International Dental Journal 2017; 67: 221–228

SCIENTIFIC RESEARCH REPORT

doi: 10.1111/idj.12289

Attitude of dental hygienists, general practitioners and

periodontists towards preventive oral care: an exploratory
study
Eric Thevissen1,2, Hugo De Bruyn1,3, Roos Colman4 and Sebastiaan Koole1
1
Department of Periodontology and Oral Implantology, Dental School, Ghent University, Ghent, Belgium; 2Praktijk voor Parodontologie,
Hasselt, Belgium; 3Department of Prosthodontics, School of Dentistry, Malm€ o, Sweden; 4Biostatistics Unit, Department of
o University, Malm€
Public Health, Ghent University, Ghent, Belgium.

Introduction: Promoting oral hygiene and stimulating patient’s responsibility for his/her personal health remain challeng-
ing objectives. The presence of dental hygienists has led to delegation of preventive tasks. However, in some countries,
such as Belgium, this profession is not yet legalized. The aim of this exploratory study was to compare the attitude
towards oral-hygiene instructions and patient motivational actions by dental hygienists and by general practitioners/peri-
odontists in a context without dental hygienists. Materials and Methods: A questionnaire on demographics (six items),
oral-hygiene instructions (eight items) and patient motivational actions (six items) was distributed to 241 Dutch dental
hygienists, 692 general practitioners and 32 periodontists in Flanders/Belgium. Statistical analysis included Fisher’s exact-
test, Pearson’s chi-square test and multiple (multinomial) logistic regression analysis to observe the influence of profes-
sion, age, workload, practice area and chair-assistance. Results: Significant variance was found between general practi-
tioners and dental hygienists (in 13 of 14 items), between general practitioners and periodontists (in nine of 14 items)
and between dental hygienists and periodontists (in five of 14 items). In addition to qualification, chair-assistance was
also identified as affecting the attitude towards preventive oral care. Conclusion: The present study identified divergence
in the application of, and experienced barriers and opinions about, oral-hygiene instructions and patient motivational
actions between dental hygienists and general practitioners/periodontists in a context without dental hygienists. In
response to the barriers reported it is suggested that preventive oriented care may benefit from the deployment of dental
hygienists to increase access to qualified preventive oral care.

Key words: Dental hygienists, general practitioners, periodontists, oral-hygiene instruction, patient motivation, questionnaire study

root planing, patient counselling and guidance, taking

INTRODUCTION
impressions and placing temporary restorations7. In
Oral hygiene and professional preventive care are contrast, in some countries dental hygienists are legally
essential prerequisites for the management of caries and not allowed to work, let alone to provide dental treat-
periodontitis1,2. Promotion of good home-care habits, ment. Consequently, dentists and periodontists are
including emphasis on patients’ own responsibility for responsible for providing preventive therapy8.
their personal oral health, is paramount for long-term Based on epidemiological data, K€ onig et al.9
treatment success3. This includes educating patients reported differences in periodontal health between
about self-care, the need for regular dental visits, fluo- countries in Europe. The authors suggested the
ride application, dental sealants, nutrition advice and approach toward periodontal care in a country as an
smoking cessation4,5. In many countries, dental hygien- important determinant. Furthermore, a relationship
ists play an important role in oral health education and was demonstrated between the prevalence of
preventive measures6. They provide preventive and/or untreated periodontal disease and limited access to
supportive therapy. Their role is established within the care performed by a qualified dental hygienist10. The
medico-legal framework of a country and ranges from above-mentioned studies suggest a positive impact on
independent to supervised practice. It includes, for access to prevention and oral health care in countries
example, taking dental radiographs, data screening, where dental hygienists are active. This is further
application of local anaesthetic, calculus removal and illustrated by Madianos et al.11 who identified better
© 2017 FDI World Dental Federation 221
Thevissen et al.

