Tobacco use has been linked to periodontal

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1 Milieu in Dental School and Practice Improving Tobacco Dependence Education for Dental and Dental Hygiene Students at Loma Linda University School of Dentistry Margie R. Arnett, M.S.; Nadim Z. Baba, D.M.D., M.S.D.; Darlene Cheek, M.P.H., R.D.H. Abstract: In a general effort to facilitate dental professionals effective tobacco-dependence education (TDE), the student part of the project reported here had three purposes: ) to promote tobacco cessation activities in the dental school clinic, ) to evaluate dental and dental hygiene students confidence level in treating tobacco-dependent patients, and 3) to determine the frequency, duration, and depth with which the students assisted tobacco-dependent patients. Surveys of senior dental and dental hygiene students at the Loma Linda University School of Dentistry were conducted in 008. Of the twenty-seven questions on the survey, nineteen related to the procedures students performed and questions asked of patients, one question asked how many minutes students spent counseling patients, and seven questions related to barriers to incorporating TDE activities. Only 56.5 percent of the responding dental students reported they routinely asked and advised about their patients smoking behaviors, but 87.5 percent of the responding dental hygiene students reported they routinely did so. After the curricular intervention, the follow-up survey found that the dental students more frequently showed their patients the effects of tobacco on the oral mucosa and more frequently discussed pharmacotherapy options and made referrals during routine care. Until all dental and dental hygiene students are required to meet written board and clinical competencies in TDE and given adequate mentoring by clinical faculty to treat tobaccodependent patients, the likelihood of seeing major improvements in tobacco-cessation treatment in dental practices is low. Prof. Arnett is Assistant Professor, School of Dentistry, Loma Linda University; Dr. Baba is Professor, Department of Restorative Dentistry, School of Dentistry, Loma Linda University; and Prof. Cheek is Assistant Professor of Dental Hygiene, School of Dentistry, Loma Linda University. Direct correspondence and requests for reprints to Prof. Margie R. Arnett, School of Dentistry, Loma Linda University, 09 Anderson Ave., Loma Linda, CA 9350; phone; fax; marnett@llu.edu. Keywords: tobacco cessation education, tobacco, dental students, dental hygiene students, dental education Submitted for publication /5/0; accepted 8/8/ Tobacco use has been linked to periodontal disease, delayed wound healing, and oral cancer,, and previous studies have found a need to enhance didactic and clinical tobacco-dependence education training in dentistry. 3-7 Numerous studies have evaluated tobacco-cessation services in dental settings and advocated for the dental profession to be a more effective resource for these patients. 8- However, when oral health professionals identify adverse effects of tobacco use in their patients, they are likely to treat the symptoms but not the cause. The American Dental Association (ADA) and the American Dental Hygienists Association (ADHA) established standards for the treatment of tobaccodependent patients more than a decade ago, 3,4 yet research has found that many dentists report a lack of training 5 and are unfamiliar with the Public Health Service guideline and usually do not follow its recommended steps. 6 As recently as , only 34.9 percent of practicing dentists in the United States reported advising their patients to quit using tobacco. 7 A previous article from our study on improving tobacco dependence education (TDE) at Loma Linda University School of Dentistry (LLUSD) discussed clinical practices, knowledge, and attitudes among faculty members regarding TDE. 8 This article reports on LLUSD dental and dental hygiene students perceptions regarding barriers to treatment, confidence in their treatment abilities, and clinical activities related to their tobacco-dependent patients. Methods Prompted by a university-wide tobacco-curriculum initiative, a Tobacco Treatment Committee was formed at the School of Dentistry in 007. The goal of the university s initiative was for all students in and graduates from the Schools of Dentistry, Medicine, Nursing, and Pharmacy to have the ability to treat tobacco-dependent patients appropriate to their discipline. The School of Dentistry s Tobacco 47 Journal of Dental Education Volume 76, Number 4

