Innovations in Restorative Hygiene

The United States Health Resources and Service Administration (HRSA) targeted improved access to care for children age 0 to 5 by creating the grant opportunity, “Predoctoral Pediatric Training in General Dentistry and Dental Hygiene.” In 2017, the University of Washington (UW) School of Dentistry in Seattle became one of 13 recipients of this opportunity. The UW grant “Early Childhood Oral Health Training Program,” or EChOTrain, initially targeted three primary areas and a fourth area was added when HRSA offered grant recipients supplemental funding in the area of childhood obesity prevention.

The objectives of the EChOTrain grant are:

1. To enhance the didactic and clinical curriculum in pediatric dentistry for predoctoral students.
2. To leverage the restorative training required in prelicensure dental hygiene programs in the state of Washington. It includes training in the provision of preventive and restorative care for children ages 0 to 5.
3. To pair predoctoral dental students with medical students during their pediatric rotation, offering interprofessional education for both cohorts, as medical students learn to include oral health screening and ­anticipatory guidance for parents in well baby/child visits.
4. To learn how oral health professionals can play a role in addressing the challenge of childhood obesity.

This article focuses on the objective to enhance training for prelicensure dental hygiene students in the care of children ages 0 to 5.

Enhanced Training

The need for enhanced training for predoctoral dental students and prelicensure dental hygiene students in the care of young patients is grounded in the lack of access to care for vulnerable children.¹ Beyond financial issues, children ages 0 to 5 face barriers related to the availability of trained oral health professionals. According to a survey of dentists, only one-third feel their dental school experience adequately prepared them to treat young children.² Dentists who lack adequate exposure to preschool children during dental school training are more likely to avoid treating these children and to refer them to specialists.³ Unfortunately, there is a lack of pediatric dentists to meet the demand, and these providers may not be geographically accessible because specialists are often located in population centers that provide an adequate patient pool.^4,5 Enhanced training of the dental team—both predoctoral dental students and prelicensure dental hygiene students—has the potential to address these access to care limitations.

SCOPE OF PRACTICE

The scope of dental hygiene practice varies by state. Currently 20 states allow dental hygienists to place and carve/contour amalgam and composite restorations. The limited literature on utilization of restorative hygiene has demonstrated potential for increased efficiency and production.⁶ Washington is unique in that it is the only state in which restorative training is required for licensure of graduates from its dental hygiene programs. This requirement has been in place since the early 1970s, and it includes education in the administration of local anesthesia and nitrous oxide. Licensed dental hygienists in many other states often choose to get additional training (when available) through programs designed for expanded function dental assistants to learn to place and carve/contour amalgam and composite restorations.

ADVANCED TRAINING

EChOTrain seeks to leverage Washington’s unique prelicensure dental hygiene restorative training requirement. At present, prelicensure training emphasizes the restoration of permanent teeth. EChOTrain aims to utilize the current dental hygiene education model in Washington, where dental hygiene students have a strong foundation in performing restorative procedures. It will build on this model to equip dental hygiene students with specialized training to perform restorative procedures specific to young children ages 0 to 5. This will maximize the therapeutic services that dental hygienists are educated to provide, increase their value to the dental team, and offer an effective way to extend the dental workforce in areas of need.

The enhanced training for prelicensure dental hygiene students is a three-pronged approach that includes:

1. Didactic training necessary to provide care for children ages 0 to 5
2. Experiential learning in the UW Pediatric Dental Clinic
3. Community-based experience in providing care to young children

During the first year of the EChOTrain grant, we focused on developing the curriculum for this training. In year two, we are piloting the curriculum with a small cohort of prelicensure dental hygiene students from a local community college. The third, fourth, and fifth years will allow measured expansion of the program to include an increased number of dental hygiene students.

GETTING PREPARED

An initial assessment of the dental hygiene programs in Washington revealed that children age 5 and younger were not being seen in their restorative teaching clinics, while children younger than 4 were not being seen for preventive services such as sealants, fluoride treatment, and prophylaxis. A gap analysis of a typical community college dental hygiene program curriculum allowed an assessment of didactics in the care of children ages 0 to 5. The program provided education in pediatric dental anatomy and basic behavior guidance for children. However, the in-depth curriculum review revealed a lack of didactic and/or clinical training in the following: causes and prevention of early childhood caries (ECC), administration of local anesthesia to young children, use of restorative materials and techniques for 0 to 5 year olds, and knee-to-knee technique for providing oral hygiene instruction, fluoride treatment, and anticipatory guidance to their parents.

