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1 Professionl I s s u e s Too Use Cesstion Servies Provided y Dentists nd Dentl Hygienists in Mnito: Prt 1. Influene of Prtitioner Demogrphis nd Psyhosoil Ftors Dougls J. Brothwell, BEd, DMD, MS, DDPH; Shirley C. Gelskey, BS, MPH, PhD Contt Author Dr. Brothwell Emil: rothwel@.umnito. ABSTRACT Ojetive: Despite high rtes of too use, overwhelming evidene of detrimentl effets on orl helth, smokers desire to stop using too nd the vilility of effiious rief intervention ounselling (BIC) strtegies, the delivery of esstion servies y dentl prtitioners is, t est, inonsistent. The purpose of this prt of our study ws to ssess BIC prtie ptterns mong dentists nd dentl hygienists in Mnito nd to determine whether demogrphi or psyhosoil ftors influene BIC delivery. Methods: A pre-piloted survey ws miled to ll liensed dentists (547) nd registered dentl hygienists (566) in the provine. Results: In ll, 514 orl helth prtitioners responded for 46.2% response rte. Most orl helth prtitioners in Mnito re not providing onsistent BIC; however, 54.9% (279/508) of survey respondents dvise smokers to quit. Women liniins re more likely to sk, ssess nd ssist ptients nd tend to dvise ginst smoking more frequently thn men; younger prtitioners re more likely to sk nd ssess rediness to quit smoking thn older prtitioners; dentl hygienists re more likely to provide ssistne to quit thn dentists. Assisting is the servie lest frequently provided y prtitioners. The rriers to providing BIC re different for mle nd femle prtitioners nd for dentists nd dentl hygienists; prtitioners with more psyhosoil rriers provide BIC less frequently thn those reporting fewer rriers. Only 36.9% (188/510) of prtitioners report feeling dequtely prepred to ssist smokers to quit. For ittion purposes, the eletroni version is the definitive version of this rtile: In 2002, over 37,000 Cndins died from too-relted uses, inluding ner, hert disese nd lung disese. This mens tht the numer of potentil yers of Cndin life lost from too in 2002 ws 515,607. The totl eonomi ost of too use tht sme yer ws nerly $17 illion. 1 Too use is ssoited with inresed risk of orl nd phryngel ner, leukoplki, periodontitis, delyed wound heling nd ompromised periodontl tretment outomes. 2 6 The Cndin Too Use Monitoring Survey 2007 reported tht 19.2% of Cndins over 14 yers of ge were urrent smokers. Provinilly, the rte of smoking rnged from 14.4% in British Columi to 24.0% in Sskthewn. 7 JCDA Deemer 2008/Jnury 2009, Vol. 74, No

2 Brothwell Tle 1 Distriution y type of prtie, gender nd ge for respondents who nswered this question (n = 498) Type of dentl professionl Men ge (SD) n (%) Generl dentist 45.3 (10.9) 235 (100) Men 47.3 (10.8) 180 (77) Women 39.0 (8.8) 55 (23) Speilist 47.5 (10.4) 40 (100) Men 49.1 (10.1) 34 (85) Women 38.7 (8.1) 6 (15) Hygienist 38.8 (8.5) 223 (100) Men 39.6 (9.7) 8 (4) Women 38.8 (8.5) 215 (96) Totl 42.6 (10.4) 498 (100) Men 47.3 (10.7) 222 (45) Women 38.8 (8.5) 276 (55) SD = stndrd devition. Most smokers express desire to quit. In 2005, 54% of Ontrio smokers expressed n intention to quit within 6 months nd, of those, 25% wnted to quit within the next 30 dys. 8 Primry re liniins, inluding orl helth professionls hve n opportunity nd responsiility to enourge their smoking ptients to quit. 9 Brief (3-minute) too use esstion servies, lso known s rief intervention ounselling (BIC), provided y helth professionls, inluding dentists nd dentl hygienists, inreses esstion rtes To e most effiious, BIC must inlude the following 4 steps: sk ll ptients whether they smoke; dvise ll smokers to quit; ssess ptients rediness to quit; offer ssistne to smokers redy to quit. 9 Additionl guidne provided y dentl professionls during the quit proess is lso importnt in mximizing ptient suess. Despite the high rte of too use, overwhelming evidene of its negtive helth onsequenes, smokers desire to quit nd the vilility of effetive BIC, the delivery of suh servies y dentl nd medil liniins is, t est, inonsistent. 