2 Treatment Committee consists of chairs and faculty members from the departments of oral diagnosis, radiology, and pathology; periodontics; dental hygiene; restorative dentistry; dental research; and dental school administration. Three faculty members on the committee received one-on-one training from national experts in the field and attended three Society for Research on Nicotine and Tobacco annual scientific sessions. A survey of faculty members was conducted in 008 to identify their clinical practices, knowledge, and attitudes about tobacco-dependence education. 8 After receiving the results of that survey, the committee created a curriculum map and focused on improving TDE in the dental and dental hygiene curricula and the clinic (Table ). Six faculty development courses were offered free of charge to all faculty members. Course topics, which were based on the self-reported deficiencies identified by the faculty and other requests, included diagnosis and treatment planning, motivational interviewing, behavior modification, and pharmacotherapy. The purpose of the student part of our study was threefold: ) to promote tobacco-cessation activities in the dental clinic; ) to assess the dental and dental hygiene students confidence levels to treat tobacco-dependent patients; and 3) to determine the frequency, duration, and depth with which the students assisted tobacco-dependent patients. Senior dental students and senior dental hygiene students were surveyed in 008 (the survey is available from the corresponding author). We ed an introductory letter to the ninety-three senior dental students and forty-two senior dental hygiene students, with a link to an online questionnaire using Participation was anonymous and voluntary. SurveyMonkey has the ability to track and remind nonresponders to the survey without violating the anonymity of the participants. The initial was followed by a ten-day reminder, a twenty-one-day reminder, and a final reminder at thirty days. Individual invitation letters were also placed in students school mailboxes requesting their participation in the study. The survey was adapted with permission from the instrument used by Gordon et al. 9 Our survey included questions on demographics, clinical procedures, and perceived barriers and contained subcategories about oral effects of tobacco use, pharmacotherapy, counseling skills, follow-up, and documentation. The first section covered the frequency and type of procedures students performed on patients. The second section focused on time devoted Table. Timeline for implementing expanded tobacco dependence education for dental and dental hygiene students at Loma Linda University School of Dentistry November 007 Curriculum review Curriculum mapping Intensive faculty development March 008 Faculty survey Tobacco Treatment Committee formed July 008 st survey of dental and dental hygiene students Increased curricular hours (to 8 hours dental and 4 hours dental hygiene) 5 hours of faculty development November 009 NWS and FTND added on axium (clinical software program) March 009 nd survey of dental and dental hygiene students February 00 Biomechanical markers on clinic (CO monitors) July-August 00 Faculty calibration, 5 hours Patient brochures created and placed in lobby to patients. The third section inquired about barriers related to providing TDE. Of the total twenty-seven questions, nineteen related to the types of procedures the students performed and questions asked of their patients; one question asked how many minutes students spent counseling patients; and seven questions related to barriers to incorporating TDE activities in routine care. The second student survey was conducted nine months after faculty members received five hours of faculty development courses on TDE (Table ). The questions on the second survey were identical to the first and were used to assess students confidence levels after faculty development and curricular enhancements. Six faculty development courses were provided to faculty members (Table ), and based on student and faculty responses, eight hours of TDE instruction were added to the senior dental students oral diagnosis course and four hours of instruction were added to the senior dental hygiene lectures. Eventually, these lectures were incorporated into both curricula (Tables 3 and 4). Results of both surveys were analyzed by the Health Research Consulting Group of Loma Linda, using Statistical Package for the Social Sciences for Windows (SPSS v. 5.0, April 0 Journal of Dental Education 473