Across the state of Washington, the EChOTrain team has conducted several focus group interviews in pediatric dental practices that employ dental hygienists. This has helped parse out what aspects of prelicensure education prepare dental hygienists to practice in these settings and what is missing. These sessions have revealed that much of the skill set is acquired on the job, and offices typically develop a training plan for new hires. This includes developing critical behavior guidance skills and becoming familiar with the unique dynamics of a pediatric dental practice. The dental hygienists in these practices are seen as invaluable members of the team. By utilizing dental hygienists’ full scope of practice—both restorative and preventive skills—the team is able to provide care to more patients and the pediatric dentist is able to spend more time interacting with patients and parents.

IMPLEMENTATION OF TRAINING

The EChOTrain dental hygiene didactic curriculum emphasizes training in restorative materials/techniques and local anesthetic/nitrous oxide administration for very young children. Dental hygiene students will learn the following: behavior guidance techniques best suited to elicit cooperation from this age group, appropriate anticipatory guidance, and how to interact with parents. Students will be introduced to the concept of social determinants of health to gain a more in-depth understanding of the epidemiology of the disease of early childhood caries. They will learn about risk factors and preventive strategies, how to offer nutritional counseling, and the use of silver diamine fluoride for both the prevention and treatment of dental caries.

EChOTrain has developed a series of 17 videos that demonstrate dental procedures for children ages 0 to 5. These videos facilitate the delivery of didactic material to predoctoral dental students and prelicensure dental hygiene students. Additionally, the curriculum includes five learning modules that present students with content on oral health literacy, social determinants of health, children with special needs/autism, childhood obesity prevention and nutrition, and preparing for restorative hygiene in pediatric dentistry. Both the videos and modules may, in the future, serve other states that wish to introduce aspects of EChOTrain, as their workforce models and scope of practice for dental hygiene expand.

Experiential learning in the pediatric dental clinic will overlap with the didactic instruction, pairing hands-on laboratory practice with the opportunity to observe and be guided by pediatric dentists and dental residents treating very young children. Using this model, students will practice an aspect of pediatric dental care and then be able to immediately observe the technique being utilized on live patients.

In the community-based setting, dental hygiene students will provide preventive and restorative care to children ages 0 to 5 under the guidance of trained and calibrated preceptors. Their experiences will include knee-to-knee oral hygiene instruction and fluoride varnish treatments, anticipatory guidance, nutritional counseling, administration of local anesthesia/nitrous oxide, and placing rubber dams and restorations. It is anticipated that their experiences in both of these safety-net settings will provide exposure to social determinants of health and offer experiences that will develop cultural humility.

CONCLUSION

The American Academy of Pediatric Dentistry recommends that all children are seen for their first dental visit by age 1 and have access to a dental home. EChOTrain seeks to further this goal by preparing dental students and dental hygiene students to confidently provide team-based care to very young children. With this enhanced skill set, dental hygienists will be equipped to provide necessary dental services in the general, specialty, and community settings where the youngest patients need those most.

REFERENCES

1. Oral health in America: a report of the Surgeon General. J Calif Dent Assoc. 2000;;28:685–695.
2. Rich JP 3rd, Straffon L, Inglehart MR. General dentists and pediatric dental patients: the role of dental education. J Dent Educ. 2006;70:1308–1315.
3. McQuistan MR, Kuthy RA, Damiano PC, Ward MM. General dentists referral of children younger than age 3 to pediatric dentists. Pediatr Dent. 2005;27:277–283.
4. Nainer SM. State-based distribution of US pediatric dentists in private practice. Pediatr Dent. 2015;37:502–507.
5. Guarnizo-Herreño CC, Wehby GL. Dentist supply and children’s oral health in the United States. Am J Public Health. 2014;104:e51–e57.
6. Beazoglou TJ, Chen L, Lazar VF, et al. Expanded function allied dental personnel and dental practice productivity and efficiency. J Dent Educ. 2006;70:1308–1315.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2018;5(10):32–35.