toothbrushing habits in adult patients in health-care population patterns, in terms of socio-economic break-
systems with dental hygienists, such as the Nordic down. Both regions speak the same language (Dutch)
countries, Germany and the Netherlands, compared but have a different organization of oral health care. In
with other European countries. the Netherlands, preventive and/or supportive oral care
In countries without dental hygienists, both general is commonly provided by dental hygienists. Their com-
practice dentists and periodontists have the task of petences are based on a 4-year educational programme,
providing preventive and supportive care, in addition including clinical training, and they are allowed to
to diagnostic, curative and/or specialised care. Pen- practice independently14. Belgian legislation only
nington et al.12 assumed no difference in treatment allows dentists to provide in-mouth oral care. As a
effectiveness between general practitioners and peri- result, dental hygiene as a profession is illegal and non-
odontists if both clinicians were to spend the same existent. Hence, preventive and/or supportive therapy
time devoted to care. Consequently, a clinician’s allo- is provided by general practitioners and recognized spe-
cated time to perform supportive periodontal care cialists. Within the group of specialists, periodontists
was suggested as a good predictor for the overall are directed towards preventive and periodontal care,
effectiveness of care. In line with this argument, pre- whereas orthodontists are mainly focussed on
ventive care by dental hygienists would be highly orthodontic treatment and oral surgeons on surgery. In
effective because their work is solely orientated order to graduate in Belgium as a general practitioner
towards prevention and supportive care. Furthermore, or a periodontist, students are required to undergo a 5-
it ensures that the level of care reflects the educational year undergraduate curriculum followed by an addi-
level of the caregiver13. tional year of vocational training or a 3-year specialist
The previous studies illustrate two strategies in the training programme, respectively. Comparison between
access and provision of preventive and supportive oral these contexts provides the opportunity to analyse the
health care in Europe, involving dental hygienists, attitudes towards the provision of oral-hygiene instruc-
general practitioners and periodontists. Considering tions and patient motivational actions between dental
the differences in educational level and focus of the professionals in a health-care system, with and without
professions, one can question whether both dental dental hygienists.
hygienists and general practitioners/periodontists pro- A questionnaire was developed to investigate the
vide similar preventive/supportive oral therapy. dental professionals’ attitudes; the questionnaire con-
Hence, the present exploratory study investigated tained 20 multiple choice items about demographics
the attitude of dental hygienists, general practitioners (n = 6), oral-hygiene instructions (n = 8) and patient
and periodontists regarding provision of oral hygiene motivation (n = 6). Items about demographics
instructions and performing patient motivational included qualification of the professional, age, work-
actions as an important attribute for preventing dental load, area of practice and availability of chair-assis-
caries and periodontal disease. The study aimed to tance. Items about oral-hygiene instructions and
answer two research questions: patient motivational actions aimed to explore the
views of three dental professions (dental hygienists,
• What attitudes have general practitioners and peri- general practitioners and periodontists), based on per-
odontists in an oral health-care system without den- sonal opinions, reflections and habits in daily-practice.
tal hygienists towards provision of oral-hygiene Items included interproximal hygiene instruction,
instructions and performing patient motivational non-compliance, sale of oral-hygiene products, the
actions compared with dental hygienists? relationship between efforts and results, factors per-
• In addition to qualification, is the attitude towards ceived to contribute to oral-hygiene level and patient
giving oral-hygiene instructions and performing motivation. Before the study, the questionnaire was
patient motivational actions influenced by profes- pretested by a panel of five dental experts for validity
sional variables, such as age, workload, area of and ambiguity of wording.
practice or availability of chair-assistance? The questionnaire was distributed to participants of
three training events on the management of periodon-
tal diseases for dental hygienists in three locations in
MATERIALS AND METHODS
the Netherlands. Furthermore, during five postgradu-
In response to the research questions, the present study ate courses on patient management in dentistry,
compared the attitude towards oral-hygiene instruc- organised in five different locations in Flanders (Bel-
tions and patient motivational actions by dental gium), participants were asked to complete an identi-
hygienists working in the Netherlands and general cal questionnaire.
practitioners and periodontists in Flanders in the north- Before each training event/course, a letter was pre-
ern part of Belgium. The Netherlands and Flanders are sented to the participants, explaining the background
neighbouring western developed societies with similar and aims of the study. Furthermore, the participants
222 © 2017 FDI World Dental Federation
 Attitude towards preventive care