3 Chicago, IL), and the results of the first and second surveys were compared. Results The dental students response rate was 9.5 percent on the first survey and 67 percent on the second survey. The dental class consisted of seventy men and thirty women. The dental hygiene students Table. Details of faculty development provided to faculty members by topic Course Title Hours Number of CDE Attended Provided Tobacco-Dependence Education 33 Effective Tobacco Treatment 7 3 Tobacco Dependence, Diagnosis, and Treatment 64 Patient Treatment and Diagnosis 59 3 Tobacco Cessation and the Dental Team 50 Tobacco Dependence and Pharmacology 6 3 had a response rate of 90. percent on the first survey and a 97.6 percent response rate on the second survey. The dental hygiene class consisted of thirty-six women and two men. Both dental and dental hygiene students had an overall non-significant improvement in their composite scores (Table 5). Both dental and dental hygiene students also reported perceiving fewer barriers to treating tobacco-dependent patients after the curricular intervention. Neither dental nor dental hygiene students reported an increase of time (in minutes) spent with their patients on TDE and no increase in time spent on patient follow-up care at the time of the post-intervention survey. On the second survey, after the curricular intervention, the dental students did report more frequently showing their patients the adverse effects of tobacco on the oral mucosa (p=0.05) and reported having more pharmacotherapy discussions and referrals (p=0.08). Fifty-six percent of the responding dental students and 85 percent of the responding dental hygiene students reported they routinely asked and advised about their patients smoking behaviors. As expected, Table 3. Comparison of tobacco dependence education in the dental curriculum, academic years and 00 Course Number and Name Topics Covered Number of Hours Topics Covered Number of Hours DNES 708: Introduction to the Dental Profession DNES 707: Personal Development DNES 78: Communication and Interpersonal Relations ODRP 75 and 76: Patient Diagnosis and Treatment Plans Health history, diagnosing/ assessing lesions, pathology, oncology 0 Overview, use, types of TDE; TDE and dental profession; forms of tobacco, history, benefits/barriers to quitting 0 Lifestyle changes to prepare to quit, social support, 5As, 5Rs, ARMR 0 Motivation to quit, quit plan and day, quitlines, slips vs. relapses, handling social situations Health history, axium tabs, diagnosing/assessing lesions, pathology, oncology, using CO monitors PHRM 50: Pharmacology 0 Neurochemistry, addiction, pharmacotherapy ODRP 8: Oral Medicine PERI 765: Special Topics in Periodontics DNES 794: Public Health Dentistry Overview, use, types of TDE; TDE and dental profession; forms of tobacco, history, addiction Effects of tobacco in oral cavity, periodontal disease (moved from ODRP 8) 0 Effects of tobacco in oral cavity, periodontal disease Rx to Change module Resources, case studies, roleplay, review (no change) 474 Journal of Dental Education Volume 76, Number 4

4 the dental hygiene students reported spending more time with their patients providing counseling and discussing pharmacotherapy options and behavior modification than the dental students (Table 5). The ADA and ADHA minimum expectations for dental hygiene students were adequately met by these students responses for knowledge, attitudes, and time spent treating tobacco dependence. However, there was a deficit at the baseline survey and a decline at the post-intervention survey related to follow-up care for tobacco treatment and monitoring a patient s tobacco use. Considering the ADA and ADHA recommendations for three minutes of tobacco counseling per patient, 6,7 these dental hygiene students are adequately providing counseling with a self-reported time of eight minutes. Table 4. Comparison of tobacco dependence education in the dental hygiene curriculum, academic years and 00 Course Number and Name DNHY 3: Preclinical Dental Hygiene DNHY 405: Intro to Periodontology ODRP 3: General Pathology and Oral Pathology Topics Covered Number of Hours Topics Covered Number of Hours Intro to axium and health history form; intro to intra/ extraoral exam (EO/IO) for pre-cancer/cancer of clinical patients Effects of tobacco use on periodontal disease, wound healing (postsurgical and nonsurgical procedures), dental implants Effects and recognition of tobacco use on the human body and oral cavity; special emphasis on precancerous and cancerous lesions. + clinical practice with dental hygiene faculty supervision ¾ ½ Intro/overview tobacco use; intro to axium health history (how to access and use tobacco treatment code); EO/IO exam Effects of tobacco use on periodontal disease, wound healing (postsurgical and nonsurgical procedures), dental implants Effects and recognition of all types of tobacco use on the human body and oral