9,17 19 This inonsisteny my e explined y numer of psyhosoil ftors, inluding the prtitioner s opinions, ttitudes nd pereptions out intervening in ptient s hoie to use too 20,21 s well s indequte trining in BIC. 22 The purpose of prt 1 of our study ws to ssess the delivery of BIC y dentists nd dentl hygienists in Mnito nd to investigte whether their opinions, ttitudes or pereptions regrding BIC influene their delivery. In prt 2, we will report whether dentl shool urriulum-sed BIC trining influenes BIC % of professionls prtie ptterns mong dentists nd dentl hygienists following grdution. Methods Ptients served Nerly ll (91% 100% ) M ost (75% 90% ) Mjority (51% 74% ) S om e (25% 50% ) A few (1% 24% ) None (0% ) Ask Advise Assess Assist Figure 1: BIC steps provided y Mnito dentl professionls Survey Methods A smpling frme listing ll liensed dentists (n = 547) nd registered dentl hygienists (n = 566) in Mnito ws otined from the provinil liensing ody. The frme inluded ll dentl professionls who were eligile to prtise in the provine, s liensing nd registrtion re requirements for prtie. On June 6, 2003, pkge ontining overing letter onfirming support from the provinil liensing ody, n informtion nd onsent form, self-dministered questionnire nd selfddressed stmped return envelope ws miled to eh person in the smpling frme. An identil follow-up pkge sent to non-responders on July 9, 2003, resulted in smll numer of dditionl responses. Survey Instrument A strutured, pre-piloted questionnire ws used to ollet demogrphi informtion nd too-use esstion servies delivered s well s pereived rriers ssoited with providing these servies. Mny questions required respondents to selet from the following 6 hoies: nerly ll ptients (91% 100%), most (75% 90%), mjority (51% 74%), some (25% 50%), few (1% 24%) nd none (0%). As it is desirle tht dentl prtitioners provide BIC to most ptients (75% or more), the originl 6-point sle ws ollpsed into dihotomous vriles used for χ 2 nlyses, seprting respondents who reported providing servies for most ptients from those providing the servies less frequently. Sttistil Anlyses Dt entry for this study ws performed y dentl student enrolled in the University of Mnito s BS dentistry progrm, using Sttistil Pkge for the Soil 905 JCDA Deemer 2008/Jnury 2009, Vol. 74, No. 10

3 Too Cesstion Servies Tle 2 Distriution of respondents y sex nd strtegy used to ssist most ( 75%) of their ptients Strtegy All, no. (%) Men, no. (%) Women, no. (%) Disuss speifi quit strtegies (n = 495) 78 (15.8) 22 (10.0) 56 (20.4) Set quit dte (n = 488) 45 (9.2) 11 (5.1) 34 (12.5) Provide self-help mterils (n = 489) 42 (8.6) 16 (7.4) 26 (9.6) Suggest niotine pth (n = 487) 50 (10.3) 16 (7.4) 34 (12.6) Suggest niotine gum (n = 485) 33 (6.8) 11 (5.1) 22 (8.2) Suggest upropion (n = 484) 43 (8.9) 16 (7.4) 27 (10.0) Refer to esstion progrm (n = 487) 34 (7.0) 8 (3.7) 26 (9.6) Follow-up dentl ppointment (n = 506) 42 (8.3) 11 (4.9) 31 (11.1) Perentges for the men nd women re sed on the totl numer of mle nd femle respondents for eh question. Signifint differene etween men nd women y χ 2 nlysis, p < Signifint differene etween men nd women y χ 2 nlysis, p < Sienes (SPSS 14.0 for Windows, SPSS In ) SPSS ws lso used to produe frequeny distriutions nd to look for ssoitions etween vriles (χ 2 nd ANOVA). χ 2 nlysis ws used to ompre respondents who reported providing servies for most ( 75%) of their ptients with those providing the servies less frequently. Ethil Approvl The study ws pproved y the Helth Reserh Ethis Bord of the University of Mnito. Results Prtitioner response rte ws 46.2%. Of the 514 prtitioners who responded, 243 were generl dentists (47.3%), 41 were dentl speilists (8.0%) nd 230 were dentl hygienists (44.7%). Men ge of respondents ws 42.6 yers (stndrd devition [SD] 10.4); 55.3% (276/498) were women (Tle 1). Beuse BIC