were instructed to provide one answer per question assistance, a multiple (multinomial) logistic regression
(i.e. the response that corresponded most to the par- analysis was applied with bias-corrected accelerated
ticipant’s opinion). The questionnaire was anony- (BCa) bootstrapping (n = 1000) to validate the model
mous. Written consent was obtained from all and avoid overfitting.
participants involved in the study. Dental profession- All statistical analyses were performed using SPSS
als who preferred not to participate were asked to 22.0 (IBM Corp., Armonk, NY, USA). The signifi-
mark the questionnaire as ‘unanswered’. The study cance level was pre-set at P ≤ 0.05.
was conducted in full accordance with the World
Medical Association Declaration of Helsinki, and ethi-
RESULTS
cal approval was granted by the Ghent University
Hospital Ethics Committee. In the Netherlands, 283 of 350 participants in the
Demographics were described using frequencies and training events returned the questionnaire, resulting in
percentages. To compare the results between dental a response rate of 81%. Questionnaires completed by
professionals in the Netherlands and Flanders, three dentists or dental assistants (n = 42) were excluded
subgroups were created based on their qualifications: from the analysis. Accordingly, 241 questionnaires
dental hygienists in the Netherlands; and general prac- were included in the study, representing 8% of the
titioners and periodontists in Flanders. Both general Dutch dental-hygienist population15. A total of 1037
practitioners and periodontists were included because questionnaires were distributed among Flemish dental
the latter focus on treating periodontal diseases and, professionals. Seven-hundred and ninety-one question-
given the field of interest, are expected to have a focus naires were returned, resulting in a response rate of
towards preventive care which is similar to that of 76%. Fifteen questionnaires were marked as ‘unan-
dental hygienists. swered’, indicating refusal to participate and, in addi-
The variable age was subdivided into three categories tion, 52 questionnaires were completed by dental
(<35 years, 35–54 years and >54 years). These cut-off professionals other than general practitioners and
points are largely aligned with three types of profes- periodontists, including orthodontists, oral surgeons
sional careers. In Belgium, periodontology was intro- and dental assistants, and were also excluded. Conse-
duced as a new discipline in the 5-year undergraduate quently, 724 questionnaires were analysed – 692 were
dental curriculum in 1979. Consequently, dental pro- completed by general practitioners and 32 by peri-
fessionals older than 54 years of age never had the odontists, representing 16% and 36% of the popula-
opportunity to study periodontology during undergrad- tion of both professions, respectively16. A detailed
uate education. On the other hand, general practition- overview of demographics concerning age, workload,
ers younger than 35 years of age all graduated after the area of practice and the availability of chair-assistance
recognition of periodontists as specialists was legally is depicted in Table 1.
adopted. Furthermore, the variable workload was sub- When comparing subgroups, statistically significant
divided into two subgroups (<30 hours per week or differences were found in 13 of 14 items between gen-
≥30 hours per week). This cut-off point coincides with eral practitioners and dental hygienists, in nine of 14
the minimum hours required for Belgian dentists to items between general practitioners and periodontists
enter the national convention between the profession and in five of 14 items between periodontists and den-
and the health insurance system. This convention regu- tal hygienists. General practitioners reported provid-
lates reimbursement for oral care. The variable area of ing oral-hygiene instructions outside the patients’
practice discriminates between urban dental clinics and mouth (38%) or in-mouth demonstrations (56.8%),
rural clinics. Rural areas generally have fewer dental periodontists preferred in-mouth demonstrations
professionals per capita and urban clinics are often (100%) and dental hygienists indicated that they used
multidisciplinary and employ a larger number of assist- a combination of strategies (51.9%) or solely in-
ing personnel. The availability of chair-assistance (with mouth demonstrations (46.1%). Furthermore, both
or without) was expected to be an important factor periodontists (93.3%) and dental hygienists (96.3%)
influencing the delegation of preventive tasks such as reported that they provided interproximal hygiene
oral-hygiene instructions and patient motivational instructions to every patient, as opposed to general
actions to assisting personnel. practitioners (57.8%) who reported only to instruct
To investigate the differences between subgroups, patients with assumed compliance. A higher propor-
Fisher’s exact tests were used for dichotomous ques- tion of general practitioners (32.3%), than of dental
tions and Pearson chi-square tests were used for ques- hygienists (23.3%) and periodontists (19.4%),
tions with three or more answer options. P-values reported difficulties in reprimanding patients on their
were adjusted for multiple testing using Bonferroni homecare. In addition, 32.2% of general practitioners
correction. In addition, to correct for the variables indicated lack of time as a complicating factor for
age, workload, area of practice and chair-side oral-hygiene instructions, whilst only a minority of
© 2017 FDI World Dental Federation 223
Thevissen et al.

