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T his work m ay not b e reproduced in w hole o r in part, by photocopy o r o th er m e a n s, without th e perm ission of th e author. / i_ I^ l National Library of Canada Bi)liothèque nationale du Canada Acquisitions and Bibliographic Services Acquisitions et services bibliographiques 395 WaKngton street Ottawa ON K1A0N4 Canada 395, me WaKngton Ottawa ON K1A0N4 Canada YourW Ourm The author has granted a non­ exclusive licence allowing the National Library of Canada to reproduce, loan, distribute or sell copies of this thesis in microform, paper or electronic formats. L’auteur a accordé une licaice non exclusive permettant à la Bibliothèque nationale du Canada de reproduire, prêter, distribuer ou vendre des copies de cette thèse sous la forme de microfiche/film, de reproduction sur papier ou sur format électronique. The author retains ownership of the copyright in this diesis. Neidier the thesis nor substantial extracts from it may be printed or odierwise reproduced without the author’s permission. L’auteur conserve la propriété du droit d’auteur qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation. 0-612-62470-6 Canada APPROVAL N am e; Patricia Covington D egree: M aster of S cience T h esis Title: THE INFORMATION SEEKING PATTERNS OF DENTAL HYGIENISTS IN NORTHERN BRITISH COLUMBIA AND THEIR R E SP O N S E TO THE 1993 FLUORIDE GUIDELINES. Exam ining Com mittee: Chair: Dr. Bill Morrison D ean of th e Faculty o f R e search and G rad u ate S tudies University o f N orthern British Columbia Supervisor: D ean of th e Fa&ilt^/Of Health and Hum an S c ien c es University o f Northern British Columbia Faculty M ember: P ro fesso r D ana E d g e, RN, MSN Nursing Program m e, Faculty of Health and Hum an S c ie n c e s University of Northern British Columbia Faculty M ember: Dr. B r u ^ Z u m b o Psychology Program m e, A c u ity of Health and H um an S c ie n c e s University of Northern British Columbia External E xam ined P ro fesso r B(fnnie Craig, Dip. D.H., M.Ed., R.D.H. Director, Dental Hygiene D egree Program Faculty of Dentistry University of British Columbia D ate A pproved: [ jU i f \ ^ — — 11 ABSTRACT Information a c c e s s is n e c e ssa ry for th e health c a re professional to stay current and provide good patient c are. W hen organizations c h a n g e policy o r recom m endations, it is im portant for th e information to b e d issem in ated to th e practitioners in th e field. T he s u c c e s s o f th e information dissem ination is d e p e n d e n t on both th e organization an d practitioner. T h e literature indicates th a t m o st health c a re professionals a re d e p e n d e n t on oral an d printed information so u rc e s su ch a s d iscu ssio n s with co lleag u es and reading joum al articles. Although th e re h a s b e e n a n explosion of electronic information retrieval an d com m unication m ethods, health c are providers h a v e b e e n slow to a d o p t th e s e m eth o d s. T h ere a re few stu d ies th a t h ave specifically looked a t th e inform ation-seeking practices of den tal hygienists. This descriptive stu d y explored th e m eth o d s th at den tal hygienists in northern British C olum bia h a v e utilized to a c c e s s information. T he 1993 C an ad ian Dental A ssociation fluoride guidelines w ere u se d a s th e b a sis of a "case study" to investigate if dental hygienists had a c c e s s e d and ad o p te d recently revised information. A self-adm inistered q u estio n n aire w a s s e n t to th e 130 dental hygienists registered in th e North an d 106 co m p leted q u estio n n aires w ere retum ed for a re s p o n se rate of 81.5% . T h e findings sh o w th a t dental hygienists in northern British Colum bia a re utilizing traditional information so u rc e s. T h e m ost frequently utilized m eth o d s to obtain inform ation are: discu ssio n with colleagues, reading joum al articles, and reading m ailings from th e British Colum bia Dental H ygienists A ssociation and the C ollege of D ental H ygienists of British Colum bia. T he lea st utilized information so u rc e s a re th e indices to th e literature an d electronic information so u rc es. G eographic isolation, lack V lU of electronic information so u rc e s and c o st w ere identified a s th e top th ree barriers to information a c c e s s . D ental hygienists n e ed to tak e m ore professional responsibility for obtaining information. If th ey b e co m e “co m p u ter literature” an d sta rt to a d o p t th e n ew er m eth o d s of electronic information retrieval and com m unications m ethods, th ey will b e ab le to o vercom e so m e of th e barriers to information a c c e s s . This group h a s m a d e c h a n g e s in their practice a n d opinions th a t c orrespond with th e revisions in th e 1993 CDA fluoride guidelines. However, a s dental hygienists h av e q u e stio n s an d c o n c e m s a b o u t fluorides, th e re is still a n e e d for m ore direct dissem ination of information on this topic. IV TABLE OF CONTENTS P ag e A bstract ii T able of C o n ten ts iv List of T ab les vi List of Figures vili A cknow ledgm ent ix Dedication X C h ap ter O n e Introduction S tatem en t of th e Problem Background of the 1993 CDA Fluoride G uidelines Information Dissemination of th e 1993 CDA Fluoride Guidelines 1 1 2 6 C h ap ter Two Review of th e Literature Information-Seeking by Health C a re Providers Fluorides Sum m ary of Literature Review P u rp o se of th e Study Significance of the Study 9 9 15 21 22 23 C h ap ter T h ree M ethods and Materials Population Study Population R esearch Design D ata Analysis 24 24 25 27 32 C h ap ter Four R esults Dental Hygienists of the North Sum m ary Information Seeking P attem s Sum m ary R e sp o n se to the 1993 CDA Fluoride G uidelines Sum m ary 33 33 39 39 50 51 57 C h a p te r Five D iscussion an d implications Dental Hygienists of th e North Infonnation Seeking M ethods R e sp o n se to th e 1993 CDA Fluoride G uidelines Limitations o f th e S tudy Implications of th e Findings For M em bers of th e Profession ForCD H BC For BODHA For E ducational Institutions Future R esearch Conclusion 59 59 61 65 68 69 69 70 71 72 75 76 R e feren c e s 77 A ppendices A ppendix A - T he C anadian Dental A ssociation 1993 Fluoride G uidelines A ppendix B - Approval of R e search from th e C ollege of Dental Hygienists of British Colum bia A ppendix C - C over Letter and Q uestionnaire A ppendix D - UNBC R esearch Ethics C om m ittee Certificate o f E thics A pproval Appendix E - Definition of T erm s 81 82 87 90 102 104 VI LIST OF TABLES T ab le Page 1. N um ber of R e sp o n d e n ts by CDHBC District 29 2. N um ber of R esp o n d e n ts by Health Units 30 3. A ge C ateg o ries of Northern British Colum bia Dental H ygienists 33 4. N orthern British Colum bia Dental H ygienists' G raduation y e a r ran g e s from D ental H ygiene School 34 5. N orthern British Colum bia Dental Hygienists' School of Dental Hygiene G raduation 35 6. E m ploym ent Settings for Northern British Colum bia D ental H ygienists 36 7. S e n s e of G eographic and P ractise Isolation for Northern British C olum bia D ental H ygienists by Health Unit Region 38 8. N orthern British Colum bia Dental Hygienists' Utilization o f Information S o u rc es 41 9. N orthern British Colum bia Dental Hygienists' Utilization of Printed Information S o u rces 42 10. N orthern British Colum bia Dental H ygienists' Utilization of Electronic Information S o u rces 43 11. N orthern British Colum bia Dental Hygienists* Ranking of H elpfulness of Information S o u rces 45 12. N orthern British Colum bia D ental Hygienists' Ranking of H elpfulness of Printed an d Electronic Information S o u rc es 46 13. N orthern British Colum bia Dental H ygienists' Ranking of B arriers to Information A ccess 48 14. Information A c ce ss M ethods th a t N orthem British C olum bia D ental H ygienists W ould P refer to H ave D eveloped 49 V II 15. N orthem British Colum bia Dental Hygienists' M ethods o f Learning a b o u t th e 1993 Fluoride Guidelines 51 16. T he M ost V aluable Learning S o u rces of th e 1993 CDA Fluoride G uidelines for N orthem British Colum bia Dental Hygienists 53 17. P ractice C h a n g es by N orthem British Columbia D ental H ygienists a s a R esult of th e 1993 CDA Fluoride G uidelines 54 18. Opinion C h a n g es ab o u t Fluorides by Northem British Colum bia Dental Hygienists a s a R esult of th e 1993 CDA Fluoride G uidelines 55 19. N orthem British Colum bia Dental Hygienists' N eed for More Information on Fluorides 56 20. P atien t C o n cem s About Fluorides a s R eported by N orthem British Colum bia Dental Hygienists 57 V lll LIST OF FIGURES Figure Page 1. CDHBC Districts In Northem British Columbia 26 2. H ealth Unit R egions in Northem British Columbia 31 IX ACKNOWLEDGMENTS A project su c h a s this c an n ot b e accom plished alone a n d I would like to ack n o w ledge th a t I am indebted to a n u m b er of people. First, I would like to th an k th e den tal hygienists in northem British C olum bia w ho participated in my study. W ithout their participation, this th e s is could not h av e b e e n com pleted. I h o p e th a t this re se a rc h will contribute to th e im provem ent of information a c c e s s for d en tal hygienists in th e North. Secondly, I would like to th an k my th e sis com m ittee for their g u id an c e a n d p a tien c e a s I struggled through all th e s te p s of com pleting this th esis. I h a v e learn ed m uch in th e last y e a r a s a result of their help. I ap p reciate Dr. F ish’s g u id an c e in looking beyond th e fluoride guidelines to th e issu e of information a c c e s s . I a lso a p p re cia te m y fam ily's love a n d su p p o rt while I w ent back to school again! And th an k you to friends an d c o lleag u es w ho offered m any w ords of support in th e last year. DEDICATION T his th e s is is d e d ic ated to th e m em ory of my father. Jo h n C. Knight. This w a s his d rea m for m e and I wish h e w a s alive to s e e it c o m e true. C h ap ter O ne Introduction T h e twentieth century h a s s e e n an unp reced en ted growth of th e am oun t of information th a t is available to the general public. Information is a highly regarded com m odity in today's society. T here h a s b e en an explosion of published m aterials and th e d evelopm ent of com puter hardw are a n d softw are h a s greatly increased th e ability to sto re information. T he phenom enal growth of th e information industry an d th e Internet d e m o n stra te s th e d em a n d for a c c e s s to information. T h ere h a s also b e e n a large explosion in the am o u n t of biom edical information th a t is available to th e health c are practitioner. O ne of th e m ost challenging responsibilities for health c a re providers is to keep p a ce with th e growing know ledge b a s e an d developing technology so they m ay stay com petent a n d continue to m eet th e health c a re n e e d s of th e public. Health practitioners m ust continue to leam and " . . . b e a b le to a d ju st p a ttem s of practice throughout a c a re e r in o rd er to provide state-of-the-art-care " (Jeffcoat & Clark, 1995, p. 170). Professional associations, licensing bodies an d educational institutions fac e th e challenge o f supporting health c a re providers in m eeting society's health c a re n e ed s. All m ust work to g eth er to prom ote " . . . a re sp e c t for sc ie n c e and research ; a com m itm ent to lifelong continuing education; an d an environm ent th a t will lead to a highly developed s e n s e of eth ics . . . " (Neidle, 1990, p. 564). S ta te m en t of th e Problem Many a re a s of dental and dental hygiene practice h av e s e e n recent c h a n g e s requiring providers to a c c e s s current information and ad ju st their p attem s of practice. 2 Yet, th e re is limited information on how dental practitioners a c c e s s information, particularly in m ore rem ote locations. This th esis e x am in e s th e m eth o d s th a t dental hygienists in northem British Columbia have utilized to leam a b o u t a n d incorporate new o r revised information into their practice. O ne particular a n d highly relevant a re a of revised information th at h a s b e e n recently dissem in ated to th e dental professio n s is th e u s e of fluorides. H ence, th e revised fluoride guidelines introduced in 1993 by th e C an ad ian Dental A ssociation (CDA) h av e b e e n u se d a s a "case study" in this th e sis to investigate and understand information a c c e s s by dental hygienists in northem British Colum bia. In this introductory chapter, the background of th e 1993 CDA fluoride guidelines is fully explained. A review of th e literature on information seeking m eth o d s of health care providers, fluoride u se and th e prevalence of fluorosis is provided in C h a p te r Two. B ackground of th e 1993 CDA Fluoride G uidelines In creased research, e x p an d ed technology and changing p a tte m s of d is e a s e a re fo rces th at im pact on the practice of dentistry and den tal hygiene. O n e particular a re a th a t h a s b een affected by th e s e forces is the u se of, a n d reco m m en d atio n s for, fluorides. Historically, th e u se of fluoride in com m unity w a ter supplies h a s g e n erate d public controversy and referenda. T h ere h a s often b e e n public co n cem a s to w hether or not fluorides c a u s e cancer, birth d e fects and o th er ills. T h e current issu e s in th e dental literature focus on “how m uch is too m uch” fluoride (Burt, 1995; Clark, 1993; Horowitz, 1995; Levy, Kiritsy, & W arren, 1995; Riordan, 1993). Through th e 1990s, recom m endations for fluoride u sa g e h a v e ch an g ed a n d sev eral countries a re in th e p ro c e ss of m aking fluoride guideline ch an g e s, particularly in th e a re a of fluoride su p p le m e n ts (Burt, 1995; Clark, 1993; C larkson, 92; JADA, 94; Riordan, 1993). T herefore, den tal practitioners m u st b e p rep ared to provide a c c u ra te Information o n th e benefits a n d sa fety of fluorides to th e public. A ccording to Mr. Brian H enderson, th e CDA Director of E ducation, A ccreditation and P rofessional Sen/Ices, th ree dentists. Dr. C hris Clark from th e University o f British Colum bia, an d Drs. Hardy LImeback an d R alph B urgess from th e University o f T oronto, took