cavity; special emphasis on precancerous and cancerous lesions. DNHY 38: Pharmacology 0 Intro to addiction, intro to pharm; treatment modalities (Clinical Guidelines: Treating Tobacco Use and Dependence by the U.S. Public Health Service) DNHY 46: Dental Health Ed I DNHY 47: Dental Health Ed DNHY 43: Public Health Dentistry DNHY : Senior Clinic Neurochemistry, assessment, motivational interviewing (MI), intro pedagogy including 5 stages of change; intro to U.S. Public Health Service s Clinical Guidelines Review TDE; group community oral health presentations (including TD) with dental hygiene faculty supervision at elementary and high schools and community Intro to community resources; case studies; field work Perform EO/IO on every clinical patient treated; clinical comp in tobacco treatment/counseling; TD patients in OSCEs Neurochemistry, assessment, MI, intro pedagogy including 5 stages of change; intro to U.S. Public Health Service s Clinical Guidelines; manage tobacco-dependent patient with follow-up; modify treat to sustain quit didactic field work didactic field work ¾ No change Same, but with addition of health advocacy Same as previous with increased time and followup in treatment/counseling supervised by dental and dental hygiene faculty ½+ practice with dental hygiene faculty supervision ½ ½ ½ didactic field work + didactic field work -4 April 0 Journal of Dental Education 475

5 Table 5. Change in dental and dental hygiene students responses from first survey (008) to second survey (009) Dental Hygiene Students (n=36) Dental Students (n=59) Mean (SD) Mean (SD) Mean (SD) Mean (SD) p-value Procedures total score 6.56 (6.64) 6.50 (.) (.68) 48.4 (0.76) <0.00,3 Showing oral tobacco s 3.50 (.5) 3.44 (.3).7 (.3).78 (.5) 0.05 <0.00 effects < Pharmacotherapy 5.89 (.44) 6.8 (.94) 3.7 (.80) 4.4 (.73) <0.00,3 Counseling skills 9.03 (7.5) 30.5 (5.64) 3.73 (6.06) 4. (5.54) <0.00,3 Follow-up 6.56 (3.86) 5.6 (3.5) 3.68 (.08) 4.3 (.) Documentation.83 (.78) 3.03 (.40) 0.8 (.7) 0.49 (.5) <0.00,3 Barriers total score 7.3 (4.35) 6.39 (3.89) 9.36 (4.08) 8.78 (3.73) <0.06 < Time spent (in minutes) 8.75 (4.53) 7.36 (3.7) 5.5 (6.47) 4.43 (4.54) <0.00 < SD=standard deviation DS over time. Group effect at Group effect at 009. There were no improvements in the amount of time the senior dental students spent monitoring patients, modifying treatment, and following up with these patients while they were patients of record at Loma Linda University School of Dentistry. The tobacco treatment protocol for the clinic was updated in axium (v. 4.6 Exan Academic, Port Coquitlam, BC, Canada). Two evidence-based tools, Fagerström Test for Nicotine Dependence (FTND) 0 and a nicotine withdrawal symptoms quiz, were included to provide quantitative analysis and direction to students. Discussion The 008 senior dental and dental hygiene student statistics were only suggestive of improvements, but axium reports showed an impact over time in future classes who benefitted from the improved and increased TDE instruction in both curricula. Three years after TDE changes were made at LLUSD, student TDE treatment practices increased from an annual total of three (008) to thirty-seven tobaccodependent patients counseled in 00 a dramatic improvement. There were differences between the time dental students and dental hygiene students spent educating patients and treating tobacco addiction in the clinical setting. This difference appears to have grown due to the clinical tobacco treatment competency mandated for all dental hygiene students (but not for dental students) and the integration of tobacco-dependence treatment information into the dental hygiene students objective structured clinical examinations (OSCEs). The TDE clinical competency was initiated over a decade ago in the dental hygiene department as a minimal graduation requirement and has developed into the complex management of multiple clinical sessions. The clinical session requirements for dental hygiene students include assessment of addiction, tobacco use, and tobacco quit history; motivational interviewing skills; and discussions about appropriate pharmacotherapy options with assistance from a dental faculty member. Follow-up assessment of quit attempts at subsequent clinical appointment are discussed during the dental hygiene process of care (Table 4). Dental students, on the other hand, receive clinical points for clinical procedures but do not receive clinical points for treating tobacco-addicted patients. Although improvement was reported by dental students over the nine-month interval, it may also be relevant that both surveys were conducted during these students senior year when they have clinical requirements to complete and minimal didactic education. There is a need at LLUSD to develop clinical competencies for tobacco treatment skills, and we recognize the need for further faculty training to improve clinical integration, consistent with the Coan et al. and Barker and Williams studies. Additionally, 476 Journal of Dental Education Volume 76, Number 4