Table 1 Demographic data, including qualification, dental hygienists and periodontists is presented in
age, workload, area of practice and chair-assistance Table 2.
Multivariate analysis demonstrated significant vari-
Demographic variable
ance in answers between the subgroups of variable
Qualification qualification in 12 of 14 items, chair-assistance in nine
(n = 965) General Periodontist Dental of 14 items, age in five of 14 items and area of prac-
practitioner (n = 32) hygienist tice in two of 14 items. Workload did not influence
(n = 692) (n = 241) the responses to the questions about oral health
Age instructions and/or patient motivational actions.
<35 years 62 (7.5) 7 (21.9) 117 (48.5) The professionals in the younger age groups consid-
35–54 years 380 (55.8) 20 (62.5) 100 (41.5) ered interdental cleansing as being of greater impor-
>54 years 250 (36.7) 5 (15.6) 19 (7.9)
Unknown 0 (0.0) 0 (0.0) 5 (2.1) tance than did their counterparts in the eldest age
Workload group. Dental professionals in urban clinics were
<30 hours/week 118 (17.0) 6 (18.8) 113 (46.9) more inclined to always inform patients about their
≥30 hours/week 561 (81.1) 25 (78.1) 111 (46.0)
Unknown 13 (1.9) 1 (3.1) 17 (7.1) periodontal condition than were dental professionals
Area of practice in rural clinics and assisted professionals reported to
Rural 282 (40.7) 4 (12.5) 34 (14.1) experience greater job satisfaction.
Urban 397 (57.4) 27 (84.4) 169 (70.1)
Unknown 13 (1.9) 1 (3.1) 38 (15.8) Table 3 presents a detailed overview of significant
Chair-assistance differences between the subgroups of the investigated
With 157 (22.7) 27 (84.4) 46 (19.1) variables per dichotomous question. Table 4 presents
Without 523 (75.6) 5 (15.6) 179 (74.3)
Unknown 12 (1.7) 0 (0.0) 16 (6.6) a detailed overview of significant differences between
the subgroups of the investigated variables per ques-
Values are given as frequency (%).
tion with more than two answer options. Some confi-
dence intervals appeared non-estimable because of
periodontists (10.7%) and dental hygienists (5.0%) quasi complete separation and are indicated as ‘NE’
reported this barrier. The vast majority of dental in Table 4.
hygienists (88.7%) perceived type of toothbrush as
important compared with 62.3% of general practi-
DISCUSSION
tioners and 71.0% of periodontists. Significantly more
periodontists (62.5%) and dental hygienists (87.6%) In the present study, a questionnaire on oral-hygiene
advised the use of electric toothbrushes to more than instructions and patient motivational actions was dis-
50% of their patients, and significantly more peri- tributed among dental hygienists in the Netherlands
odontists (87.5%) sold in-office home-care products. and general practitioners and periodontists in Flanders
Concerning patient motivational actions, both peri- in order to compare their attitudes toward preventive
odontists (93.8%) and dental hygienists (85.9%) were oral care. The results demonstrated significant differ-
more inclined to always inform patients about their ences in the provision of oral-hygiene instructions and
periodontal condition than were general practitioners patient motivational actions between dental hygienists
(38.5%). Furthermore, they were significantly more and general practitioners, as well as between general
satisfied with their efforts (87.5% of periodontists and practitioners and periodontists. Regarding patient
82.8% of dental hygienists) than were general practi- motivational questions, no significant differences were
tioners (38.8%) and were more inclined to repeat noticed in the answers by dental hygienists and peri-
instructions in non-compliant patients (79.3% of peri- odontists compared with general practitioners. Quali-
odontists and 86.6% of dental hygienists vs. 64.9% fication and the presence/absence of chair-assistance
of general practitioners). Nurture was identified by were the most influential factors; age and area of
general practitioners as the factor contributing most practice had less impact; and workload did not affect
to the oral-hygiene level of a patient (60.9%), whilst the attitude towards oral-hygiene instructions or the
periodontists (62.1%) and dental hygienists (42.3%) performance of patient motivational actions.
emphasized the influence of the dental professional. A The similarities in attitude about patient motiva-
patient-centred approach was reported by periodon- tional actions between dental hygienists and periodon-
tists (76.6%) and dental hygienists (73.9%) as being tists might be explained by the fact that both are
the most important approach to enhance patient moti- aware of the need for patient compliance as an essen-
vation. General practitioners also considered other tial prerequisite to succeed in the non-surgical and
options as appropriate, such as fear of losing teeth surgical treatments of periodontal disease17. Neverthe-
(21.8%) and the patient’s confidence in the dentist less, significantly different approaches to oral-hygiene
(18.3%). A detailed overview of the results and differ- instructions were found between both subgroups, sug-
ences between the answers of general practitioners, gesting a divergence in instruction techniques6.
224 © 2017 FDI World Dental Federation
 Attitude towards preventive care