th e Initiative to organize a national w orkshop on th e Issu e of fluorides (p erso n al com m unication with Mr. H enderson, July 31, 1995; Clark, 1993). On April 9-11, 1992, th e w orkshop on fluorides w a s held In Toronto, during which dental scientists, d en ta l public h ealth an d paediatric specialists review ed a n d ev alu ated current literature on fluorides (CDHA letter to m em bers. S e p t 1992). T his w orkshop, th e C a n ad ian C o n feren ce on th e Evaluation of C urrent R eco m m en d atio n s C oncerning Fluorides, w a s financially sp o n so re d by Proctor an d G am ble of C a n a d a , H ealth and W elfare C a n a d a , and th e M edical R e se a rc h Council of C a n ad a . T h e p u rp o se of th e w orkshop w a s to determ in e th e a p p ro p ria te n ess of th e existing C an ad ian D ental A ssociation fluoride recom m endations (Clark, 1993). T h e goal w a s to develop revised recom m endations for public e x p o su re to fluoride a t th e low est p o ssib le level, a n d y e t m aintain optimal low levels of d en tal caries (Clark, 1993). T h e c o n fe re n c e a d d re s s e d five q u e stio n s " . . . how d o fluorides work; Is th e prev alen ce o f d en tal fluorosis Increasing; d o e s a particular fluoride th era p y put children a t risk to d en tal fluorosis; how m uch fluoride a re children Ingesting; an d how effective Is th e particular therapy" (Clark, 1993, p. 272). T h e im portance a n d effectiveness of w ater fluoridation w a s reaffirm ed during th e co n feren ce. However, several c h a n g e s to reco m m en d atio n s for o th er so u rc e s of 4 fluorides w ere m ad e . Dietary fluoride supplem entation w as th e m o st significant a re a of change. Previously, fluoride sup p lem en ts w ere recom m ended for all children receiving w a ter th a t w a s not fluoridated a t th e optimal level o f 1 ppm . (Clark, 1993). T h e fluoride guidelines now s ta te th a t dietary fluoride su p p lem en ts should not b e u se d by children u n d e r th ree , w h eth er o r not they a re receiving fluoridated w ater. After th e a g e of three, fluoride su p p le m e n ts should b e recom m ended for only for individuals or g roups who a re a t high risk for caries (Clark, 1993; Riordan, 1993). (S e e Appendix A for a com plete copy of th e 1993 CDA fluoride guidelines.) T h e reco m m en d atio n s from th e C anadian C onference on th e Evaluation of C urrent R eco m m en d atio n s C oncerning Fluorides were th en forwarded to th e C an ad ian Dental A ssociation for consideration. T he new recom m endations w ere reviewed by th e ap p ro p riate CDA com m ittees an d w ere adopted by th e CDA board in April 1993 (Clark, 1993). H ow ever th e new guidelines h ave not b e e n universally adopted a c ro ss C a n ad a . T h e revisions to th e fluoride supplem entation sc h ed u le h ave cre ate d so m e controversy A s th e national professional body, th e CDA provides policy an d position sta te m e n ts, with th e provincial licensing bodies having the right to ad o p t o r reject CDA policies (p erso n al com m unication with Mr Brian H enderson, July 31, 1995). According to Mr. H en d erso n , Q u e b e c h a s show n th e m ost reluctance to ad o p t th e new guidelines, m ost likely d u e to its high prevalence of caries and low num ber of fluoridated com m unities. T h e Q u e b e c O rder o f D entists, th e Q u eb ec A ssociation of P aediatric D entists a n d th e Q u e b e c A ssociation of Com m unity Health D entists have all d isag reed with CDA's new guidelines (R efuse, 1993). A nother im portant group th at h a s not adopted an d im plem ented th e new guidelines is th e C a n ad ian Paediatric Society (CPS). T he C P S ta k e s exception to th e c h a n g e s in 5 fluoride supplem entation, stating th a t th e new levels a re too low and no d a ta is available on th e efficacy of caries protection a t th at level (R afuse, 1993). Or. Tony H argreaves, a d en tal consultant to th e British Columbia Ministry of Health who h a s b e e n working with th e m edical com m unity to gain their a cc e p ta n c e of th e 1993 CDA fluoride guidelines, sp e c u la te d th at a lack of consultation with th e m edical comm unity during th e p ro c e ss of changing th e guidelines m ay have contributed to their lack of a c c e p ta n c e a fter th e fact. Dr. H arg reav es also s ta te s th at th e m edical community believes th a t d en tists a re overreacting to th e fluorosis problem (personal com m unication July 27, 1995). Mr. H en d erso n of th e CDA, a g re e s th a t this view of overreaction to fluorosis could b e related to th e lack of adoption of th e guidelines (personal com m unication July 31, 1995). Mr. H en d erso n an d Dr. H argreaves a re in continuing contact with th e m edical com m unity an d working tow ards its a cc ep tan c e of th e 1993 CDA fluoride guidelines. H ealth C a n a d a h a s not adopted th e new fluoride guidelines. Mr. H enderso n w a s u n su re why th e re h a s b e e n a holdup of a c c ep tan c e (personal com m unication July 31, 1995). He h a s b e en in contact with th e Deputy Minister of Health C a n a d a a n d h a s s e n t all d ocum entation and reports. S haron Amer, a dental hygienist w ho is a n Advisor for th e Issu e s, Analysis and Planning Unit in th e Health C are and Issu e s Division of Health C a n a d a w as a n invited ob serv er an d participant a t th e 1992 CDA fluoride w orkshop. S h e confirm ed th at Health C a n a d a h a s d o n e nothing ab o u t the guidelines (personal com m unication, March 6 1996). S h e stated th at d u e to m any recen t c h a n g e s an d cu tb ack s, th e fluoride guidelines a re a low priority for Health C a n ad a . According to Ms. Amer, H ealth C a n a d a m ay not respond a t all to th e guidelines. Ms. A m er su g g e ste d th at th e Medical Services Branch of Health C a n a d a b e co n ta cted to s e e w hat fluoride recom m endations a re being followed. T he F ederal 6 D ental T h erap y program , which is part of th e Medical Services Branch, provides dental se rv ic e s to First N ations p eople on reserv e s. T he federal dental th erap ists are, in fact, following th e 1993 CDA fluoride guidelines (personal com m unication with Laurel W hite, a fed eral den tal th era p ist in British Colum bia, April 25, 1996) At th e provincial level, th e C ollege of D ental S urgeons of British Colum bia (CDSBC), th e licensing body for d e n tists in British Columbia, h a s reviewed a n d ad o p te d th e guidelines. T h e British C olum bia Ministry of Health adopted th e new CDA guidelines a n d h a s reco m m en d ed th at th ey b e followed by health unit perso n n el (personal com m unication with Dr. Tony H argreaves, July 2 7 ,1 9 9 5 ). However, sin ce not all p o ssib le p rescrib ers of fluoride su p p le m e n ts follow th e sa m e guidelines, m em b ers of th e public c an receive mixed m e s s a g e s . A family doctor or pediatrician, w ho a re following th e old fluoride guidelines, m ay recom m end to a m other of a two y e ar old child living in a nonfluoridated a re a th a t th e child should b e taking fluoride supplem en ts. T he m o th e r m ay call th e a re a health unit a n d b e told th e opposite by th e com m unity health n u rse o r com m unity den tal hygienist, w ho a re following th e 1993 CDA fluoride guidelines. It is not known w hat fluoride su pplem ent recom m endations m ight b e m ad e in a private practice d en tal office. Inform ation D issem ination of th e 1993 CDA Fluoride G uidelines Inform ation regarding th e new reco m m en d ed guidelines h a s b e e n m a d e available to British C olum bia dental practitioners in several different w ays. T he results of th e April 1992 c o n fe ren c e w ere published a s a speciality feature article in th e M arch 1993 issu e of Jo u rn al of th e C an ad ian D ental A ssociation. This joum al is s e n t to all m em b ers of th e CDA, w ho m ay m ak e it available to their em ployees. T he C ollege of Dental 7 S u rg e o n s of British C olum bia (CDSBC) s e n t two m ailings on th e reco m m en d ed fluoride c h a n g e s to all licensed d en tists in th e province. T he first mailing, s e n t J u n e 1 8 ,1 9 9 2 , c o n siste d of a copy of th e p ro p o sed c h a n g e s. An information s h e e t to help d en tists explain th e new fluoride recom m endations to their patien ts w a s m ailed on N ovem ber 10, 1992. At th a t tim e d en tal hygienists w ere regulated by th e CDSBC, bu t they did not receive individual m ailings. It w a s th e responsibility o f th e d en tist to s h a re th e information with th e den tal hygienists an d a s s is ta n ts em ployed in th e office. D ental hygienists in northem British C olum bia could h ave received th e information in o th e r w ays. D ental hygienists w ho w ere m em b ers o f th e C an ad ian D ental Hygienists A ssociation (CDHA) w ere s e n t a mailing of th e new reco m m en d atio n s d a te d S ep tem b er 14, 1992. T h e N orthem British Colum bia D ental H ygienists S ociety sp o n so re d a d ay long continuing e d u ca tio n program on May 3 0 ,1 9 9 3 , in Prince G eorge, which included a two h our section on th e new reco m m en d ed fluoride guidelines. During th e spring of 1995 th e d en tal se rv ic e s staff of th e N orthem Interior H ealth Unit s e n t a mailing of th e speciality featu re article "Appropriate U se of Fluorides in th e 1990s" by Chris Clark from th e M arch, 1993 issu e o f Jo u m al of th e C an ad ian D ental A ssociation to all dental offices in th e region of th e N orthem Interior Health Unit. O n S e p te m b e r 25, 1995, th e Prince G eo rg e an d District D ental S ociety sp o n so red a continuing educatio n c o u rse on dental co n tro v ersies with Dr. Jo h n H argreaves a s th e g u e st sp eak er. T h e u s e of fluorides w a s o n e of th e topics d isc u sse d . T he guidelines h av e also b e e n a topic of discussion se v era l tim es during th e 1995 an d 1996 s e s s io n s of th e N orthem British Columbia D ental H ygienists Literature Review Study Club. W hile th e d issem ination of information regarding th e 1993 CDA fluoride guidelines is ongoing, th e effe ctiv en e ss of this dissem ination is unknown. R e s p o n s e s a n d c h a n g e s 8 in clinical practice of individual dentists and den tal hygienists a re also unknown. A c c e ss to information on th e 1993 CDA fluoride guidelines and resulting practice c h a n g e s by dental hygienists in northem British C olum bia form ed th e c a s e stu d y for this th esis. C hapter Two Literature Review T he review of th e literature will include th e topics of th e inform ation-seeking m eth o d s of health c a re providers, th e discovery of fluoride, fluoride so u rc e s a n d p rev alen ce of fluorosis. An exhaustive review of th e topics is beyond th e sc o p e of this th esis, how ever th e literature se lec te d w as d eem ed a s m o st relevant for dental hygienists. Inform ation-Seeking bv H ealth C are Providers A dictionary definition for information is "knowledge acquired through ex p erien ce or study" (Collins C oncise English Dictionary. 1992). For th e health c a re provider, know ledge is acquired by both experience and study. However, e v en th e ex p erien ced health c a re provider m ay d esire additional information for decision-m aking an d providing quality c a re in clinical practice. Therefore, for th e p u rp o se s of this paper, information will b e defined a s " . . . organized d a ta or know ledge th a t provides a b a sis for decision making" (Gravois. 1993. p. 10). Although information is n e ed e d for decision m aking a n d providing good care, o n e can b e overw helm ed by th e am ount of information th a t is available. T h ere h a s b e e n m uch discu ssion in th e m edical an d dental literature a b o u t th e escalatin g growth of information a n d th e difficulties for th e health c a re provider to k e e p up with it all (Blythe. 1992; D ee & Blazek. 1993; Gravois. 1993; S trother & L ancaster. 1986). T h ere is g en eral a g re e m e n t th a t no professional can read all th e published work in their field, yet m any re a so n s exist for health practitioners to ad o p t system atic m eth o d s of staying current. T h e s e re a so n s include: patient expectations, p re s su re s from licensing b o dies 10 : an d professional asso ciatio n s, a n d th e p ro p er utilization o f research a n d tech n o lo g y in practice. Health c a re providers h av e m any s o u rc e s of available information. E ach so u rc e of ■i i information requires different skills an d re so u rc e s to b e properly utilized. N um erous ■< stu d ie s hav e b e e n co n d u cted to exam ine th e m e th o d s th a t health c a re providers u s e to s e e k information. This literature review will fo cu s on th re e m ajor c ateg o ries of I I information so u rc e s: oral, printed, a n d electronic so u rc e s. S eeking information from oral so u rc e s h a s b e e n a traditional m ethod for c en tu rie s in health c a re a n d still is a well a c c e p te d m ethod. E xam ples of oral information so u rc e s are: asking a colleague, formal a n d informal p e e r discu ssio n groups, d isc u ssio n s with product s a le s rep resen tativ es, attending professional m eetings a n d conventions, an d continuing education c o u rses. S tu d ies sh o w th a t information gained by h u m an c o n tact a re preferred by m any health c a re p ro fessio n als (Bird & Heekin, 1994; D ee & Blazek, 1993, G ravois, 1993; L undeen, Tenopir, & W erm ager, 1994; M arshall, 1992; S trother & L an caster, 1986). R e a s o n s cited for th e p re fe ren c e for oral information include: e a s e of accessibility; convenience; tim e efficiency; a n d th e perception of it being a n a ccu rate, tru sted a n d confidential so u rc e of information (D ee & Blazek, 1993). A ccording to Jeffco at & Clark (1995, p. 176), " . . . continuing educatio n re p re se n ts th e m ajor m ech an ism for lifelong learning for dentists". Continuing education an d atten d in g professional m eetin g s c a n b e a two w ay com m unication m ethod a s it " . . . re p re se n ts a m ech an ism for clinicians to inform re se a rc h e rs o f their n e e d s for new re se a rc h a n d their ex p erien c e with th e results o f re se a rc h