sores for generl dentists nd speilists were not sttistilly different, their sores were ollpsed into single group. Most respondents (84.1%) were grdutes of the University of Mnito. BIC Prtie Ptterns Rtes of provision of speifi BIC steps y Mnito dentl professionls re shown in Fig. 1 nd dihotomous results re summrized elow. Ask: Only 33.0% (169/512) of respondents reported sking most ( 75%) ptients if they smoke. Women were signifintly more likely (p < 0.01) to sk out too use thn men (37.6% vs. 26.7%); dentists nd hygienists hd similr rtes (31.4% nd 34.9%, respetively; p > 0.05). The men ge of those sking most ptients out too use ws signifintly lower (p < 0.01) thn those who sked less often (40.9 vs yers). Advise: Despite the low proportion of professionls sking out the smoking sttus of most of their ptients, 54.9% (279/508) of respondents reported dvising most smoking ptients to stop. There ws non-signifint tendeny for more women thn men to dvise most ptients to quit smoking (58.1% vs. 49.8%; p > 0.05). Dentists nd hygienists hd similr rtes (54.4% nd 55.5%; p > 0.05). The men ge of those dvising most ptients ws not signifintly different (p > 0.05) from those who dvised less often (43.0 nd 42.1 yers). Assess: This ws not ommon BIC servie, with only 197 out of 498 (39.6%) responding professionls ssessing the esstion interest of most ptients. Women were signifintly (p < 0.001) more likely thn men to ssess rediness to quit (45.8% vs. 29.5%). Similrly, hygienists ssessed more thn dentists (47.1% vs. 33.5%; p < 0.01). The men ge of those ssessing most ptients interest in quitting ws signifintly lower (p < 0.01) thn tht of those who ssessed less often (41.1 vs yers). Assist: Assisting interested smokers to quit ws the lest ommon BIC step, with only 116 out of 510 respondents (22.7%) providing this servie. Women were signifintly (p < 0.01) more likely thn men to ssist interested smokers (27.3% vs. 16.1%). Hygienists ssisted t higher rte thn dentists (28.5% vs. 18.1%; p < 0.01). There ws no signifint differene (p > 0.05) in the men ge of those ssisting most ptients ompred with those who ssisted less often. Assisting strtegies used y prtitioners for most smokers who were interested in quitting re shown in Tles 2 nd 3. Prtitioner-Pereived Brriers to the Delivery of BIC Seven questions in the survey ddressed rriers to providing speifi BIC. Most providers reported tehnil rriers (time, ptient resistne, trining) s shown in Tles 4 nd 5. Fewer thn 50% of respondents reported finnil rriers (lk of reimursement nd insurne overge). Women were more likely thn men to report ptient resistne (87.8% vs. 76.7%; p < 0.01) nd fer of lienting ptients (73.8% vs. 60.2%; p < 0.01) s rriers. JCDA Deemer 2008/Jnury 2009, Vol. 74, No

4 Brothwell Tle 3 Distriution of respondents, y professionl group nd strtegy used to ssist most ( 75%) of their ptients Strtegy All, no. (%) Dentists, no. (%) Hygienists, no. (%) Disuss speifi quit strtegies (n = 503) 81 (16.1) 30 (10.8) 51 (22.7) Set quit dte (n = 496) 46 (9.3) 16 (5.9) 30 (13.5) Provide self-help mterils (n = 496) 42 (8.5) 20 (7.3) 22 (10.0) Suggest niotine pth (n = 495) 52 (10.5) 20 (7.3) 32 (14.5) Suggest niotine gum (n = 492) 33 (6.7) 14 (5.1) 19 (8.7) Suggest upropion (n = 492) 45 (9.1) 15 (5.5) 30 (13.6) Refer to esstion progrm (n = 494) 34 (6.9) 13 (4.7) 21 (9.5) d Follow-up dentl ppointment (n = 514) 44 (8.6) 23 (8.1) 21 (9.1) Perentges for the dentists nd hygienists re sed on the totl numer of dentist nd hygienist respondents for eh question. Signifint differene etween dentists nd hygienists y χ2 nlysis, p < Signifint differene etween dentists nd hygienists y χ2 nlysis, p < d Signifint differene etween dentists nd hygienists y χ2 nlysis, p < Tle 4 Provider-reported rriers to providing esstion servies, y sex Brrier All, no. (%) Men, no. (%) Women, no. (%) Amount of time required (n = 487) 310 (63.7) 135 (63.4) 175 (63.9) Lk of trining (n = 488) 411 (84.2) 