Table 2 Responses to the questions on oral-hygiene instructions (OHI) and patient motivational actions (PM) pre-
sented as a percentage, according to the answer option given and to the type of dental professional [general practi-
tioner (GP), dental hygienist (DH) and periodontist (P)]
Question Answers GP (%) DH (%) P (%) GP vs. DH (P) GP vs. P (P) P vs. DH (P)

OHI1 How do you give oral-hygiene Demonstration outside the 38.0 2.0 0.0 <0.001* <0.001* <0.001*
instruction? mouth
In-mouth demonstration 56.8 46.1 100
Combination of previous 5.2 51.9 0.0
options
OHI2 When do you give To every patient 37.2 96.3 93.3 <0.001* <0.001* >0.999
interproximal hygiene When I assume the patient 57.8 3.7 6.7
instruction? will comply
When I’ve got some time 5.0 0.0 0.0
left
OHI3 Is it difficult for you to No 67.7 76.7 80.6 0.033* 0.501 >0.999
reprimand patients on their Yes 32.3 23.3 19.4
home care?
OHI4 Which factor complicates the There is no such factor 23.7 23.4 46.4 <0.001* 0.027* 0.024*
provision of oral-hygiene Lack of time 32.2 5.0 10.7
instruction? Lack of patient’s interest 44.1 71.5 42.9
OHI5 Interproximal hygiene No 91.5 96.2 90.0 0.042* >0.999 0.411
instruction is not so Indeed 8.5 3.8 10.0
important
OHI6 For oral-hygiene instruction No 62.3 88.7 71.0 <0.001* >0.999 0.033*
the type of toothbrush does Indeed 37.7 11.3 29.0
not matter
OHI7 I advise use of an electric No 59.8 12.4 37.5 <0.001* 0.048* 0.003*
toothbrush to >50% of my Yes 40.2 87.6 62.5
patients
OHI8 Do you sell home-care No 29.8 37.5 12.5 0.090 0.132 0.009*
products in your practice? Yes 70.2 62.5 87.5
PM1 I always give patients No 61.5 14.1 6.2 <0.001* <0.001* 0.831
information about their Yes 38.5 85.9 93.8
periodontal condition
PM2 Do your efforts to motivate No 61.2 17.2 12.5 <0.001* <0.001* >0.999
patients correlate with the Yes 38.8 82.8 87.5
results obtained?
PM3 Do patients with poor oral No 25.7 60.8 50.0 <0.001* 0.024* 0.933
hygiene show less respect for Yes 74.3 39.2 50.0
your work?
PM4 What if patients do not I repeat over and over 64.9 86.6 79.3 <0.001* 0.249 0.267
comply with your again
instructions? I don’t address the issue 20.2 7.1 3.4
I would refer to an 14.9 6.3 17.2
auxiliary such as a DH
PM5 Factor contributing most to Nurture 60.9 36.8 20.7 <0.001* <0.001* 0.519
the oral-hygiene level of the Socio-economic status 17.6 19.7 13.8
patient? Influence of partner 3.3 0.4 0.0
Influence of media 2.4 0.8 3.4
Influence of dentist 15.8 42.3 62.1
PM6 What factor contributes most Patient-centred approach 52.0 73.9 76.7 <0.001* 0.057 0.408
to motivate patients? Patient’s confidence in 18.3 10.8 0.0
dentist
Fear of losing teeth 21.8 5.8 13.3
Persuasiveness of dentist 7.9 9.5 10.0