a s it is a d a p te d in clinical practice" (Jeffcoat & Clark, 1995, p. 176). Il Printed s o u rc e s of information a re widely available and utilized by health c a re providers. T h e s e so u rc e s include textbooks, journal articles, a b stra c t services, product literature, an d new sletters from professional associations an d licensing bodies. S tu d ies hav e varied findings regarding th e value and u s e of printed so u rc e s of m aterials. L undeen e t al. (1994) found th a t th e majority of rural health c a re practitioners in Hawaii primarily utilized th e following information so u rces; joum al articles, new sletters, reports an d books. However, focus groups conducted by th e editors of th e Joum al of th e A m erican D ental A ssociation found th a t d en tists prefer not to read original re se a rc h literature (Jeffcoat & Clark, 1995). T h e focus groups show ed th a t den tists would rath er re a d . . sum m ary p a p e rs th a t p re se n t clinically relevant topics in a very re a d ab le form rath e r th an a s d a ta to b e interpreted by th e clinician " (Jeffcoat & Clark, 1995, p. 176). D ee & Blazek (1993) found th at th e num ber of textbooks ow ned ranged from z ero for th re e physicians to 200 for two physicians in a qualitative study of information n e e d s of 12 rural Florida physicians. T h e n um bers of joum als subscribed to by this s a m e group ran g ed from zero to nine or m ore (D ee & Blazek, 1993). This study also found th at library a c c e s s did not acc o u n t for differences in joum al subscriptions nor th e n u m b er of tex tb o o ks ow ned. Of th e six physicians with a c c e s s to a hospital library, only o n e u se d it frequently (D ee & Blazek, 1993). Given th e sm all sam ple in this study, th e resu lts should not b e generalized to all rural physicians. Kunzel an d Sadow sky (1991) a sk e d a sam p le of general practice den tists in th e United S ta te s how often they u s e various so u rc e s of information ab o u t patient m ed ications an d o th er ty p es of m edical m anagem ent. T he preferred ch o ices w ere co lleag u es, th e patient's physician, an d th e Physician's D esk R eferen ce (FDR) which is th e A m erican counterpart to th e Com pendium of Pharm aceuticals and S pecialties 12 (C PS) u se d in C a n a d a . Professional m eetings and Journals a re u sed le ss frequently for - patient m edications and o th er m edical problem s, p erh ap s b e c a u s e th e information gain ed from th o se so u rc es is not specific enough for individual care. Interestingly, th e information so u rc e lea st u se d w as th e pharm aceutical representative. Kunzel a n d S adow sky (1991) sp e c u la te th a t this m ay be d u e to skepticism of th e drug industry by health c a re providers. A stu d y of factors encouraging and discouraging u se of nursing resea rch findings found th a t n u rse s ranked monthly research new sletters m ost helpful (Pettengill, Gillis & Clark, 1994). N u rses then preferred resea rch m eetings, continuing education p rogram m es, com p u ter networks, interactive software, and resea rch study guides, in th a t o rd er (Pettengill e t al., 1994). In a study on th e u se of information so u rc e s in th e field of aging, Bird an d Heekin (1994) found th at joum al literature ranked first. Professional m eetings an d d iscu ssio n s with c o llea g u es w ere a close se co n d and third (Bird & Heekin, 1994). G ravois (1993) found th a t th e information so u rc es u sed m ost frequently by dental hygienists w ere continuing edu cation courses, d iscu ssio n s with colleagues, an d joum als, in th a t order. T he literature s e e m s to show consistency in health care providers’ p referen ce for information gained from d iscussions with colleag u es and joum al articles. How joum al articles a re a c c e s s e d rem ains a question sin ce stu d ies on information seeking p ractices sh o w a co n sisten t trend of low u sa g e of library services and d a ta b a s e s e a rc h e s (Bird & Heekin, 1994, D ee & Blazek, 1993; Gravois, 1993; Lundeen e t al., 1994; S tro th er & L ancaster, 1986). T h ere h a s b e e n a n explosion of electronic information retrieval and com m unication m ethods. In th e last ten years, th e new field of health informatics h a s b e e n dev elo p ed . : 13 : J o n e s , Navin, Barrie, Hlllan an d K inane (1991, p. 191) quoted th e W orld H ealth ; O rganization's definition of health inform atics . . a s th e com bination of tech n o lo g y an d j j m ethodology which m a k e s possible th e com p u ter-assisted collection, sto ra g e , i I p ro cessin g , retrieval, distribution a n d m a n a g e m e n t of information.” A s m edical libraries : h av e ad ju sted to th e health inform atics a g e , com puter d a ta b a s e s h a v e rep laced card c a ta lo g u e s. W hile options to a c c e s s information by electronic m e a n s h a s grown rapidly, th e p referen ce for this m ethod by health c a re professionals h a s not. S tu d ies consistently show th a t m any health c a re providers have low co m p u ter skills a n d a low in terest in and ability to d o on-line d a ta b a s e se a rc h e s (Gravois, 1993; L u n d een e t al., 1994; Mullaly-Quijas, W ard, & WoeifI, 1994). A qualitative m arketing study w a s c o n d u cted by th e M idcontinental R egion o f th e N ational Network of Libraries o f M edicine in 1992 (Mullaly-Quijas e t al., 1994). This stu d y utilized focus gro u p s to d eterm in e th e m et an d u nm et information n e e d s of various health professionals. T h e fo cu s gro u p s consisted of physicians, n u rse s, p h arm acists, hospital adm inistrators, d entists, allied health professionals, a n d health s c ie n c e s librarians. C om pared to th e o th er focus groups, th e d en tists h ad a low familiarity with an d utilization of th e National Library of Medicine. T h e fo cu s group of d e n tists cited th e u s e of Index to D ental Literature, Medline, th e librarian, stu d y groups, detail rep resen tativ es, and perso n al joum al collections a s information s o u rc e s . All of th e fo cu s groups indicated lack of tim e, know ledge, an d com puter skills a s barriers to a c c e ssin g information. T h e Mullaly-Quijas e t al. (1994) study w a s c o n d u c te d with a limited n u m b er of sm all fo cu s gro u p s in O m ah a, N ebraska an d two o th e r n e arb y cities, so th e view s a re not necessarily rep resen tativ e of all health professionals. 14 A stu d y of th e inform ation-seeking behaviours of m edical, pharm acy, nursing, and s c ie n c e faculty a t th e University of Illinois a t C hicago w a s co n d u cted in 1991 (Curtis, W eller, & Hurd, 1993). Overall, this stu d y found a definite p referen ce for u s e o f p a p er I indices over co m p u ter m eth o d s for com pleting literature s e a rc h e s . W hile Index ': i \ M edicus and Medline w ere widely u se d by all four groups, o th er d a ta b a s e s w ere j seld o m u sed by th e m edical, p harm acy an d sc ien ce faculty. Nursing faculty re s p o n se s I sh o w ed g re a te r u s e of m ajor indices a n d d a ta b a s e s in multiple fields of study. T he I a u th o rs conclude that, e v e n a s new form ats b eco m e available for a c c e ss in g literature, : th e traditional form ats continue to b e u se d . Curtis e t al. (1993) rec o m m e n d s th a t training s e s s io n s on th e u s e of electronic d a ta b a s e s m u st b e tailored to th e a u d ien ce a n d its specific n e e d s. If university faculty n e e d tim e an d training to u s e th e electronic d a ta b a s e s , th e s e s a m e conclusions a re probably even m ore applicable to health care practitioners. For th o s e who do u se library services, th ere can b e a positive im pact on their clinical d ecisio n m aking. Hospital librarians in R ochester, New York developed a resea rch project to explore th e im pact of library services on th e clinical decision m aking of p h y sicians (Marshall, 1992). T he participating physicians w ere a sk e d to re q u e st inform ation related to a clinical c a s e a n d then ev alu ate its im pact on th e c a re of their p atien ts. Four hundred a n d forty-eight physicians a g re ed to participate in th e study, but only 2 2 7 retum ed th e q u estionnaires. R esponding physicians reported th e following b eh av io u rs a s a result of th e library information: a c h a n g e of advice to th e patien ts (71% ), a c h a n g e in trea tm e n t (59.6% ), a c h a n g e of diagnostic te s ts (50.5% ), an d c h a n g e in d rugs (45.2% ) (Marshall, 1992). This study d e m o n stra te s how a c c essin g inform ation through a library c an have a positive im pact on patient c are. I :j '5 T h e Internet offers new Information options to health c a re providers. T ietze and 1 H uber (1995) d isc u ss th e Internet options which a re available to n u rse s su ch a s th e I "gophers" of N urse and Nightingale, bulletin b o ard s posting nursing information, and Ej mail lists of nursing interests. Tietze and H uber (1995) s ta te that, although th ere a re I I m any so u rc e s of electronic information currently available to n u rse s, their u s e by n u rses I I is not w idespread. In a n editorial in th e Joum al of th e A m erican D ental Association. Meskin (1995) d is c u s s e s how few dentists have a c c e s s e d th e information superhighw ay. For dentists th at a re team ing to utilize th e Internet, opportunities for information e x ch an g e a re available. For exam ple, a n orthodontic electronic bulletin board w a s sta rte d in 1994 (Zemik, 1994). This electronic study club provides su b scrib ers with an opportunity to d isc u ss c a s e s , journal articles a n d new technologies (Zemik, 1994). W hite multiple so u rc es of information a re available, m any health c are professionals only utilize a few of th e m ethods. This m ay limit their ability to rem ain current and provide quality c a re for their patients. Yet, health c a re providers h av e a professional obligation to k eep p a c e with th e growing knowledge b a s e an d developing technology of their field. A recen t exam ple of a significant ch an g e in th e know ledge b a s e in th e practice of den tal hygiene is th e new recom m endations govem ing th e u se of th e various so u rc e s of fluorides. In C hapter O ne, th e s e new recom m endations have b e en d isc u sse d . T he following section provides an oven/iew of th e u s e of fluorides. Fluorides During th e early 1900s, investigations b eg an a s to why p eople in certain geographic a re a s exhibited mottled enam el. Mottled enam el or fluorosis is a n aesth e tic condition of I 16 'i ! th e tee th th at can range in seventy from faint white streaking to brown staining and j pitting (Pendrys, 1991). Dr. Frederick McKay, investigating this problem in C olorado, I I attributed this condition to som ething that w as p resen t in th e drinking w ater (Burt, 1992). I Dr. H. Trend ley D ean, a public health officer b eg an working on th e investigation in 1931 I and shifted th e e m p h a sis from m ottled enam el to th e observ ed p h e n o m en o n of th e I I few er caries th at w as a sso c ia te d with it (Burt, 1992). In 1931, a scientist with Alcoa I identified th e a g e n t a s fluoride, which som etim es occurred naturally in w ater so u rc e s I (Burt, 1992). I I After this discovery. Dr. D ean w anted to determ ine if th e possibility of adding fluoride to w ater would d e c re a s e th e caries rate, which w a s m uch higher in th e 1 9 3 0 s an d 1940s than p re se n t d a y caries ra te s (Burt, 1992). By 1945, th e ran g e of .7 ppm to 1.2 ppm had b e en determ ined a s th e optimum am o u n t to ad d to drinking w ater which would d e c re a s e caries without causing m ottled enam el (Burt, 1992). S in ce then, m an y cities an d tow ns in North A m erica h ave a d d ed fluoride to their drinking w a ter supplies. Ja n u a ry 1995 w a s recognized a s "...the 50th anniversary of th e first controlled additional fluoride to a public w ater supply” (Burt, 1995, p. 37). In th e 1940s and early 1950s fluoride w as not readily available to th e g en eral public. O ver th e years, how ever, fluoride h a s becom e available in m any form s su ch a s to o th p aste, m outh rinses, topical applications a t th e dental office, an d dietary su p p lem en ts. A halo o r diffusion effect h as also occurred a s fluoride can b e found in s u b s ta n c e s such a s infant formula, infant food, juice, so d a , an d c an n e d fo o d s which a re prepa. e d with fluoridated w ater a n d then later co n su m ed in nonfluoridated com m unities (Levy e t al., 1995). Fluoride also occurs naturally in a num ber of s u b s ta n c e s su ch a s bottled water, te a , chicken, fish, a n d seafood (Levy e t al., 1995). 1 17 Today, p eo p le a re e x p o se d to multiple fluoride so u rc e s, a n d while th e overall I p rev alen ce rate of c aries h a s dropped significantly, co n cern over fluorosis h a s risen. 1 T he tee th m ost su scep tib le to fluorosis a re th e p e rm a n e n t maxillary incisors which a re J i forming a t a g e s 22 to 25 m onth s (Nouqah. Horowitz. & W ag en er. 1994). T h e y inappropriate u s e or incorrect am o u n ts of fluoride a t th is tim e would b e th e prim ary I c a u s e of dental fluorosis. Swallowing of fluoridated dentifrices, e x c e s s e x p o su re to II fluoride in food an d drinks, inappropriate prescribing p rac tic es of providers, a n d j I incorrect u sa g e of fluoride su p p le m e n ts by p atien ts c a n all lead to dental fluorosis. A I n u m b er of articles an d stu d ie s h av e d isc u sse d a n d attem p ted to m e a su re a p e rs o n 's ? overall fluoride intake (Lewis e t al.. 1994; Levy 1992; Levy e t al.. 1995; N ourjah e t al., I j 1994). O ther stu d ies h a v e investigated th e p rev alen ce an d severity of d en tal fluorosis I (Clark. Mann, W illiamson & Berkowitz, 1993, 1994; Ellwood & O'M ullane. 