184 (85.6) 227 (83.2) Ptient resistne (n = 485) 402 (82.9) 165 (76.7) 237 (87.8) Fer of lienting ptients (n = 491) 333 (67.8) 130 (60.2) 203 (73.8) Unfmilir with referrl options (n = 480) 364 (75.8) 158 (75.2) 206 (76.3) Lk of dequte reimursement (n = 487) 210 (43.1) 116 (53.7) 94 (34.7) No insurne overge for servie (n = 480) 231 (48.1) 109 (51.2) 122 (45.7) Perentges for the men nd women re sed on the totl numer of mle nd femle respondents for eh question. Signifint differene etween men nd women y χ 2 nlysis, p < Signifint differene etween men nd women y χ 2 nlysis, p < Tle 5 Provider-reported rriers to providing esstion servies, y professionl group Brrier Overll, no. (%) Dentists, no. (%) Hygienists, no. (%) Amount of time required (n = 495) 315 (63.6) 170 (62.7) 145 (64.7) Lk of trining (n = 496) 417 (84.1) 230 (84.2) 187 (83.9) Ptient resistne (n = 493) 409 (83.0) 215 (78.8) 194 (88.2) Fer of lienting ptients (n = 499) 340 (68.1) 171 (62.4) 169 (75.1) Unfmilir with referrl options (n = 488) 370 (75.8) 196 (73.1) 174 (79.1) Lk of dequte reimursement (n = 495) 212 (42.8) 138 (50.4) 74 (33.5) No insurne overge for servie (n = 487) 234 (48.0) 136 (50.2) 98 (45.4) Perentges for the dentists nd hygienists re sed on the totl numer of dentist nd hygienist respondents for eh question. Signifint differene etween dentists nd hygienists y χ 2 nlysis, p < Signifint differene etween dentists nd hygienists y χ 2 nlysis, p < Men were more likely to report lk of reimursement (53.7% vs. 34.7%; p < 0.001) s rrier. Hygienists were signifintly more likely thn dentists to report ptient resistne (88.2% vs. 78.8%; p < 0.01) nd fer of lienting ptients (75.1% vs. 62.4%; p < 0.01) s rriers, wheres dentists were signifintly more likely to report lk of reimursement (50.4% vs. 33.5%; p < 0.001) s rrier. To etter understnd the degree to whih pereived rriers ffet delivery of BIC, pereivedrriers vrile ws lulted for eh provider y dding the numer of positive responses from those nswering ll 7 questions. Rnging in vlue from 0 to 7, the men totl numer of rriers reported ws 4.7 (SD 1.8). No signifint ssoitions were found etween sex or type of provider nd the totl numer of 905 JCDA Deemer 2008/Jnury 2009, Vol. 74, No. 10

5 running heder Tle 6 Numer of pereived rriers y frequeny of BIC servie BIC step Frequeny of servie Ask Most ptients ( 75%) Fewer ptients (< 75%) Advise Most ptients ( 75%) Fewer ptients (< 75%) Assess Most ptients ( 75%) Fewer ptients (< 75%) Assist Most ptients ( 75%) Fewer ptients (< 75%) Men no. rriers reported (SD) 4.3 (2.0) 4.9 (1.7) 4.5 (1.9) 4.9 (1.7) 4.3 (1.9) 4.9 (1.8) 3.9 (1.8) 4.9 (1.8) SD = stndrd devition. Signifintly different from Most ptients group y ANOVA, p < Signifintly different from Most ptients group y ANOVA, p < Signifintly different from Most ptients group y ANOVA, p < rrier reported. As shown in Tle 6, dentl professionls who reported providing BIC to most ptients hd signifintly lower pereived-rrier sores thn professionls providing the servies less frequently. Disussion Most orl helth professionls in Mnito re not providing BIC to most of their ptients. This study hs identified numer of demogrphi nd psyhosoil ftors tht pper to influene the BIC prtie ptterns of dentl providers in Mnito. Influene of Age, Sex nd Type of Professionl on BIC Delivery We found differenes etween sexes, ges nd types of professionls in terms of the delivery of ertin BIC steps. Women were signifintly more likely to sk, ssess nd ssist nd hd non-signifint tendeny to dvise ginst smoking more frequently thn men. Dentl hygienists re often responsile for ptient edution nd motivtion nd often hve time to devote to BIC. Despite this, they were no more likely thn femle dentists to sk their ptients whether they smoke. Younger prtitioners were more likely to sk nd ssess rediness to quit smoking thn older prtitioners. Most respondents (84.1%) were Mnito grdutes nd, s ll grdutes in the provine hve reeived too use esstion trining sine 1998, 23 their BIC trining my hve influened their BIC prties. A previous study of delivery of BIC y dentl nd dentl hygiene students t the University of Mnito showed signifint inrese (23%) in students dvie to quit servies fter BIC trining ws inluded in their urriulum. 