Differences between subgroups (GP vs. DH, GP vs. P, P vs. DH) are displayed by P-values based on Fisher’s exact tests (used for dichotomous
questions) and Pearson chi-square tests for questions with two or more answer options. Values of P were adjusted for multiple testing using
Bonferroni correction.
*P ≤ 0.05.

The majority of general practitioners reported practitioners, than of periodontists and dental hygien-
working without chair-assistance in comparison with ists, indicated lack of time as a complicating factor
a minor proportion of the participating periodontists for oral-hygiene instructions.
and dental hygienists. According to Suga et al.18 gen- Additionally, national variations in reimbursement
eral dental clinics are focussed to a greater extent on of oral care may also have influenced the differences
the financially more rewarding restorative treatments in attitude of dental hygienists compared with those
than on preventive oriented care. Both findings may of general practitioners and periodontists. In the
explain why a higher proportion of general Netherlands, preventive care, including oral-hygiene

© 2017 FDI World Dental Federation 225

Thevissen et al.

Table 3 Logistic regression analysis of dichotomous questions on oral-hygiene instruction (OHI) and patient moti-
vational actions (PM)
Question (answers) Factor comparison P-value OR 95% CI for OR

Lower Upper

OHI3 Is it difficult for you to reprimand >0.999

patients on their home care? (no,
yes)
OHI5 Interproximal hygiene instruction <35 years vs. >54 years 0.016 0.255 0.075 0.672
is not so important (no, indeed) 35–54 years vs. >54 years 0.002 0.321 0.164 0.549
OHI6 For OHI the type of toothbrush GP vs. DH 0.001 4.233 2.237 9.679
does not matter (no, indeed) P vs. DH 0.003 4.208 1.257 12.404
OHI7 I advise use of an electric GP vs. DH 0.001 0.095 0.054 0.150
toothbrush to >50% of my P vs. DH 0.001 0.155 0.063 0.365
patients (no, yes) Ass+ vs. Ass 0.040 1.455 1.044 2.085
OHI8 Do you provide oral-hygiene GP vs. DH 0.001 2.273 1.408 3.924
products in your clinic? (no, yes) P vs. DH 0.014 3.480 1.115 10.849
Ass+ vs. Ass 0.003 1.689 1.150 2.656
PM1 I always give patients information GP vs. DH 0.001 0.129 0.073 0.200
about their periodontal Ass+ vs. Ass 0.001 2.168 1.416 3.323
condition (no, yes) Rural vs. Urban 0.002 0.586 0.431 0.788
PM2 Do your efforts to motivate GP vs. DH 0.001 0.114 0.070 0.163
patients correlate with the Ass+ vs. Ass 0.001 1.919 1.376 2.765
results obtained?
PM3 Do patients with poor oral GP vs. DH 0.001 0.129 0.078 0.196
hygiene show less respect for Ass+ vs. Ass 0.001 2.168 1.459 3.206
your work? (no, yes) Rural vs. Urban 0.001 0.586 0.438 0.773

The results are presented as level of significance (P-value), odds ratio (OR) and confidence interval (95% CI for OR). Only statistically signifi-
cant outcomes are displayed, including qualification [general practitioner (GP) vs. dental hygienist (DH); periodontist (P) vs. DH], assistance
(Ass+ vs. Ass ), area (Rural vs. Urban), age (<35 years vs. >54 years, 35–54 years vs. >54 years). Bias corrected accelerated (BCa) bootstrap-
ping (n = 1000) was applied to validate the model and avoid overfitting.