1995; I Nowjack-Raym er, Selwitz, Kingman, & Discoll, 1995; Riordan, 1993). T he 1986 National H ealth Interview Study co n d u cted in th e United S ta te s collected information on current u s e of fluoride-containing products (N ouqah e t al.. 1994). In this i study, d a ta w as exam ined to d eterm ine fluoride intake for children younger th a n two y e a rs old. T hey found th a t nearly half of th e s e children w ere reported to u s e a t le a st o n e type of fluoride product. By a g e three, alm ost 96% of th e children w ere using a t le a st o n e type of fluoride product. Nourjah e t al. (1994) su g g e ste d th at health c a re providers and p a re n ts should b e b e tter e d u c a te d a b o u t fluoridated dentifrices a n d su p p lem en ts, particularly w hen th ey live in fluoridated com m unities. Unfortunately, m any ad ults a re not aw are of th e fluoridation sta tu s of their com m unity (B em ard-B onnin e t al.. 1993; Nourjah e t al.. 1994). 3 18 ■4 I P a re n ts a re also often unaw are of th e actual fluoride content o f products they a re !using for th eir children. A study in 1991 a t R egina’s Child Health Clinics surveyed 293 1>p a re n ts on their u s e of fluoride and vitamin su p p le m e n ts (Kot & H asselback, 1993). II Fifty-three p e r c e n t of th e re sp o n d en ts indicated using a fluoride su p p lem en t for their I child, but a follow-up check on th e su p p lem en t n a m e brand show ed th at only 39% w ere I actually giving a fluoride su p p lem en t (Kot & H asselback, 1993). I- Ingestion of to o th p a ste by young children is a n o th e r potential m ethod for th e ;d e v elo p m en t o f d ental fluorosis. In C a n ad a , th e re is alm ost universal u s e of fluoridated to o th p a ste, yet p a re n ts a re often unaw are of th e large am ount of fluoride, 1000-1100 parts p e r million (ppm), th at exists in m ost m ajor b ran d s of toothpaste. In a p a p e r for th e 1992 CDA fluoride workshop. Levy review ed th e literature regarding fluoride intake from fluoride dentifrices. Levy (1992) concluded th a t th e literature show s th a t young children a re ingesting large am o u n ts of fluoride from fluoridated to o th p a stes. W hile th e availability of multiple fluoride so u rc e s h a s lowered th e overall caries rate, th e re a re c o n c e rn s a b o u t th e rising potential for dental fluorosis. A s a result, a n u m b er of stu d ie s h a v e b e e n conducted to determ ine th e prevalence and severity of dental fluorosis. A stu d y of th e prevalence of dental fluorosis w a s conducted by N ow jack-Raym er e t al. (1995) on children w ho had participated in a n eight-year clinical trial of th e e ffectiv en ess of th re e different sch o o l-b ased fluoride procedures. Children w ere random ly a ssig n e d to o n e of th re e groups: (a) rinsing o n c e a w eek with .2% neutral sodium fluoride; (b) chewing, rinsing, an d swallowing a neutral 2.2 mg sodium fluoride ta b let on a daily b asis; or, (c) using both pro ced u res. At a follow-up exam ination in 1992, 4 48 children w ere exam ined for fluorosis levels using D ean's Fluorosis Index. 19 I I i Overall the prev alen ce of fluorosis w as low with only 4.5% or 20 participants having fluorosis. No statistically significant differences in fluorosis prevalence w ere found by treatm en t m ethod, a g e or tee th affected (Nowjack-Raymer e t al., 1995). T here w ere six children in th e Nowjack-Raym er e t ai. study (1995) w ho exhibited m o d erate or se v e re fluorosis. T he investigators questioned th e p aren ts of th e s e children to try to u n d erstan d why this had occurred. This further investigation found th at . . all of th e children presenting with m o d erate or higher classifications o f fluorosis had Ingested quantities of fluoride g rea ter th an optimal from so u rc es other th a n th e fluoride regim ens a t school" (Nowjack-Raymer e t al., 1995, p. 169). Primarily th e s e children had b e e n e x p o sed to high levels of fluoride earlier than 5 y ears old. N ow jack-R aym er e t al. (1995) concluded th at under strict supervision, school-based fluoride program s can b e u sed safely in nonfluoridated com m unities. Although A m erican stu d ies on this subject a re num erous, Clark (1994) s ta te s th at little resea rch on th e prevalence of dental fluorosis h a s t)een conducted in C a n a d a . In a recen t study, Clark e t al. looked a t ex p o su re to fluoride sources, the p rev alen ce of caries, and severity o f fluorosis of school a g e children in two com m unities in British Columbia; Kelowna which is fluoridated a t 1.2 ppm and V em on which h a s le s s th an 0.1 ppm fluoride in th e w ater (Clark, Hann, W illiamson, & Berkowitz, 1994a, 1994b). In this sa m e study, Clark e t al. (1993) also investigated th e children and p aren ts' level of a esth e tic concern with fluorosis. Schools in both cities w ere stratified by socioeconom ic sta tu s and th en random ly selected to participate in th e study. A total of 3126 children from a g e s six to 14 w ere ask ed to participate in th e study. Five hundred an d ten children from V em on a n d 621 children in Kelowna participated in th e study (Clark e t al., 1993, 1994a 1994b). T hey I3 20 I I w ere exam in ed for p rev alen ce o f dental c arie s using th e modified ,1 Dg MFS index, an d I severity of fluorosis using th e T ooth S urface Index of Fluorosis (TSIF). T h e Dg MFS i index c o u n ts n u m b ers of tooth su rfa c e s with incipient c arie s a n d cavitated caries, a s 4 j well a s m issing and filled tooth su rfaces. T h e TSIF s c a le runs from 0 to 7 with 0 I rep resen tin g no fluorosis p resen t. At th e tim e of th e exam ination, children w ere a sk e d if I th ey liked th e colour o f their front te e th (Clark e t al., 1993). P a re n ts w ere a sk e d to i I co m p lete a questio n n aire on dem ographic information, fluoride ex p o su re, dietary I history, a n d level of co n cem a b o u t th e colour of their child's te e th (Clark e t al., 1993, i 19 9 4 a, 1994b). In th a t study, Clark e t al. (1994a, 1994b) found th a t children with lifelong ex p o su re to fluoridated w a te r had 35% few er caries o r filled tooth su rfa c e s th a n th o s e with no sy stem ic fluoride ex p o su re. Children w ho h a d taken fluoride su p p le m e n ts for a t least fo u r y e a rs had a 26% reduction in caries o r filled tooth su rfa c e s th an th o s e with no sy ste m ic e x p o su re (Clark e t al., 1994a 1994b). Sixty p e r c e n t o f th e children exam ined h ad fluorosis on a t le a st two tooth su rfa ce s, with th e majority (52% ) a t a 1 level on th e T SIF (Clark e t al., 1993). Clark e t al. (1993) found only se v e n p e r c e n t of th e children in V ernon a n d 10% of th e children in Kelowna to have fluorosis levels of two o r m ore. T he children a n d th eir p a re n ts in th e TSIF sc o re ran g e of four or m ore did h av e a esth etic c o n c e rn s a b o u t tooth colour (Clark e t al., 1993). Burt (1995) d is c u s s e s th e varying view points on th e p rev alen ce a n d im portance of fluorosis. O n e point of view is th a t m o st p e o p le with mild fluorosis d o not know th a t they h a v e it a n d a re unconcerned. O n th e o th er hand, o th ers a re c o n ce rn e d th a t fluorosis could b e c o m e a public health issu e and Jeopardize th e caries reduction s e e n from th e u s e of fluorides (Burt, 1995). W hile dental practitioners m ay vary on their viewpoints on 21 I fluorosis, it certainly h a s g e n e ra te d m uch discussion in th e re c e n t literature (Burt, 1995; Ii Clark, 1993; Clark, e ta !;, 1993; Pendrys, 1991; Riordan, 1993). Also, various j I organizations have held m eetin g s to d isc u ss th e optim um level of total fluoride intake. IA E u ro p ean m eeting w a s held in B russels in 1991, th e C a n ad ian D ental A ssociation I held a w orkshop in 1992, th e A m erican Dental A ssociation h a d a c o n fe ren c e in 1994, j a n d th e A m erican A ssociation for Public H ealth Dentistry held a sym posium on fluoride J j in O cto b er 1994 (Burt, 1995; Clark, 1993; Clarkson, 1992; JADA, 1994). i After organizations m e e t on issu e s, su ch a s fluoride, a n d m ak e policy d ecisions, it is 1 i im portant for th e information to b e dissem in ated to th e practitioners in th e field. T he s u c c e s s of th e information dissem ination is d e p e n d e n t on both th e organization an d th e individual practitioner. S u m m ary of Literature Review T h e literature w as review ed to determ ine th e inform ation-seeking practices of health c a re professionals. Overall, h ealth c a re providers se e m to prefer oral a n d printed so u rc e s of information. H ealth c a re professionals tend to h av e low co m p u ter literacy skills a n d to b e uncom fortable in th e electronic environm ent. Lack o f tim e, low c o m p u ter literacy, an d lack of familiarity with d a ta b a s e s a re often cited a s barriers to information a c c e s s . M any health c a re providers do not a c c e s s libraries an d their serv ices, even w hen th ey a re in c lo se proximity. T h e literature w as se a rc h e d to identify stu d ies th at looked specifically a t th e inform ation-seeking practices of d en tists and dental hygienists. However, this au th o r a n d o th ers (Gravois, 1993; Kunzel & Sadow sky, 1991; Norton & Y aegar, 1992) have found few published stu d ie s on th e p rac tises of this group alone. S o m e stu d ie s on th e I I topic of inform ation-seeking practices of health care practitioners have included d en tists ■I i but not dental hygienists in their research . Given th e lack of research in this a re a , it is I I difficult to determ ine if d entists and dental hygienists differ in their inform ation-seeking I m eth o d s from other health care personnel. T here a re re a so n s why th ere could b e iI differences. Typically d entists and dental hygienists work in solo offices a n d h ave 9 g limited daily co n tact with colleagues a s com pared to th o se in m edical professions. Also I m any provinces and s ta te s have m andatory continuing education requirem ents for relicensure of d en tists an d dental hygienists. Therefore, professionals in th e d en tal iI profession often d e p en d upon the lecture form at of continuing education c o u rs e s a s p I their primary so u rc e of information. Given the lack of information on this group, i1 particularly in C a n a d a , further exploration is w arranted. I This literature review h a s also p resen ted a brief discussion on fluoride including: its discovery, multiple so u rc es, and concem over fluorosis. T he research h a s show n a rise 1 I in th e num bers of children with mild fluorosis. Dental hygienists m ust b e ab le to a c c e s s ] information regarding fluorides so th ey m ay properly counsel p atients on th e correct u s e 1 I an d safety of fluorides. P u rp o se of th e Studv T he p u rp o se of this resea rch w a s to determ ine how dental hygienists in northem British C olum bia a c c e s s information. This research project explored w hat information so u rc e s a re utilized an d valued by northem dental hygienists. Barriers to a c c e ssin g current information w ere also identified. Additionally, dem ographic information on d en tal hygienists in northem British Columbia w as gathered. î T h e research q u estio n s w ere: I 1. W hich information so u rc e s do dental hygienists utilize? ■II 2. W hich information so u rc e s do dental hygienists regard a s m o st helpful? I 3. W hat a re th e barriers to a cc e ssin g current information? Ia 4. W h at a re th e m eth o d s by which dental hygienists received information regarding th e I 1993 CDA fluoride guidelines? É I 5 . Have dental hygienists m ade any changes in their opinions, u se , an d reco m m en d atio n s I of fluorides a s a result of th e 1993 CDA fluoride guidelines? ^ Significance of th e Studv i I I This re sea rch provides im portant information regarding d en tal hygienists in northem British Colum bia. S everal conclusions and recom m endations h av e b e e n m a d e b a se d I on th e findings. T h e se conclusions and recom m endations will b e o f valu e an d interest to th e British Colum bia D ental Hygienists A ssociation (BCDHA), th e professional asso ciatio n , to th e C ollege of Dental Hygienists of British C olum bia (CDHBC), th e licensing body and to educational institutions th a t provide den tal hygiene entry ed u catio n and continuing education courses. 24 C h a p te r T h ree M ethods and M aterials I T h e p u rp o se of this study w a s to determ ine th e information n e e d s a n d infbrm ation- I seeking m eth o d s of dental hygienists in northem British Colum bia. A s a c a s e study, th e I re sea rch investigated how this group h ad received information on th e CDA 1993 y I fluoride guidelines. T he re sp o n se to this information and s u b s e q u e n t practice c h a n g e s I h a s b e e n explored. Population According to th e C ollege of D ental H ygienists of British C olum bia (CDHBC), a s of July 14, 1995, th ere w ere 1634 registered dental hygienists in British C olum bia. Two h undred of th e 1634 had non-practising registration sta tu s. A s of July 1995, th e re w ere 932 d en tal hygienists who w ere current m em b ers of th e British C olum bia D ental Hygienists A ssociation (BCDHA), th e professional association. W hile all d en tal hygienists in British Colum bia m u st b e registered a n d licensed by CDHBC, m em b ersh ip in BCDHA is voluntary. A bias could b e introduced if th e population w a s defined by th o s e d en tal hygienists w ho a re m em b ers of BCDHA. T herefore, it w as decid ed to ap p ro a ch th e CDHBC for a mailing list of den tal hygienists. Perm ission to co n tact registered d en ta l hygienists in northem British Colum bia by mail w a s obtained from th e C ollege o f D ental H ygienists of British Colum bia in O ctober, 1995 (s e e A ppendix B for th e written s ta te m e n t of perm ission). T h e mailing labels w ere provided by th e CDHBC. # 25 'I Studv Population II T h e stu d y population for this resea rch con sisted of the 130 d en tal hygienists in ■II northem British Colum bia registered with CDHBC. For the p u rp o se s of this survey, I northern British Colum bia w as identified a s th e districts of Northwest, Prince G eorge, I an d P e a c e River a s defined by th e College of Dental Hygienists o f British Colum bia (se e II Figure 1). T h e s e a re th e s a m e northem districts a s defined by th e previous licensing I body, th e C ollege of D ental S u rg eo n s of British Columbia. This is also th e region th a t is I Identified a s th e northem co m p o n en t of th e British Columbia D ental H ygienists I A ssociation. I T h e g eo g rap h ic definition of this a re a is 100 Mile H ouse and north to th e Yukon I Border, a n d from th e Alberta border to th e Q u een Charlotte Islands. T h ere a re two 1 m ajor highw ays th at travel north to south an d e a s t to w est in this a re a . Extrem e i I w e a th e r conditions during th e winter m ak es road, air and ferry travel tim e consum ing, ■J j a t tim es unpredictable, and even d an g ero u s. T he econom y in th e northem region is primarily re so u rce b a se d . As of th e 1991 C e n su s, th e total population for northem British Colum bia w as 319,953 (Statistics C anada). T he largest city in this a re a is Prince G eo rg e which had a population of 69,653 a t th e tim e of the 1991 C e n su s (Statistics C a n a d a ). T h e 1996 population of Prince G eorge is approxim ately 75,000 (personal com m unication with Prince G eo rg e City Hall, April 22, 1996). 