systemic health and the provision of comprehensive care, many oral health professionals may not be adequately trained to identify, provide education, and communicate with patients regarding the oral/systemic nature of eating disorders. The findings from this study indicate that there is a need for appropriate training to better prepare oral health professionals for comprehensive patient care.

Evolution of dental school clinics as patient care delivery centers

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

The dental education environment

The second in a series of perspectives from the ADEA Commission on Change and Innovation in Dental Education (CCI), this article presents the CCI's view of the dental education environment necessary for effective change. The article states that the CCI's purpose is related to leading and building consensus in the dental community to foster a continuous process of innovative change in the education of general dentists. Principles proposed by CCI to shape the dental education environment are described; these are critical thinking, lifelong learning, humanistic environment, scientific discovery and integration of knowledge, evidence-based oral health care, assessment, faculty development, and the health care team. The article also describes influences external to the academic dental institutions that are important for change and argues that meaningful and long-lasting change must be systemic in nature. The CCI is ADEA's primary means to engage all stakeholders for the purpose of educating lifelong learners to provide evidence-based care to meet the needs of society.

Increasing dentists' capacity for secondary prevention of eating disorders: identification of training, network, and professional contingencies

The incidence of eating disorders has increased substantially over the last forty years. Primary care physicians and dentists share a parallel challenge for secondary prevention of anorexia nervosa and bulimia nervosa. The dentist, in particular, has a uniquely important and valuable role with respect to assessment of oral and physical manifestations, patient communication, referral, case management, and restorative care. Despite this crucial role, few dentists are engaged in eating disorder-specific secondary prevention. The purpose of this study was to explore beliefs, attitudes, and experiences of general dentists regarding eating disorder-specific secondary prevention behaviors using focus group methodology. Three ninety-minute focus groups were conducted with twenty-one general dentists (seventeen male, four female) recruited from the 2004 Academy of General Dentistry Leadership Conference. Data from the focus groups were analyzed to identify two over-arching themes and associated subthemes with regard to supports and barriers to eating disorder-specific secondary prevention practices. Analysis of data revealed that training, network, and dental professional contingencies emerged as places of influence for increasing capacity among dentists with regard to secondary prevention of eating disorders. This exploratory assessment identifies leverage points where strategic interventions including curriculum development, policies, and practices can be developed to support and sustain secondary preventive clinical behaviors among dentists.

Educational strategies associated with development of problem-solving, critical thinking, and self-directed learning

This article was developed for the Commission on Change and Innovation in Dental Education (CCI), established by the American Dental Education Association. CCI was created because numerous organizations within organized dentistry and the educational community have initiated studies or proposed modifications to the process of dental education, often working to achieve positive and desirable goals but without coordination or communication. The fundamental mission of CCI is to serve as a focal meeting place where dental educators and administrators, representatives from organized dentistry, the dental licensure community, the Commission on Dental Accreditation, the ADA Council on Dental Education and Licensure, and the Joint Commission on National Dental Examinations can meet and coordinate efforts to improve dental education and the nation's oral health. One of the objectives of the CCI is to provide guidance to dental schools related to curriculum design. In pursuit of that objective, this article summarizes the evidence related to this question: What are educational best practices for helping dental students acquire the capacity to function as an entry-level general dentist or to be a better candidate to begin advanced studies? Three issues are addressed, with special emphasis on the third: 1) What constitutes expertise, and when does an individual become an expert? 2) What are the differences between novice and expert thinking? and 3) What educational best practices can help our students acquire mental capacities associated with expert function, including critical thinking and self-directed learning? The purpose of this review is to provide a benchmark that faculty and academic planners can use to assess the degree to which their curricula include learning experiences associated with development of problem-solving, critical thinking, self-directed learning, and other cognitive skills necessary for dental school graduates to ultimately become expert performers as they develop professionally in the years after graduation.

The case for change in dental education

This article introduces a series of white papers developed by the ADEA Commission on Change and Innovation (CCI) to explore the case for change in dental education. This preamble to the series argues that there is a compelling need for rethinking the approach to dental education in the United States. Three issues facing dental education are explored: 1) the challenging financial environment of higher education, making dental schools very expensive and tuition-intensive for universities to operate and producing high debt levels for students that limit access to education and restrict career choices; 2) the profession's apparent loss of vision for taking care of the oral health needs of all components of society and the resultant potential for marginalization of dentistry as a specialized health care service available only to the affluent; and 3) the nature of dental school education itself, which has been described as convoluted, expensive, and often deeply dissatisfying to its students.

Sex differences among dentists regarding eating disorders and secondary prevention practices

BACKGROUND

The purpose of this cross-sectional study was to assess sex differences among dentists pertaining to current behaviors and behavioral beliefs with regard to eating disorders.

METHODS

The authors collected data via a self-administered paper-and-pencil questionnaire from a randomized sample of 350 practicing male and female dentists.

RESULTS

The results showed a low level of practice regarding secondary prevention (that is, measures leading to early diagnosis and prompt intervention) of eating disorders. The authors found statistically significant differences, with more female than male dentists reporting that they assessed patients for oral cues (P < .001), more female dentists reporting that they provided specific dental care instructions (P = .038) and more female dentists referring patients who have oral signs of eating disorders (P = .028). They also found sex differences with regard to mediating factors. Female dentists had greater knowledge of oral manifestations of eating disorders (P = .001), greater knowledge of physical cues of anorexia nervosa (P < .001), greater perception of the severity of anorexia nervosa (P = .007) and greater knowledge of physical cues of bulimia nervosa (P < .001).

CONCLUSIONS

Although the dentist may be the first health care provider to assess oral effects of eating disorders, his or her involvement may be influenced in part by sex and sex-related health beliefs.

CLINICAL IMPLICATIONS

Female dentists may be more sensitive to oral cues related to women's health issues. Further research is warranted to explore the mediating factors regarding secondary prevention of eating disorders.

Integration of oral health care and mental health services: Dental hygienists' readiness and capacity for secondary prevention of eating disorders

Often the first to observe overt health effects of eating disorders, dentists and dental hygienists play a fundamental role in the secondary prevention of eating disorders. The purpose of this study was to explore readiness and capacity for integration of oral health and mental health services. Employing a randomized cross-sectional study based upon the Transtheoretical and Health Belief Models, data were collected from 378 dental hygienists. Results reveal that the majority do not currently engage in secondary prevention practices. Only 18% of respondents indicated referring patients exhibiting oral manifestations of eating disorders to treatment. Significantly increasing the likelihood of assessment, referral, and case management included modifying factors regarding greater perceived self-efficacy, and knowledge of oral cues of disordered eating, as well as the individual's perception pertaining to severity of eating disorders. Implications for bridging dental care to mental health services include increasing behavioral capacity among dental hygienists via consciousness raising and improved self-efficacy.