Table 4 Multinomial regression analysis of compound questions about oral-hygiene instruction (OHI) and patient
motivational actions (PM)
Question Answer options Factor comparison P-value OR 95% CI for OR

Lower Upper

OHI1 How do you give OHI? Demonstration outside mouth GP vs. DH 0.001 NE
Demonstration outside mouth Ass+ vs. Ass 0.009 0.401 0.195 0.837
In-mouth demonstration GP vs. DH 0.001 16.119 7.776 39.409
In-mouth demonstration P vs. DH 0.002 NE
OHI2 When do you give To every patient GP vs. DH 0.001 NE
interproximal hygiene To every patient Ass+ vs. Ass 0.005 NE
instruction?
OHI4 Which factor complicates There is no such factor Age <35 years vs. Age >54 years 0.014 0.409 0.181 0.830
the provision of OHI? There is no such factor Age 35–54 years vs. >54 years 0.023 0.603 0.382 0.941
Lack of time GP vs. DH 0.001 6.560 3.093 19.492
PM4 What if patients do not I repeat over and over again GP vs. DH 0.002 0.333 0.155 0.593
comply with your I repeat over and over again Ass+ vs. Ass 0.015 0.576 0.373 0.912
instructions? I don’t address the issue Ass+ vs. Ass 0.001 0.319 0.165 0.524
I don’t address the issue Age <35 years vs. Age >54 years 0.020 0.291 0.091 0.709
PM5 Factor contributing most Nurture GP vs. DH 0.001 5.983 3.473 11.588
to the oral-hygiene level Socio-economic status GP vs. DH 0.002 2.883 1.470 6.290
of the patient? Influence of partner Age <35 years vs. Age >54 years 0.019 NE
Influence of media GP vs. DH 0.004 NE
PM6 What is the most Patient-centred approach Ass+ vs. Ass 0.007 0.487 0.303 0.789
important factor to Patient’s confidence in dentist GP vs. DH 0.040 2.319 0.975 5.479
motivate patients? Patient’s confidence in dentist Ass+ vs. Ass 0.001 0.298 0.145 0.535
Fear of losing teeth GP vs. DH 0.001 6.129 2.162 21.392
Fear of losing teeth P vs. DH 0.011 NE
Fear of losing teeth Ass+ vs. Ass 0.001 0.277 0.148 0.512

Results are presented as level of significance (P-value), odds ratio (OR) and confidence interval (95% CI for OR). Only statistically significant
outcomes of the subgroups Qualification [general practitioner (GP vs. dental hygienist (DH); periodontist (P) vs. DH], Assistance (Ass+ vs.
Ass ) and Age (<35 years vs. >54 years, 35–54 years vs. >54 years) are given. Bias corrected accelerated (BCa) bootstrapping (n = 1000) was
applied to validate the model and avoid overfitting. P < 0.05. NE, not estimable because of quasi complete separation.