26 Figure 1 I ipD H B C Registration Districts lyvhich a re Subdivisions of ^Electoral District 1 Cni.LEGE OF W orth W est District #Bums Lake W o u sto n |S m ith ers pThe H azeltons iT e rrac e |Kitlm at fPrince R upert iQ u e en C harlottes iste w a rt Bella C oola H Y G I E N I S T S OF B R I T I S H C O L U M B I A SCHEDULE TA BRITISH COLUMBIA ELEaO RAL DISTRICTS IP e a c e River District T um bler R idge Chetwynd D aw son C reek Fort S t Jo h n Fort N elson Prince G eoroe District M ackenzie Fort St. J a m e s F ra se r Lake V anderhoof Prince G eorge McBride V alem ont Q u esn el W illiams Lake 100 Mile H ouse DENTAL c % LEGEND 1 2 3 4 5 SthaM »Â - CARIBOO NORTH - VANCOUVER ISLAND/COAST — LOWER MAINLAND — OKANAGAN - KOOTENAYS From Registianrs Handbook (1995), used wilhpannission. ■I 27 â R e se a rc h Design I I T h e design w a s a cross-sectlonal, descriptive study. A questio n n aire for self- 1 adm inistration w a s developed by th e au th o r during A ugust, S ep tem b er, a n d O ctober of % 0 1995 a n d d esig n ed for co d ed d a ta entry. T he survey co n sisted of th re e sectio n s; (a) 1 d em o g rap h ics with 16 closed e n d e d questions; (b) re s p o n s e to th e 1993 CDA fluoride guidelines with nine clo sed -en d ed , an d o n e o p e n -en d ed q uestions; an d , (c) information seek in g practices with five Likert-type sc a le design q u estio n s, two clo sed -e n d ed q u estio n s, a n d two o p e n -e n d ed questions. (S e e A ppendix C for copy o f questionnaire an d c o v er letter.) P articipants w ere a lso a sk e d if they would b e willing to participate in further d iscu ssio n of th e issu e s by telep h o n e. If willing, th ey w ere a sk e d to give their n a m e and te le p h o n e nu m b er an d sign a c o n se n t form included with th e mail questionnaire. This w a s strictly voluntary an d all further information obtained by telep h o n e w a s to b e kept strictly confidential. However, it w as not n e c e ssa ry to co n tact re sp o n d e n ts by telep h o n e d u e to th e a cc e p ta b le re s p o n se rate by mail (81.5%). On O ctober 25, 1995, th e proposal w a s subm itted to th e UNBC R e se a rc h Ethics C om m ittee. Approval for th e study w as granted on N ovem ber 28, 1995 (s e e Appendix D). To help e n su re validity of th e questionnaire, a pilot study w a s co n d u cted . Pilot testin g of th e questionnaire w a s conducted on a c o n v en ien ce sa m p le of se v e n dental hygienists in parts of th e province o th er th an th e north. T h e questio n n aire w as mailed on N ovem ber 16, 1995 to eight practising dental hygienists with a n explanation of th e p u rp o se of th e pilot te s t an d instructions for participation. P articipants w e re a sk e d to read th e cover letter th a t would acco m p an y th e survey, com plete th e survey an d 28 participate in a follow-up p h o n e call. P hone co n tact w a s m a d e by this investigator with sev en of th e eight den tal hygienists betw een N ovem ber 28 a n d D e ce m b er 3, 1995. T he eighth dental hygienist w a s n o t contacted a s a correct p h o n e n u m b er could not b e o btained for th a t p erso n . Information w a s so u g h t on th e a p p e a ra n c e and layout o f th e questionnaire, length of tim e to com plete th e q uestionnaire, and clarity o f instructions a n d question s. Com pleting th e questio n n aire took an av erag e of thirty m inutes for th e se v en pilot study participants. F e e d b a c k on th e co v er letter and q uestionnaire w a s positive. Several su g g e stio n s w ere m a d e for slight layout c h a n g e s and clarification of a few q uestions. T h e se v e n d ental hygienists involved with th e pilot te s t w ere a s k e d to mail their com pleted surveys b a ck to th e investigator. T he d a ta from th e pilot stu d y surveys w a s not utilized in th e actual study. T h e th esis com m ittee w as notified of th e pilot study I resu lts an d s u b s e q u e n t m odifications to th e questionnaire. I T h ree s e ts of mailing labels w ere obtained from th e CDHBC in D ecem ber, 1995. I S in ce D ece m b er would not b e a good m onth for mailing out a survey, it w a s d ecid ed to I I wait until Jan u ary , 1996. T h e first mailing took p lace on Ja n u a ry 8 ,1 9 9 6 an d co n sisted 3 of a co v er letter, questionnaire, a n d a stam ped, se lf-a d d resse d reply envelope. -1 1 S u b jects w ere informed th a t th e questionnaire had b e e n n u m b ered for th e p u rp o se s of checking re s p o n se s, but th a t all re s p o n se s would rem ain a n o n y m o u s an d confidential. A two w eek d ead lin e (Jan u ary 24, 1996) w as given in th e c o v er letter for retum ing th e survey. A rem inder po stcard to all potential participants w a s m ailed on Ja n u ary 15, 1996. T h e re s p o n se rate for th e first mailing w as 71 p e r c en t (93 o u t of 130). Two w ere retu rn ed a s non-deliverable. O n Ja n u a ry 30, 1996 a se co n d mailing w a s s e n t to th e 35 29 |n o n -re sp o n d e n ts, consisting of a cover letter, survey and sta m p e d self-a d d resse d return ^en v elo pe. O ne w a s retum ed a s non-deliverable. T he se c o n d mailing produced thirteen m m ore re sp o n se s, giving a total retum rate of 81.5 p e r cen t (106 out of 130). R e sp o n se i b y CDHBC district is show n in T able 1. i Table 1 w 1 N um ber of R e so o n d e n ts bv CDHBC District 1 CDHBC 1 District Total N um ber of Dental Hygienists 1 Northwest 38 29 76.3% 1 P e a c e River 12 10 83.0% 1 Prince G eorge -80 -67 83.7% I 130 106 81.5% Total Frequency of R e sp o n se s P e r cen t R e sp o n se W hile developing th e questionnaire, it w a s determ ined th a t it would b e helpful to I have a m ethod of identifying th e district th e resp o n d en t w as from without infringing upon I I anonymity. Asking re sp o n d en ts to indicate their com m unity or town would have jeo p ard ized th e prom ise of anonym ity a s there a re a num ber of northem com m unities with only a few dental hygienists. Although m ost resp o n d en ts would probably not know which CDHBC district they w ere in, it w as speculated th at th e y would b e ab le to identify their health unit region. Although the health units regions d o not exactly m atch th e CDHBC districts, this would perm it a n a s s e s s m e n t of re s p o n se by g eographic a re a . # # K S ee Figure 2 for a m ap of British Colum bia Health Units.) T able 2 p re s e n ts th e re s p o n s e of dental hygienists by health units. 1 ilT ab le 2 i i N um ber of R e sp o n d e n ts bv Health Units Health Unit Frequency of R e sp o n se s Per cent R e sp o n se Northern 53 50.0 Skeena 24 22.6 P e a c e River 7 6.6 C ariboo 18 17.0 did not know _4 3.8 106 100.0 Total 30 31 Figure 2 IH ealth R egions of Interest for T h esis British C o lu m b ia Health Regions C arlboo hOO Mile H ouse ■^Williams Lake JiQ uesnel IB e lla C oola 16 S k e e n a Q ueen C harlottes Prince R upert Stew art Kitimat T errace The H azeltons Sm ithers iH oustan [17 P e a c e River iTum bler Ridge Chetwynd Dawson C reek I Fort S t Jo h n d Fort N elson HfALIH MOONS l . C lK ooMw r 1. CM M lK oaiiM ir 18 N orthem Interior I M ackenzie Fort S t J a m e s B um s Lake F raser Lake V anderhoof Prince G eo rg e McBride V alem ont 4. NortiOkMMfM 5. SoMh O k m e a n C. Sou*C«Nrai 7. UpptrfnamViMmr a. CanMl fnMT V alar S. ■■iwiiiy 10. ShnonfitaMT 11.C oM C aribaM 13. CM kilV anceiw w M M d i In o rd er to e n h a n c e th e re s p o n se rate, a sta te m e n t of e n d o rse m e n t o f th e stu d y w as I so u g h t from BCDHA. An article ab o u t th e study w a s also subm itted to OUTLOOK, th e i quarterly publication of th e British Colum bia Dental Hygienists A ssociation. T h e article 0 1 I w a s subm itted in tim e for th e W inter publication which w as sch ed u led for a m id-January re le a s e . T he article w as a c c e p te d for th e W inter issu e and a sta te m e n t of e n d o rs e m e n t w a s given by th e Executive Council of BCDHA an d included with th e article. T h e im pact of th e article in th e OUTLOOK W inter issu e on th e re s p o n se ra te is not known. D ata A nalvsis T h e Statistical P a c k ag e for th e Social S c ien ces (S P S S ) for W indows, version 6.1, w a s u se d for d a ta analysis. D ata analysis included th e calculation of descriptive sta tistics an d cross-tabulations. -J i ] I C h a p te r Four I T h e objectives of th e research w ere to: (a) Investigate th e information n e e d s a n d R esults I a c c e s s for dental hygienists in northem British Columbia, (b) learn how th ey a c c e s s e d 1 information on th e 1993 CDA fluoride guidelines, (c) determ ine th e re s p o n se of th is i group to th e 1993 CDA fluoride guidelines, (d) explore if th ere w ere a n y differen ces I b etw een th e re s p o n s e s by health unit region or graduation y e ar range, an d (e) d e sc rib e I th e ch aracteristics of northem British Colum bia dental hygienists. D ental H voienists in th e North T he study population for this study co n sisted of o n e hundred an d thirty den tal hygienists in northem British Columbia. T he total resp o n se rate w as 81.5 p e rc e n t (106 o u t of 130). Of th e 106 respondents. 102 w ere fem ales (96.2%) and 4 w ere m a le s (3.8% ). T h e a g e ran g e for th e study population w as from 22 to 4 9 y ears old, with a m ea n a g e of 33 years. T ab le 3 A ge C ateg o ries of Northem British Colum bia Dental Hygienists R ange n P e r c en t 20-29 y e ars 30-39 y e ars 40-49 y e ars 35 52 19 33.0 49.1 17.9 Total 106 100.0 34 T h e ran g e of y e a rs for graduation from den tal hygiene school w a s 1966 to 1995. jTabie 4 sh o w s th e ran g e of den tal hygiene graduation y e ars for re sp o n d e n ts. Although jth e a v e ra g e a g e of th e northem dental hygienist is 33 years, in term s o f ex p erien ce, th e ■] j majority o f northem dental hygienists a re young practitioners. T able 4 sh o w s th a t o u t of ! 106 re sp o n d e n ts, 62 (58.5% ) h a v e le s s th an 5 y e a rs of practice e x p erien ce an d , ■i Ifurtherm ore, 86 (81% ) h ave le s s th an 10 y e a rs o f experience. j j I T ab le 4 ■N orthem British C olum bia D ental Hvoienists* G raduation Y ear R a n g e s From D ental H voiene School R ange n P er cent 1966-70 1971-75 1976-80 1981-85 1986-90 1991-95 4 6 4 6 24 62 3.8 5.7 3.8 5.7 22.6 58.5 106 100.0 Total For m any y e a rs th e re h a s b e e n a perceived sh o rta g e of dental hygienists in British C olum bia, especially in th e north. As of M arch 15, 1987, th e re w ere 2 4 licen sed dental hygienists in northem British C olum bia with five in th e N orthw est district, th re e in th e P e a c e River district a n d 16 in th e Prince G eo rg e district (telephone com m unication with S a ra h Banvick, Adm inistrator for CDHBC. M arch 1 8 ,1 9 9 6 ). T he last te n y e a rs h av e s e e n a rapid growth in th e n u m b er of licensed den tal hygienists in northem British C olum bia. 35 I D ental hygienists currently practising in northern British C olum bia h av e co m e from a I variety of program s. However, it is cle ar from T able 5 th a t th e den tal hygiene program I a t th e C ollege of N ew C aled o n ia h a s provided th e majority of d en tal hygiene ÉI practitioners, 51 (48.1% ) in northern British Colum bia. T his is followed by 13 (12.3% ) of I I th e re sp o n d e n ts from th e University of Alberta and 10 (9.4% ) from dental hygiene sch o o ls in th e United S ta te s. O ut of th e 106 resp o n d e n ts only 17 report holding d e g re e s beyond th e dental hygiene diplom a o r a sso c ia te d e g re e . O f th o se 1 7 ,1 6 I (16.8% ) h a v e a B achelors d e g re e a n d o n e (1.1% ) h a s a M asters d e g re e . T ab le 5 N orthern British Colum bia D ental Hvoienists' S chools of D ental H voiene G raduation School n Per cent C ollege of New C aledonia University of Alberta U.S. sch o o ls University of British Colum bia O ntario sch o o ls C a m o su n V an co u v er Com m unity C ollege University of M anitoba D alhousie University W ascana C a n ad ian F orces 51 13 10 7 7 5 5 4 2 1 _L 48.1 12.3 9 .4 6.6 6 .6 4 .7 4 .7 3.8 1.9 .9 106 100.0 Total A majority of th e re sp o n d e n ts, 92 (86.8% ) sta te d th at th ey w ere m em b ers of th e British Colum bia Dental H ygienists A ssociation. Fourteen (13.2% ) a re not m em b ers of th e professional association. T h e m em bership chair of BCDHA w a s co n tacted by 36 p h o n e on March 4, 1996 to enquire w hether th e se num bers correspond to Its m em b ership figures for th e North. According to BCDHA, th e p e rc e n ta g e of northern !den tal hygienists who a re m em bers is 83% . The actual BCDHA figures on n u m b ers of I d en tal hygienists in the northern com ponent vary from CDHBC sin ce th ey include a I stu d e n t m em bers. I T h e current em ploym ent situation of this study population w as 94 (88.7% ) working I a n d 1 2 (1 1 .3 % ) not em ployed. Of th e 12 not em ployed, th re e specified th a t they w ere Ii on m aternity leaves. Dental hygienists m ay be em ployed in m ore th an o n e type of I I practice settings. R e sp o n d e n ts w ere a sk e d to check all their em ploym ent settings. T ab le 6 show s th a t th e majority of respondents, 86 (81.1%), a re working in private practice. Of th o s e 86 respondents, 62 (58.5%) are working in o n e private practice office, a