24 Dentl hygienists were signifintly more likely thn dentists to provide ssistne in the ptients efforts to stop using too. Agin, dentl hygienists my e delegted this responsiility s prt of ptient edution nd my, therefore, hve the time neessry to provide ssistne. There were no signifint differenes etween types of prtitioners, ges or genders with regrd to dvising smokers to quit. With 54.9% of prtitioners providing this servie, this ws the most frequently provided BIC step, possily euse dvising ptients to quit smoking is eoming stndrd of prtie nd is inresingly expeted y ptients who smoke. Assisting ws lest often delivered y prtitioners; this ould indite tht eoming involved in this step is often more time onsuming thn the other steps nd requires referrl to resoure knowledge nd phrmotherpy strtegies tht some prtitioners might not e wre of. These ftors should, therefore, e emphsized in BIC trining progrms within dentl shools nd in ontinuing edution ourses. It is unertin why women provide more BIC servies thn men. Dentl hygienists likely provide more BIC servies thn dentists euse these servies my e delegted to them s prt of ptient orl helth edution. Exposure to BIC trining might influene the intensity with whih prtitioners deliver BIC. Those trined in BIC presumly etter understnd the importne of their role nd hve the knowledge nd skills to provide BIC omfortly. Influene of Psyhosoil Brriers on BIC Delivery A numer of psyhosoil rriers to the provision of BIC hve previously een reported, inluding prtitioner opinions, ttitudes nd pereptions towrd too esstion ounselling. 20,21 Other reported rriers inlude lk of time, 12,19 lk of trining in BIC, 25 onern out upsetting the ptient 12,19 nd lk of reimursement. 25 Psyhosoil rriers exmined in the urrent study re listed in Tles 4 nd 5. The results of this study lerly show tht the rriers tht keep men nd dentists from providing BIC re different from those tht influene women nd dentl hygienists. Women nd hygienists were signifintly more likely to e influened y fer of ptient resistne nd liention, oth importnt onsidertions in mintining fvourle ptient rpport. Men nd dentists, on the other hnd, reported less onern with ftors ffeting ptient rpport nd signifintly more onern with reimursement nd insurne overge, oth importnt onsidertions in the usiness finnil spets of dentl prtie. This study lso shows tht prtitioners with more psyhosoil rriers deliver BIC less frequently thn those with fewer pereived rriers. Dentl edutors must ddress eh of the following rriers s prt of BIC trining in dentl shools nd ontinuing JCDA Deemer 2008/Jnury 2009, Vol. 74, No d

6 Brothwell Tle 7 Providers prepredness to help ptients quit smoking (n = 510) Level of prepredness No. of respondents (%) Very well prepred 16 (3.1) Well prepred 26 (5.1) Adequtely prepred 146 (28.6) Not well prepred 250 (49.0) Definitely unprepred 72 (14.1) Conlusions nd Prtie Considertions 1. Most orl helth professionls in Mnito re not providing BIC; however, 54.9% dvise most smokers to quit. 2. Women re more likely to sk, ssess nd ssist nd hve tendeny to dvise ginst smoking more frequently thn men. 3. Younger prtitioners re more likely to sk nd ssess rediness to quit smoking thn older prtitioners. 4. Dentl hygienists re more likely to provide ssistne to quit thn dentists. 5. Assisting is the servie lest frequently delivered y prtitioners. 6. The rriers tht keep men nd dentists from providing BIC re different from those tht influene women nd dentl hygienists. 7. Prtitioners with higher totl psyhosoil rrier sores deliver BIC less frequently thn those with lower rrier sores. 