226 © 2017 FDI World Dental Federation

 Attitude towards preventive care

instructions, patient counselling and even the follow- The present study investigated the attitude of dental
up sessions, is reimbursed and charged per unit of hygienists, general practitioners and periodontists
time19. In Belgium, oral-hygiene instructions are not towards oral-hygiene instructions and patient motiva-
reimbursed by the health insurance system because it is tional actions. A questionnaire was developed to
not considered as an autonomous activity. Patient retrieve personal opinions, reflections and ingrained
motivational actions are supposed to be performed habits starting from daily-practice situations. As a
together with a general oral-health consultation, of result, two questions (OHI5 and OHI6) were nega-
which the remuneration under reimbursement is lim- tively formulated as described by patients in practice.
ited to once a year. No further specifications or mini- This may have influenced the results owing to inatten-
mum criteria are determined20. Consequently, oral- tion or respondents reading the question too quickly.
hygiene instructions and patient motivational actions A total of 965 dental professionals participated in
are provided in the spare time between other clinical the present study, representing, respectively, 8%, 16%
activities (e.g. while waiting for anaesthesia to infiltrate and 36% of the population of dental hygienists, gen-
or at the end of a consultation). eral practitioners and periodontists. Furthermore, the
General practitioners were significantly more inclined participants displayed an age pattern similar to that
to report that their efforts to motivate patients did not of the total population of dental professionals, and
correlate with the results obtained. The obvious differ- the study population was equally distributed as a
ence between general practitioners and dental hygien- result of collection of data from multiple locations
ists in addressing preventive care is their clinical focus. within the Netherlands and Flanders. Consequently,
Whereas general practitioners have to focus on both the cohort analysed in the present study could be con-
preventive and curative aspects, the main focus of den- sidered as representative. Nevertheless, the results of
tal hygienists is preventive dentistry21. This single focus this study should be interpreted with caution. A self-
enables them to establish close engagements with their reported questionnaire was used in this study and
patients, thus creating optimal oral health. Both close introduced the risk of bias as a result of socially desir-
engagement with patients and long-term follow-up able answers30. To counteract this potential problem,
have been reported by dental hygienists to enhance job the anonymity of respondents was guaranteed.
satisfaction22. Furthermore, despite the fact that Flanders and the
In a dental-care system without dental hygienists, Netherlands are neighbouring societies with a similar
patients experiencing primary care complaints, such as socio-economic breakdown, differences in health-care
plaque-related gingivitis, are directed to general practi- organization and reimbursements of preventive treat-
tioners and/or periodontists. Of these latter groups of ments could have affected the inflow of patients and
dental professionals, both claim to spend enough time provision of therapy. Hence, these factors should be
on patient counselling and guidance, but within the considered when interpreting the results.
restricted time limits reserved for each patient23. Often Future research could investigate the preventive
counselling is insufficient and ineffective when patients therapy actually provided in the clinic and focus on
are in need of special care or require a customised the treatment outcome. To understand fully the rela-
approach24. In addition, the demand for preventive tionship between the clinician, his/her attitude toward
care is increasing, as improved personal hygiene mea- preventive dentistry and the treatment outcome,
sures in ageing populations is enabling patients to keep future studies should also address the patients’ per-
their natural dentition for longer. In response, a need is spective, as the literature suggests the presence of a
emphasised for task enlargement and/or delegation complex relationship between treatment approaches
within the oral sector25,26. and patients’ perceptions31,32.
In oral-health systems without dental hygienists, it is
also interesting to consider the economic aspects of del-
CONCLUSIONS
egating preventive tasks, including the lower expenses
for training of dental hygienists compared with training The present study has identified barriers to and diver-
for dentists, the creation of new employment in eco- gence in the application and opinions about oral
nomically hard times, increased access to preventive hygiene instructions and patient motivational actions
oral care27, lowered treatment costs and cost-saving between dental hygienists and general practitioners/pe-
reimbursement for health insurance systems and stake- riodontists working in a context without dental
holders28. Notwithstanding, the beneficial conse- hygienists. In addition to qualification, the presence/
quences for oral health, and by extension general absence of chair-assistance was also identified as
health, as a result of the professionalization of preven- affecting the attitude towards preventive oral care. In
tive care, are difficult to estimate; they are most reward- response to the reported barriers it is suggested that
ing on a long-term basis29. preventive orientated care may benefit from the

© 2017 FDI World Dental Federation 227

Thevissen et al.

deployment of dental hygienists to increase access to 17. Oruba Z, Pac A, Olszewska-Czy_z I et al. The significance of
motivation in periodontal treatment: the influence of adult
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nity Dent Health 2014 31: 183–187.
18. Suga US, Terada RS, Ubaldini AL et al. Factors that drive den-
Acknowledgements tists toward or away from dental caries preventive measures: sys-
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The authors would like to express their gratitude to
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support with data collection. Eric Thevissen received zorg.pdf.
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Conflict of interest artsen/Paginas/jaarlijks-mondonderzoek-18-65.aspx#Wat_omv
at_het_jaarlijks_mondonderzoek?.
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Email: [email protected]

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