n d 2 4 (22.6% ) a re em ployed in two or m ore private practice offices. S ev en (6.6% ) a re em ployed in public health, nine (8.5%) in education, an d n o n e in sa le s . For th e “o th er” category, o n e reported working part-time in a hospital setting for a half d ay a w eek. T ab le 6 E m olovm ent Settings for Northem British Columbia Dental Hvoienists E m ploym ent setting n private practice public health ed u catio n s a le s o th e r n=96 86 7 9 0 1 a v e ra g e # of d ay s p e r w eek 3.24 0.27 0.26 0.00 0.01 S.D. 1.55 1.03 1.03 0.00 0.05 II 37 W hen a sk e d ab o u t b reak s in dental hygiene em ploym ent, 63 (59.4% ) reported I I having no m ajor breaks in dental hygiene em ploym ent. Twenty (18.9% ) h a v e h ad less |th a n o n e y e a r break in dental hygiene em ploym ent, 20 (18.9% ) h a v e had from o n e to #th ree y e ars break in em ploym ent. Only two (1.9%) have had a b rea k in em ploym ent for ifour to six y ears and o n e (.9%) reported a longer break. T h e s e n u m b ers would se e m I I c o n sisten t with a workforce th at h a s recently en tered th e field, e v e n though it is Î Idom inated by w om en in childbearing years. I T h e questionnaire w as d esig n ed to explore th e study population's s e n s e of i geo g rap hic and practise isolation. S o m e dental hygienists in n orthem British Colum bia m ay live a n d practise in sm aller com m unities w here th ere a re e ith e r no o r very few o th er d ental hygienists in th e a re a . Physical d istan ce from o th e r d en ta l hygienists and professional activities could lead to a s e n s e of geographic isolation. W h en a sk e d if they feel th ey a re practising in geographic isolation, 50 (53.25) dental hygienists an sw ered “no" an d 4 4 (46.8%) answ ered “y e s ”. Unlike m edical health c a re professionals, dental professionals often p ractise in solo private practice offices. Typically, th e dental office will em ploy only o n e d ental hygienist. This lack of daily com m unication with other dental hygienists while actually in th e em ploym ent setting could lead to a s e n s e o f practise isolation. W hen a sk e d if re sp o n d e n ts consider they a re in an isolated practise setting, 75 (79.8% ) a n sw e red “no" a n d 19 (20.2% ) answ ered “y e s ”. Health unit regions w ere cross-tabulated with geographic isolation a n d practise isolation re sp o n se s. T able 7 show s th a t overall th e s e n s e of g eo g rap h ic isolation is g re a te r th an th e s e n s e of p ractise isolation for dental hygienists in all th e health unit regions. T ab le 7 also show s th a t m ore dental hygienists in th e S k e e n a an d P e a c e River 38 a health unit regions ex p erien ce a s e n s e of geographic isolation co m p ared to th o s e in th e s N orthem Interior and C ariboo health unit regions. T able 7 I S e n s e of G eographic and P ractise Isolation for N orthem British Colum bia I Dental Hvoienists bv Health Unit Region I _________________________________________________________________________________________ P ra ctise Isolation Health Unit Region No Y es No Y es Northern Interior 38 10 44 4 Skeena 3 17 13 7 P e a c e River 0 6 3 3 C ariboo 9 8 13 4 Do Not Know Health Unit 0 3 2 1 T h e q uestionnaire a sk e d if oth er hygienists a re em ployed w h ere th e re sp o n d e n t works, 68 (72.3% ) resp o n d ed “y e s” an d 26 (27.7%) resp o n d e d “no”. Eighty-nine (94.7% ) reported th at th ere w ere other dental hygienists w ho p ractise in their com m unity. T he results a lso found th a t 27 (29%) re sp o n d e n ts h a v e professional d isc u ssio n s with o th er den tal hygienists on a daily b a sis, 27 (29% ) on a w eekly b a sis, 31 (33.3% ) on a monthly b a sis and 8 (8.6%) on a yearly b a sis. T h e s e findings sh o w th a t th e majority of d ental hygienists in northem British C olum bia h av e fairly regular c o n tact with o th er dental hygienists. This c o rresp o n d s with th e finding of a lower s e n s e of p ractise isolation by resp o n d en ts th an w as ex p ec te d by this investigator. 39 I T h e re sp o n d e n ts w ere a sk e d a b o u t their co m p u ter skills and com puter a c c e s s . In i term s o f skills. 4 2 (39.6% ) reported little or no co m p u ter skills, 4 4 (41%) reported u s e of I c o m p u ters for g a m e s an d entertainm ent. 64 (60.4% ) reported word p rocessin g ability, I but only 18 (17%) reported u s e of sp re ad s h e e ts , nine (8.5%) c an navigate th e Internet I i and only o n e (.9%) can program m e. T he figures for com puter a c c e s s is similar. 59 I (55.7% ) h ave a c c e s s to a com puter with a fax m odem , 37 (34.9% ) to a CD-Rom. 30 Î I (28.3% ) h ave a c c e s s to a n e-mail account. 26 (24.5% ) to th e Intem et and 37 (34.9% ) I report no a c c e s s to any o f th e above. 1 ! S um m ary T h e dental hygiene workforce in northem British Colum bia is dom inated by fem ales in their tw enties an d thirties. T he workforce is a lso young in term s of work ex p erien ce with 58.5% having g rad u ated within th e last five years. T he primary form of em ploym ent for dental hygienists in th e north is in private practice. Presently, th e re is a high em ploym ent rate of registered dental hygienists. A large proportion of d ental hygienists in northem British Columbia belong to th e professional association on a voluntary b asis. T h ere is a significant s e n s e of geographic isolation for dental hygienists in th e S k e e n a and P e a c e River geographic a re a s . Dental hygienists in north em British C olum bia do not exhibit a d v an c ed com puter skills. T he majority a lso lack a c c e s s to co m p u ter services such a s e-m ail an d th e Intem et which inhibits their ability to a c c e s s current information. Inform ation S eeking P a tte m s This section of th e questionnaire w as d esig n ed to investigate th e information seek in g m eth o d s an d information n e e d s of th e study population. T he first three q u e stio n s listed 40 various information so u rc es with a d e g re e of u s e scale. A Likert-type rating sc a le I a s s e s s e d th e ran g e of u se from 1 fdailv) to 6 (never u se d ). i I T ab le 8 show s th at th e m ost frequently u sed information so u rc e in this section by I d en tal hygienists w a s discussion with colleagues on a daily or weekly b asis. This would t co rresp o n d with th e earlier finding th at th ere is often m ore th an o n e dental hygienist in II an em ploym ent setting. Thirty-five (33%) indicated they participate in a literature review I stu d y club on a monthly basis. This co rresp o n d s with th e num ber of m em b ers in th e I literature review study club b a se d in Prince G eorge. T he o th er information so u rc e s ; listed in T able 8 a re primarily u sed on an occasional or n ev er basis. T ab le 9 show s th e utilization of printed information so u rc e s by northem British C olum bia dental hygienists. R esp o n d en ts reported journal articles a re u se d m o st frequently. However, th e journal articles th a t a re read m ust b e from personally su b scrib ed jo u m als or other so u rc es th at a re readily available, a s th e Dental Index to th e Literature and other health care literature indices a re seldom u sed . Fifty-three (53% ) indicated they never u se the Dental Index to th e Literature and 76 (75.3% ) have n e v er u se d any o th er indices to th e literature. Mailings from th e professional asso c iatio n and licensing bodies are a well utilized information so u rc e on a monthly or o ccasio n al b asis. This would correspond with th e fact th at m ost of th e s e mailings a re on a m onthly or quarterly basis. I I 41 [Table 8 i N orthem British Colum bia Dental H ygienists' Utilization of Information S o u rc e s 1 1 1 3 ^Information ISources F reauency Daily W eekly Monthly O ccasion (4) (3) (2) (1) N ever (5) % % % % % X 27.4 34.0 21.7 17.0 0.0 2.3 0.0 0.0 12.7 86.3 1.0 3.88 P rofessional m eetin g s or conventions (n=106) 0.0 0.0 11.3 84.0 4.7 3.93 D iscu ssions with s a le s rep re se n ta tiv e s (n=106) 0.0 0.9 13.2 49.1 36.8 4.2 C o n tact with hygiene program (n=106) 3.8 3.8 3.8 47 .2 41.5 4.2 Literature review stu d y club (n=106) 0.0 0.0 33.0 13.2 53.8 4.21 E ducational video pro g ram s (n=106) 0.0 0.0 1.9 63.2 34.9 4 .3 3 Clinical C E c o u rs e s (n=105) 0.0 0.0 1.0 52.4 46.7 4 .4 6 Clinical Study Club (n=105) 0.0 0.0 0.0 14.3 85.7 4 .8 6 [D iscussion with icolleagues j(n=106) 1 CE lecture c o u rs e s (n=102) 42 "able 9 8 F reouencv 1Printed pInformation Daily W eekly Monthly O ccasion N ever (2) (3) (4) (5) (1) IS o u rc e s % % % % % X 1.9 6 .7 48.6 39.0 3.8 3.4 0.9 1.9 54.7 41.5 0.9 3.4 0.9 0.9 42.5 54.7 0.9 3.5 2.8 7.5 30.2 52.8 6.6 3.5 0.0 3.8 23.1 66.3 6.7 3.8 0.0 1.9 24.0 49.0 25.0 4.0 0.0 0.0 11.0 36.0 53.0 4.42 0.0 0.0 5.0 19.8 75.2 4.70 1 1Jo u rn al articles f(n=106) IMailings from professional Ia sso c iatio n 1(0=106) q 1Mailings from \ licen se body 1(0=106) •1) 1T extbooks ^(n=106) P ro d u ct literature (0=104) 1R e se a rc h a b stra c t se rv ice s (n=104) D ental Index to Literature (0=100) O th e r Indices (0=101) O f particular in terest is th e very low u s a g e of electronic o r com p u ter information se rv ic e s by den tal hygienists. T able 10 indicates th a t while a few h av e utilized e-mail, th e v a st majority of resp o n d en ts indicated th ey h av e n ever a c c e s s e d th e Intem et, 43 Medline or CINAHL by CD-Rom, or Grateful Med o r Carl U ncover for Information or recen t literature. P T able 10 i S o u rc es I Freouencv 1 1Electronic 1Information S o u rces Daily W eekly Monthly O ccasion Never (1) (2) (3) (4) (5) % % % % % X j E-mail j(n=106) 3.8 3.8 0.9 9.4 82.1 4.6 i Intem et i(n=105) 0.0 0.0 1.0 5.7 93.3 4.92 1M edline 0.0 0.0 0.0 1.0 99.0 4.99 CINAHL 1(0=105) 0.0 0.0 0.0 1.0 99.0 4.99 Grateful Med (0=105) 0.0 0.0 0.0 0.0 100.0 5.0 Carl U ncover (0=105) 0.0 0.0 0.0 0.0 100.0 5.0 ](n=105) T h e study population w a s then ask ed to indicate th e helpfulness of th e various information so u rc e s in keeping up to d a te in dental hygiene practice. T h e s e q u estio n s w ere also of a Likert-type design with a scale of 1 fven/ helofuh to 5 (not helpful) and 6 (never u se d ). Interestingly, th e totals in th e “never used" category of th e helpfulness 44 questions did not m atch th e totals of th e “n ev er used" category in q u e stio n s on th e utilization of information so u rces. W hen answ ering this section, re sp o n d e n ts m ay have never u se d a m ethod but still thought th at it could b e a helpful so u rc e o f information. The “n ev er used" category w as dropped for d a ta analysis of th e s e q u estio n s. T able 11 indicates that, overall, professional m eetings, d isc u ssio n s with colleagues, and continuing education lecture c o u rs e s a re perceived a s th e m o st helpful information so u rces. D iscussions with sa le s rep resen tativ es a re considered to b e th e le a s t helpful a information so u rce. T able 12 indicates th a t reading journal articles a re perceived a s the m o st helpful information source. T h e next two m ost helpful m eth o d s a re m ailings I from th e professional asso ciatio n s an d licensing bodies. R eading product literature is considered to b e the lea st helpful in keeping up to d a te in dental hygiene practise. With re s p e c t to the helpfulness of electronic or com puter information so u rc e s, th e vast majority of resp o n d en ts indicated they had never u se d th e s e m eth o d s. O ut of 105 re sp o n se s, 89 (84.4%) had never u se d e-mail. O ut of 104 re sp o n se s, 94 (90.4% ) had never u sed dental co n feren ces on th e Intem et, 101 (97.1%) have n e v e r u se d th e CD-Rom versions of Medline or CINAHL and 102 (98.1% ) h a v e n e v er u se d Grateful Med or Carl Uncover. T hose that had tried e-mail are divided on how helpful th ey consider I it a s an information source. T he few th at had tried o th er m eth o d s d o c o n sid er th em to b e helpful. 45 tra b le 11 iN orthem British Colum bia Dental Hygienists* Ranking of H elpfulness of In fo rm ation S o u rc es D ecree of H elofulness Very Helpful (1) Helpful (2) % % % % % X 57.3 26.2 10.7 5.8 0.0 1.7 48.6 31.4 16.2 3.8 0.0 1.8 |C E lecture c o u rse s [ (n=100) 43.0 4 8 .0 8.0 1.0 0.0 1.7 ]CE clinical c o u rse s (n=62) 51.6 33.9 8.1 6.5 0.0 1.7 Literature review ; study club (n=64) 39.1 20.3 23.4 12.5 4.7 2.2 C o n tact with jhygiene program j (n=74) 29.7 28.4 20.3 14.9 6.8 2.4 j E ducational videos 1(n=75) 14.7 36.0 28.0 18.7 2.7 2.6 Clinical study club (n=35) 31.4 28.6 5.7 28.6 5.7 2.5 1.3 7.5 38.8 42.5 10.0 3.5 ^Information IS o u rce ip ro fessio n al m eetings i(n = 1 0 3 ) |D isc u ssio n s with Ico lleag ues |(n=105) D iscu ssions with s a le s rep s (n=80) Little Not Neutral Help Helpful (3 ) (4 ) (5 ) 46 ^able 12 ^Northern British Colum bia D ental Hvoienists' Ranking of H elpfulness o f Printed in fo rm ation and Electronic S o u rc e s in fo rm a tio n iiso u rc e s D egree of H elpfulness Very Little Helpful Helpful Neutral Help (2) (3) (4) (1) Not Helpful (5) % % % % % X 39.2 43.1 16.7 1.0 0.0 1.9 37.9 39.8 17.5 4.9 0.0 1.9 ^License body m ailings |(n = 1 0 4 ) 36.5 39.4 18.3 5.8 0.0 1.9 ire x tb o o k s ^ (0=96) 33.3 30.2 24.0 11.5 1.0 2.2 R e se a rc h ab stract Services (0=78) 32.1 39.7 20.5 7.7 0.0 2.0 Dental Index to Literature (0=54) 25.9 20.4 35.2 13.0 5.6 2.5 12.9 23.8 33.7 26.7 3.0 2.8 20.5 20.5 36.4 15.9 6.8 2.7 18.8 37.6 12.5 18.8 12.5 2.7 10.0 30.0 30.0 30.0 0.0 2.8 Journal articles |(n=102) Professional association tailings |(n = 1 0 3 ) I (^Product literature 1 (0 = 101) I O ther Indices (0=44) i E-mail (0=16) ID ental co n feren ces Ion Internet (0= 10) 47 In o rd er to determ ine w hat might b e useful information so u rc e s for this study population, it w a s n e c e ssa ry to identify perceived barriers to a c c essin g information. A Likert-type design q uestion allowed resp o n d en ts to rate various barriers from 1 fhioh) to 5 (low). As show n in T able 13, the top th ree barriers identified w ere geographic isolation, lack of electronic information so u rces, and co sts. Lack of joum als an d lack of a c c e s s to library services w ere generally considered to b e low barriers to a ccessin g information. R e sp o n d e n ts w ere a sk e d to indicate how the professional association, th e licensing body an d educational institutions should allocate reso u rce s to improve a c c e s s to information. R e sp o n d e n ts could check m ore than o n e answ er. T he th ree m o st com m only preferred m eth o d s w ere: supply p a ck a g es of referen ces and journal articles, supply resea rch a b strac ts, and offer continuing education c o u rs e s on how to a c c e s s information. T h e form ation of a n e-mail study club or discussion groups w ere least preferred. T h o se th a t c h eck ed th e other category indicated th a t they w anted m ore continuing ed ucation c o u rs e s brought to their a rea. T he ch o ices indicate in T able 14 reflect th e g en eral lack of com puter skills by th e study population. 