8. Only 36.9% of prtitioners report feeling dequtely prepred to ssist smokers to quit. BIC should e onsidered routine prt of stndrd ptient re 9 ; however, most Mnito dentl prtitioners re not onsistently providing BIC to their ptients who smoke. This study hs identified numer of demogrphi nd psyhosoil ftors tht pper to influene BIC prtie ptterns. Prt 2 of this study will report dditionl ftors tht ould explin why prtitioners do not provide BIC nd wht dentl edutors need to do to retify the sitution. THE AUTHORS edution: mount of time required to provide BIC, ptient resistne, fer of lienting ptients, referrl options, reimursement nd insurne overge for BIC. As the urrent study found tht only 36.9% of prtitioners reported feeling t lest dequtely prepred to ssist smokers to quit (Tle 7), the influene of forml BIC trining in dentl shool hs een investigted nd will e reported in prt 2 of this report. The limittions of this study inlude the response rte to the survey, whih ws 46.2% fter 2 milings. It is unknown how well the respondents represent ll dentists nd dentl hygienists in the provine s no ttempt ws mde to ontt non-responders. BIC prtie ptterns my e overestimted s those responding to the survey my provide more BIC thn nonrespondents. Respondents my hve over-reported their BIC prties. The results my e generlized only to dentl prtitioners in Mnito. The survey did not ssess ll potentil rriers. Dr. Brothwell is hed of ommunity dentistry nd the diretor of the Centre for Community Orl Helth t the fulty of dentistry, University of Mnito, Winnipeg, Mnito. Dr. Gelskey is ting hed, deprtment of dentl dignosti nd surgil sienes, fulty of dentistry, University of Mnito, Winnipeg, Mnito. Correspondene to: Dr. Dougls J. Brothwell, Deprtment of preventive dentl sienes, Fulty of dentistry, University of Mnito, P128, 780 Bnntyne Avenue, Winnipeg MB R3E 0W2. The uthors hve no delred finnil interests. This rtile hs een peer reviewed. Referenes 1. Rehm J, Bliuns D, Brohu S, Fisher B, Gnm W, Ptr J, nd others. The osts of sustne use in Cnd Ottw: Cndin Centre on Sustne Ause; Aville: CCSA Douments/ s pdf (essed 2008 Nov 18). 2. Dy GL, Blot WJ, Austin DF, Bernstein L, Greenerg RS, Preston-Mrtin S, nd others. Ril differenes in risk of orl nd phryngel ner: lohol, too nd other determinnts. J Ntl Cner Inst 1993; 85(6): Msherg A, Smit A. Erly dignosis of symptomti orl nd orophryngel squmous ners. CA Cner J Clin 1995; 45(6): Tomr SL, Asm S. Smoking-ttriutle periodontitis in the United Sttes: findings from NHANES III. Ntionl Helth nd Nutrition Exmintion Survey. J Periodontol 2000; 71(5): Preer H, Bergström J. Effet of igrette smoking on periodontl heling following surgil therpy. J Clin Periodontol 1990; 17(5): Bergström J. Periodontitis nd smoking: n evidene-sed pprisl. J Evid Bsed Dent Prt 2006; 6(1): Cndin Too Use Monitoring Survey (CTUMS) Ottw: Helth Cnd; Aville: (essed 2008 Nov 18). 8. Cndin Too Use Monitoring Survey (CTUMS) Ottw: Helth Cnd; Aville: (essed 2008 Nov 18). 9. Fiore MC, Jén CR, Bker TB, Biley WC, Benowitz NL, Curry SJ, nd others. Treting too use nd dependene: 2008 updte. Wshington: Ntionl Center for Biotehnology Informtion; Aville: nlm.nih.gov/ooks/v.fgi?rid=hstt2.hpter (essed 2008 Nov 18). 10. Gordon JS, Andrews JA, Crews KM, Pyne TJ, Severson HH. The 5A s vs 3A s plus protive quitline referrl in privte prtie dentl offies: preliminry results. To Control 2007; 16(4): Severson HH, Andrews JA, Lihtenstein E, Gordon JS, Brkley MF. Using the hygiene visit to deliver too esstion progrm: results of rndomized linil tril. J Am Dent Asso 1998; 129(7): Cmpell HS, Sletten M, Petty T. Ptient pereptions of too esstion servies in dentl offies. J Am Dent Asso 1999; 130(2): Alert DA, Severson HH, Andrews JA. Too use y dolesents: the role of the orl helth professionl in evidene-sed esstion progrms. Peditr Dent 2006; 28(2):177 87; disussion e JCDA Deemer 2008/Jnury 2009, Vol. 74, No. 10

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