6 the school should develop a plan to modify the dental and dental hygiene students evaluation process for interviewing, motivating, counseling, and prescribing pharmacotherapy similar to what Cohen et al. 3 and Davis et al. 4 have proposed or the use of an OSCE as proposed by Cannick et al. 5 This study had some limitations. The surveys were self-reported and did not measure actual performance. The committee recognized that self-reported surveys can be limited by subjects who forget pertinent details or exaggerate their answers. Even though the results were not verified by faculty members in the clinic, the student surveys proved to be a useful tool to help us understand the attitudes, values, beliefs, and behaviors of these students prior to their graduation. We recognize another drawback to our study is the lack of smokeless tobacco questions in the survey. Two years after complete implementation, we will reevaluate the curricular changes and include smokeless tobacco questions on the next survey. Finally, we recognize this study is specific to Loma Linda University School of Dentistry, and its lack of generalities could possibly make implementing it difficult at other institutions. Conclusions Administrative support from the school s dean and department chairs was crucial for the quick implementation of TDE topics in the curriculum. The dental students reported improvements to their treatment practices due to the TDE curricular enhancements, combined with clinical intervention in documentation and follow-up. The dental students also showed trends towards improvement in other areas. Compared to the dental students, the dental hygiene students reported higher levels of counseling tobacco users in all areas at the baseline survey, due to a preexisting curriculum, greater faculty commitment, and clinical competencies already in place. The dental hygiene students self-reported time of eight minutes for counseling these patients surpasses the three minutes recommended by the ADA and ADHA. The dental hygiene students showed trends toward improvement in several categories from the baseline survey to the post-intervention survey; however, they had a deficit and decline at the postintervention survey in follow-up practices for tobacco treatment, which may be due to the time of year of the post-intervention survey. The dental hygiene students are typically very focused on preparing for their clinical state and regional board exams during this time. Reassessment of these students after they have practiced for several years would enhance our understanding of the effectiveness of the educational strategy implemented. For more than five years, multiple questions regarding the education and treatment of tobaccodependent patients have been included on the National Board Dental Hygiene Examination, yet until 00 such questions did not appear on the National Board Dental Examination. Dental students may see tobacco-dependence education as a less significant priority than dental core competencies, due to the lack of clinical competencies in this area. We agree with Gordon et al. s statement of the need for national standards for tobacco dependence education in U.S. dental schools. 5 However, faculty mentoring in the clinic is also needed to enhance students learning and comfort levels, which could encourage them to provide tobacco-cessation treatment for their future patients in private practice. A comprehensive electronic tobacco curriculum specific for dental schools would be helpful for national implementation. Until all dental and dental hygiene students are required to meet both written board and clinical competencies and TDE is reinforced by clinical faculty members, the likelihood of seeing major improvements in tobacco-cessation treatment in dental practices is low. REFERENCES. Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontol 007;44(): Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Godlstein MG, Gritz ER, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Clinical Practice Guideline Treating Tobacco Use and Dependence 008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 008 update. Am J Prev Med 008;35(): Giacona MB. Tobacco cessation within dental curricula in the United States and internationally. 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