48 T able 13 N orthem British Colum bia D ental Hygienists* R anking o f Barriers to Information A c cess Potential Barrier Very High (1) P erceotion of Barrier High M edium Low (2) (3) (4) Very Low (5) % % % % % X 37.1 21.9 2 2 .9 5.7 12.4 2.3 39.4 16.3 13.5 9.6 21.2 2.6 C o sts (0=104) 19.2 30.8 2 6 .0 14.4 9.6 2.6 Tim e (0=105) 18.1 24.8 2 9 .5 18.1 9.5 2.8 S h o rta g e of CE c o u rs e s (0=104) 24.0 17.3 33.7 13.5 11.5 2.7 Lack of stu d y club (0=104) 27.9 8.7 12.5 7.7 43 .3 3.3 Lack of c o m p u ter skills (0=105) 22.9 10.5 25.7 11.4 29.5 3.1 Lack of library serv ices (0=105) 20.0 12.4 19.0 8.6 4 0 .0 3.4 Practice Isolation (n=99) 15.2 13.1 32.3 9.1 30.3 3.3 9.5 13.3 31.4 21.9 2 3 .8 3.4 Lack a c c e s s journal articles (0=105) 10.5 4.8 21 .9 16.2 4 6 .7 3.8 O th er barriers (n=9) 33.3 11.1 22.2 11.1 22.2 2.8 G eographic Isolation (0=105) Lack electronic Information so u rc e s (n=104) Lack of re se a rc h an aly sis skills (n=105) 49 T able 14 Information M ethods th at Northem British C olum bia D ental H ygienists W ould Prefer to H ave D eveloped Method n Supply p a c k a g e s of referen ces an d journal articles Supply re s e a rc h a b stra c ts CE on how to a c c e s s information CE c o u rs e s by teleco n feren ce CE on c o m p u ter skills Form ation of DH H om e P a g e on th e Intem et Form ation of e-m ail Informal d isc u ssio n group Form ation of e-m ail study club O ther 94 60 52 50 47 39 29 26 11 W hen a s k e d to m ak e a num ber o n e choice from all of th e above, th e re sp o n d e n ts Ifl ag ain indicated their p reference of supplying p a c k a g e s of referen ces an d journal articles % on a topic. C ontinuing education c o u rse s on c o m p u ter skills and continuing e d u catio n c o u rs e s by telec o n fere n ce w ere th e se c o n d a n d third c h o ices in th a t order. T h e last two q u e stio n s in this section w ere o p e n -e n d e d which g a v e re sp o n d e n ts an opportunity to c o m m en t on a c c essin g information a n d on th e m andatory continuing ed u catio n sy stem for dental hygiene re-licensure in British Columbia. Sixty-nine re s p o n d e n ts m a d e co m m en ts to either o n e or both of th e s e o p en -e n d ed q u estio n s. T h ere w a s overlap in th e com m ents m a d e to both q u estio n s. O ne rea so n for th e overlap could b e th e o rd er of physical a p p e a ra n c e of th e questions. T he q u estio n asking for c o m m en ts on a c c essin g information w a s a t th e bottom of p a g e nine. 50 R e sp o n d e n ts m ay h ave an sw ered before turning th e p a g e an d seeing th e next question I I specifically on continuing education. A nother factor could b e th at dental p erso n n el a re % so ingrained to perceiving continuing education c o u rse s a s their primary m ethod of a ccessin g information th at they m ay not b e able to s e p a ra te the two c o n cep ts. T he re s p o n se s to th e s e two q u estio n s w ere collapsed and exam ined for th e m e s. T he th e m e s th a t e m erg ed from th e re sp o n se s a re d isc u sse d in C hapter Five. Sum m ary Overall, th e results indicate th a t dental hygienists in northem British Colum bia a re I utilizing traditional information so u rces. T he m ost frequently utilized m eth o d s to obtain a H Information are: d iscu ssio n s with colleagues, reading journal articles, a n d reading m ailings from th e professional association an d licensing bodies. Information so u rc e s I u sed on an o ccasional b a sis for this group include a tte n d a n c e at professional m eetings, 1 continuing education co u rses, reading textbooks, and product literature. T he least utilized information so u rc e s a re th e indices to literature and electronic information so u rc e s. N orthem dental hygienists consider professional m eetings, d iscu ssio n s with co lleagues, continuing education courses, joum al articles, and mailings from th e professional asso ciatio n and licensing body the m ost helpful so u rces of information. G eographic isolation and lack of a c c e s s to electronic information so u rc e s a re I co n sid ered to b e th e m ajor barriers to information a c c e s s . Lack of a c c e s s to joum al I articles is th e low est barrier to information a c c e s s . Dental hygienists in northem British I C olum bia would like to have several information so u rc e s further developed with I information supplied by referen ce lists and p a c k a g e s of joum al articles a s their first choice. 51 ^ R esD onse to th e 1993 COA Fluoride G uidelines w '— 0 T he first question in this section w a s a multi-item listing of possible w ays to h av e learned a b o u t th e 1993 CDA Fluoride G uidelines. R esp o n d e n ts w ere a sk e d to c h e c k all a0 M m ethods th at applied and several indicated m ore than one so u rce of learning a b o u t th e guidelines. T here w a s also th e option of checking th at they w ere unaw are o f th e guidelines. Five out of 106 resp o n d en ts (4.7% ) indicated th a t they w ere u n a w are o f th e guidelines. T h ree of th e s e five resp o n d en ts a sk e d th e author of this stu d y to s e n d th e guidelines to them . T able 15 show s th e m o st frequently c h eck ed c ateg o ries w ere leam ed from CE c o u rses, from reading journals, from mailings, d isc u ssio n s with 1 colleagues, an d leam ed while in dental hygiene program , in th a t order. Table 15 Northem British Colum bia D ental Hvoienists* M ethods of Learning a b o u t th e 1993 CDA Fluoride G uidelines 1 M ethods of learning 1 CE C o u rse s 1 R eading Jo u m a ls 1 Mailings 1 D iscussions with co lleagues 1 Dental Hygiene program ;j Em ployer j O ther so u rc e s ] U naw are of 1993 guidelines 1 S a le s rep resen tativ es 1 D ental co n feren ce on Intem et n 48 48 44 42 41 24 6 5 1 1 N=106 If resp o n d e n ts checked mailings, they w ere a sk e d to identify w here th e mailing c a m e from. This could b e a difficult question to a n sw e r a s th e m ailings w ere s e n t approxim ately th re e y e ars ago. Two (1.9% ) did not identify th e source, two (1.9% ) said 52 they c a m e from th e Ministry of Health, an d four (3.8% ) sta te d th e m ailings c a m e from th e C a n ad ian Dental A ssociation. Fifteen (14.2% ) indicated th a t th e mailing w a s from the C a n ad ian Dental Hygienists A ssociation. Tw enty-one (19.8% ) indicated th a t th e m ailings c a m e from th e C ollege of Dental S u rg eo n s of British C olum bia. At th a t tim e th e CDSBC w as th e licensing body of dental hygienists but did not s e n d a direct mailing to d en tal hygienists. CDSBC w a s relying on th e d en tists to relay th e inform ation to th e dental hygienists an d d en tal a ss is ta n ts em ployed in their offices. Yet, only 2 4 (22.5% ) $ I ch ec k ed th a t th ey leam ed a b o u t th e guidelines from their em ployer. Five o f th e I tw enty-four resp o n d e n ts w ere em ployed in public health an d th erefo re th eir em p lo y er is I3 th e Ministry of Health. H S in ce dental hygienists m ay h av e leam ed ab o u t th e guidelines from m ultiple so u rc es. they w e re a sk e d to indicate th e m o st valuable o r beneficial so u rc e of inform ation. T able i 16 sh o w s th a t resp o n d e n ts to this question indicated th at their d en tal hygiene program , I continuing education c o u rses, an d m ailings w ere th e m ost valuable s o u rc e s of I information on th e guidelines. T h e m o st valuable so u rc e of learning a b o u t th e fluoride I I guidelines while in their dental hygiene program c o rre sp o n d s with th e earlier finding th at i 62 (58.5% ) of th e northem British Colum bia dental hygienists a re in th e g rad u atio n y e ar ran g e of 1991-1995. 53 I T able 16 IT he Most V aluable L earning S o u rc e s of T he 1993 CDA Fluoride G uidelines for Northem British C olum bia D ental Hygienists S o u rce n Dental Hygiene Program CE C o u rses Mailings D iscussions w /colleagues R eading Jo u m a ls Em ployer O ther n=89 29 21 17 8 7 6 1 T he study population w a s a sk e d how th e 1993 CDA fluoride guidelines had ch an g ed their daily practice. T ab le 17 indicates th e resp o n d en ts h av e resp o n d ed to th e guidelines with c h a n g e s in th eir clinical practice. T he majority h av e m ad e c h a n g e s in their daily practice in te rm s of d iscu ssio n s with patients, oral hygiene instructions, recom m endation of fluoride su p p lem en ts and to whom they give in-offlce fluoride treatm en ts, in th a t order. No significant differences in re s p o n s e s w ere found by either I health unit region or graduation y e a r range. 54 I T able 17 I Practice C h a n g e s Bv N orthem British Columbia Dental Hygienists a s a R esult of th e 1993 CDA Fluoride G uidelines I j A rea of P ractice Y es % No % D iscussions with patien ts on fluorides (n=97) 90.7 8.2 OHI on u s e of fluorides (n=95) 80.0 20.0 Fluoride su p p le m e n ts (n=92) 76.1 23.9 In-office fluoride application (n=92) 65.2 34.8 T h e next question a d d re s s e d c h a n g e s in opinions about fluorides a s a result of th e j guidelines c h a n g e s. T able 18 show s that, while th e majority of resp o n d en ts have ch an g e d their opinions a b o u t who should receive fluoride and concern ab o u t fluorosis, they h av e not c h an g e d their opinion about the effectiveness of fluorides or w ater fluoridation. This co rre sp o n d s with th e guidelines which recom m end c h a n g e s in who should be receiving fluorides b a se d on the underlying concern of a rising prevalence of fluorosis. However, th e 1993 CDA guidelines reaffirm th e effectiveness an d continued u s e of w ater fluoridation for caries reduction. No significant differences in re sp o n se s w ere found by either health unit region or graduation y e ar range. 55 & T able 18 Opinion C h a n g e s A bout Fluorides bv N orthem British C olum bia D ental Hvoienists a s a R esult of th e 1993 CDA Fluoride G uidelines Opinion Y es % No % W ho Should R eceive Fluoride (n=104) 85.6 14.4 C oncern a b o u t Fluorosis (n=101) 71.3 28.7 E ffectiveness of Fluorides (n=97) 18.6 81.4 W ate r Fluoridation (n=97) 10.3 89.7 T he 1993 CDA fluoride guidelines h a v e not b e e n ad o p te d a c ro ss C a n a d a . A s d escrib ed in C h a p te r O ne, th e guidelines h av e not p ro g resse d through Health C a n a d a a n d th e C a n ad ian Paediatric Society still follows th e older guidelines w hen prescribing I fluoride su p p le m e n ts. Two of th e q u e stio n s looked for dental hygienists" know ledge in I this a re a . W hen a sk e d if th e Health C a n a d a h a s a c c e p te d th e guidelines, 80 (75.5% ) I indicated th a t th ey did not know, 19 (17.9% ) said ""yes" and six (5.7% ) said “no ” Î (N=106). W hen a sk e d if th e C anadian P aediatric Society h a s a c c e p te d th e guidelines. i 90 (84.9% ) did not know, six (5.7%) said “y e s ” a n d nine (8.5% ) said “no ” (N=106). S in ce th e C a n ad ian Paediatric Society is still following th e o ld er fluoride su p p le m e n t d o s a g e sc h ed u le , this is a n a re a of potential confusion for patients. T he g en eral public i 56 m ay receive conflicting information from their m edical d octor an d den tal offlce on th e reco m m en d ed d o s a g e of fluoride supplem ents. It is a c h allen g e for dental professionals to rem ain current in th e reco m m en d ed I I u s a g e of fluoride sin c e fluorides com e in m any form s an d th e know ledge b a s e I co n tin u es to c h a n g e . T he resp o n d en ts w ere a sk e d in w hat a r e a s o f fluoride they I n e e d e d m ore information and they could ch eck m ore th an o n e a re a . T h e th re e m o st I frequently c h eck ed a re a s w ere fluoride su p p lem en ts, fluoride safety, an d se lf applied I fluorides. T he resu lts in T able 19 give guidance to th e d evelopm ent of future continuing I ed u cation c o u rse s. i s T able 19 N orthern British C olum bia Dental Hvoienists' N eed for More Information on Fluorides i N eed m ore information n Fluoride su p p le m e n ts Fluoride safety S elf applied fluorides Fluorosis T y pes of fluoride E ffectiveness of fluoride In office fluorides W ater fluoridation O ther N=106 46 37 36 32 30 30 28 17 8 T h e stu d y population w a s a sk ed how often they receive q u e stio n s from p atien ts I I a b o u t fluorides an d w hat c o n ce m s patients e x p re ss regarding fluorides. Interestingly, I 83 (79.8% ) of th e re sp o n d en ts are a sk ed a b o u t fluorides by patien ts le s s th an th ree tim es a w eek. S e v e n te e n (16.3%) a re a sk e d four to six tim es a w eek a n d only four 57 m (3.8%) are a sk ed sev en to nine tim es a w eek (n=104). Patients who do a s k q u estio n s I are concerned a b o u t th e topics listed in T able 20. 0 T able 20 S P atient C o n cem s ab o u t Fluorides As R eported bv Northem British Colum bia Dental Hvoienists P atient C o n cem s Fluoride Safety Fluoride E ffectiveness Fluoride S upplem ents Fluorosis W ater Fluoridation T ypes of Fluorides O ther c o n ce m s n=104 n 82 66 59 56 45 13 9 T he last question in this section of the survey w as a n open -en d ed opportunity for resp o n d en ts to m ake com m ents regarding th e 1993 CDA fluoride guidelines an d their effect on clinical practice. A low re sp o n se to this question w a s exp ected . N evertheless, 35 resp o n d en ts took th e opportunity to com m ent. R e sp o n se s covered a broad ran g e of id eas and c o n c e m s th a t a re d isc u sse d in C hapter Five. Sum m ary W hile th ere a re c o n ce m s and q uestions about th e 1993 CDA fluoride guidelines, th e guidelines have had an im pact on the clinical practice and opinions of d en tal hygienists in northem British Columbia. T he c h an g e s in practice and opinions se e m to correspond with th e m ajor c h a n g e s in th e 1993 CDA guidelines on fluoride su p p le m e n ts and who should b e receiving fluorides. However, th ere is still a need for m ore information 58 regarding fluorides to b e directly d issem inated to dental hygienists in north em British Columbia. According to th e resp o n d en ts, patients in northem British C olum bia do not se e m to be overly c o n ce m e d ab o u t fluoride. However, it is im portant th a t d en tal hygienists a re able to accurately a d d re ss th e patient c o n c e m s an d q u e stio n s th a t d o occur. T he majority of dental hygienists in northem British Colum bia a re not a w are of th e re s p o n se of other organizations to th e 1993 CDA fluoride guidelines. T herefore, they a re not aw are of th e potential for conflicting information to b e given to th e g en eral public. I 59 C h a p te r Five D iscussion and implications T he p u rp o se of this rese a rc h w a s to determ ine th e information n e e d s an d inform ation-seeking m eth o d s of dental hygienists in northem British C olum bia. T he 1993 CDA fluoride guidelines offered a n opportunity to d eterm ine how a group of health professionals, specifically dental hygienists, obtained and incorporated revised information into practice. T h e results of this exploratory stu d y sh o w th a t th e majority of re sp o n d en ts hav e obtained th e information and incorporated it into their clinical practice. However, th e findings reveal th at this group h a s difficulties with a c c e ss in g information and h a s m any q u estio n s a b o u t fluorides a n d th e 1993 CDA fluoride guidelines. E xplanations for th e findings a re offered. Dental H voienists in th e North T he rec en t growth in th e nu m b er of dental hygienists in northem British C olum bia a p p e a rs to b e eliminating th e perceived historical sh o rtag e of th e profession in this region. In 1987 th ere w ere 2 4 licensed dental hygienists in th e northem p a rt o f British Colum bia (personal com m unication with S arah Barwick, A dm inistrator for CDHBC, March 18, 1996). As of January. 1996 th e re w ere 130 licensed dental hygienists in th e sa m e geographic a re a s (num ber supplied by CDHBC). A contributing facto r to this rapid growth is undoubtedly th e estab lish m en t of a dental hygiene program in Prince G eorge a t th e C ollege of New C aledonia (CMC). T he program sta rte d in 1987 with th e first graduating c la ss in 1989. Although, not all CMC dental hygiene g ra d u a te s h av e 60 stay ed in th e North, th e p e rc en ta g e of study resp o n d en ts w ho g rad u a ted from CMC reflects th e influence of establishing a dental hygiene program in th e North. O ther benefits to th e d evelopm ent of th e dental hygiene profession h av e occurred from th e e stab lish m en t of a den tal hygiene program in th e North. Faculty and g ra d u a te s from th e CNC den tal hygiene program have b e e n instrum ental in th e estab lish m en t of th e Northern British Colum bia D ental H ygienists Society (NBGDHS), a local co m p o n en t of th e British Colum bia Dental Hygienists A ssociation (BCDHA). G ra d u a te s of th e CNC program started a literature review stu d y club a n d faculty h av e serv ed a s m entors for th e stu d y club which is b a se d in Prince G eorge. Dental continuing education program s a re offered a t th e C ollege of N ew C aledonia m aking m ore continuing education credits acc essib le to dental hygienists in th e North. & Historically, th e majority o f d ental hygienists in northem British C olum bia felt isolated co m p ared to their counterparts in th e Lower Mainland, d u e in part to th e few n um bers of den tal hygienists in northem British Columbia. This study sh o w s th a t th e feeling of isolation is changing. Dental hygienists in th e N orthem Interior Health Unit region have little s e n s e of geographic isolation com pared to d ental hygienists in th e o th er th ree 1 health unit regions. T he growth in num bers of dental hygienists an d of professional m activities h av e probably influenced this c h an g e of attitude. Dental hygienists in th e C ariboo Health Unit h ave le ss s e n s e of geographic isolation th an th o s e in th e S k e e n a a n d P e a c e River Health Units. This m ay b e partially d u e to th e fact th a t they can tak e b e tte r ad v an tag e of th e professional opportunities in Prince G eo rg e. T he majority of dental hygienists in th e C ariboo a re only o n e to th ree hours drive from Prince G eorge. However, th o se in th e S k e e n a o r P e a c e River Health Unit regions would h ave to m ake a five to eight hour drive, o n e way, to participate in 61 professional activities in Prince G eorge. During th e winter, driving to P rince G eorge b e c o m e s m ore difficult a n d th e e x p e n s e of airfare a lso inhibits their ability to travel. M em bership in a professional association h a s m any benefits, especially a s an information so u rc e for th o se practicing in m ore rem ote locations. W hile BCDHA h a s alw ays enjoyed a relatively high voluntary m em bership, Jan u ary an d February 1996 sa w a further in cre ase in m em bership. Both th e m em bership chair an d executive director of BCDHA sp e cu la te th a t this in cre ase corresp o n d s with th e current licensing renew al cycle (personal com m unications with Nancy Sewell and Cindy Ewan, March 4, 1996). T he C ollege of D ental H ygienists of British Colum bia (CDHBC) now requires proof of m alpractice insurance a s a p art of licensure. O ne w ay of obtaining m alpractice in su ra n ce is through m em bership in th e C anadian Dental Hygienists A ssociation (CDHA) of which BCDHA is a provincial com ponent. Although CDHBC h a s no v ested in terest in prom oting m em bership in BCDHA, this se rv e s a s an illustration o f how th e req uirem ents of o n e organization c an im pact on another. Information Seeking M ethods T h e p u rp o se of this study w as to determ ine how dental hygienists in th e North a c c e s s information. T h e majority o f dental hygienists in northem British C olum bia a re re c en t g ra d u a te s with nearly 60% of resp o n d en ts having g rad u ated within th e last five y ears. R e ce n t g ra d u a te s m ay not h av e b e e n in practice long enough to ex p erien ce an d a p p re cia te th e m ajor shifts in th e dental hygiene know ledge b a s e th at h av e tak en place T herefore, th ey m ay not y et a p p re cia te th e im portance of information a c c e s s . N evertheless, a s th e workforce m atures, information a c c e s s will b e co m e a m ore im portant issue. 62 O n e of th e rese a rc h q u e stio n s of th e study w as which information so u rc e s do dental hygienists utilize an d find m o st helpful? This study found th a t presently, th e majority o f den tal hygienists in th e North d e p e n d on th e traditional m e th o d s o f information a c c e s s . D iscussions with colleagues, continuing education c o u rse s, professional m eetings, journal articles and m ailings from th e professional a sso ciatio n a n d licensing b o d ies w ere identified a s th e m o st frequently utilized and helpful information so u rc e s. T h e s e findings a re co n sisten t with th e literature reviewed (Bird & H eekin, 1994; D ee & Blazek, 1993; Gravois, 1993; L undeen, e t al., 1994). In a sim ilar stu d y on dental hygienists' information seeking a n d c o m p u ter application practices, G ravois (1993) found th a t d en tal hygienists in A laska, D elaw are and Idaho u se d journals, new sletters, CE c o u rses, a n d d isc u ssio n s with c o llea g u es m ost often for professional developm ent. S h e also found th a t this group u se d th e following so u rc e s for information: brow se joum als, books an d new sletters; a s k a colleague; a sk th e dentist; a n d CE c o u rs e s (Gravois, 1993). In th e past, continuing ed u catio n c o u rse s by te lec o n fere n ce w ere available from University of British Colum bia, how ever they w ere discontinued sev eral y e a rs ag o . A n u m b er of resp o n d e n ts su g g e ste d th a t teleco n feren ces b e reinstituted a s th ey have found them to b e helpful information so u rc es and a c c e ssib le to th o se who live in sm aller com m unities. O n e information so u rc e th a t is easily available a t a low c o s t to northem dental hygienists is not being fully utilized. T he Northem British C olum bia Literature Review S tudy Club is b a s e d in P rince G e o rg e but it is d esig n ed for d ista n c e participation. Yet, o ver half of th e re sp o n d e n ts indicated th at they had n e v er participated in th e study club. R e sp o n d e n ts to this survey sh o w a low utilization of th e Index to Dental Literature 63 a n d o th er literature indices. P a rt of th e problem m ay b e d u e to th e limited physical location of th e s e literature indices. A p a p e r copy of th e Index to D ental Literature an d CINAHL is located a t th e C ollege of New C aledonia library. M edline a n d CINAHL a re available on CD-ROM a t th e University of N orthem British C olum bia library. T he g en eral lack of a d v a n c e d co m p u ter skills could a lso contribute to th e low utilization of th e literature Indices by electronic m ea n s. A nother contributing facto r could b e a lack of familiarity with literature indices. A num ber of re sp o n d e n ts co m m en ted on th e q u estio n n aire th at th ey did not know w hat th e Index to D ental Literature, CINAHL, an d M edline w ere. This s u g g e s ts th a t dental hygienists in northem British C olum bia n eed further education an d su p p o rt on how to a c c e s s information via th e literature indices. Similar to other health c a re providers (L undeen, e t. al., 1994; Meskin, 1995; MullalyQ uijas, e t al., 1994), d en tal hygienists lag behind in their u s e of co m p u ters and electronic m eth o d s for information a c c e s s . G ravois (1993) found th a t d en tal hygienists h av e limited application of c o m p u ters for information a c c e s s su c h a s on-line literature s e a rc h e s . This study h a s show n th at while a n u m b er of d ental hygienists in th e North own o r h ave a c c e s s to c o m p u ter equipm ent and electronic information so u rc es, their c o m p u ter skills a re not very a d v an c ed . T herefore, th ey a re not a b le to ta k e full a d v a n ta g e of m odem technology for improved information a c c e s s . N everth eless, r e s p o n s e s to th e o p e n -e n d e d q u e stio n s on this survey, sh o w ed a growing recognition of th e n e ed to leam o r im prove co m p u ter skills. S everal re sp o n d e n ts com m en ted on how in cre ased com puter literacy would e n h a n c e their a c c e s s to information. S u ch skills could definitely help o v erco m e geographic isolation. S everal re s p o n d e n ts su g g e ste d th a t th e CDHBC should c o n sid e r allowing continuing educatio n cred its for taking co m p u ter c o u rs e s an d o th e r non-dental topics on a limited b a sis. Presently, th e 64 CDHBC will only co n sid er topics directly related to th e practice of dental hygiene for continuing ed ucation points (R egistrant’s Handbook, 1995). Two q u e stio n s g av e th e resp o n d en ts a n opportunity to com m ent on information a c c e s s an d th e m andatory continuing education system for dental hygienists in British C olum bia. W hile th ere is general a c c e p ta n c e and approval of m andatory continuing ed ucatio n for d en tal hygiene re-licensure, northem dental hygienists, especially th o se o u tsid e of th e City of Prince G eorge, e x p re ssed the view th a t they a re at a definite d isa d v a n ta g e d u e to th e c o st of travel, tim e off work, child-care while out of town, an d th e low availability an d variety of co u rses. T h e se item s w ere identified a s high to m edium barriers to information a c c e s s . S o m e resp o n d en ts felt th at hygienists in m ore "rem ote" locations should b e on a different continuing education system th an th o se in th e lower m ainland. T he general c o n s e n s u s w as that information and continuing ed u catio n should b e m ore acc essib le through a variety of m ethods a n d m edia. C o n cern s and difficulties w ere also e x p re ssed regarding the CDHBC's a p p ro ach to continuing education. Several resp o n d en ts stated th at th ere had b e e n delays in knowing if a c o u rse w a s going to b e a cc ep ted by CDHBC for CE credit and in receiving notification of their CE standing. Currently, CDHBC se n d s o n e letter a y ear to m em b ers regarding their continuing education points, the sa m e procedure th at w as followed by CDSBC w hen th ey w ere th e regulatory body of dental hygienists. Several resp o n d en ts su g g e ste d th a t CDHBC w a s being overzealous in its approach to continuing education by being too restrictive in w hat c o u rse s th ey would a cc e p t for CE credit. D ue to th e n u m b er of p h o n e calls th a t CDHBC h a s received over th e last year, th e C ollege is alread y aw are of so m e of th e s e c o n c e m s and its Quality A ssu ran ce com m ittee is reviewing an d a s s e s s in g th e m andatory continuing education system for re-licensure 65 (co m m ents of Nancy Harwood, R egistrar o f CDHBC a t NBCDHS m eeting, April 14, 1996). G eographic Isolation w as Identified a s th e primary barrier to Information a c c e s s , yet it d o e s not n e ed to b e a barrier. T here a re a num ber o f potential Information so u rc e s su ch a s th e Literature Review Study Club, education video c o u rses, literature Indices, rese a rc h literature a b stra c t services, a n d .th e Intem et th a t m any o f th e d en tal hygienists In northem British Colum bia have not utilized. T hey m ay find th e s e Information so u rc e s can help them overcom e th e barrier of geographic Isolation. T h ere Is a professional obligation to leam a b o u t th e options an d develop th e skills n e c e ssa ry to utilize various information so u rces. However, dental hygienists In th e north would ap p re cia te th e su p p o rt of BCDHA, CDHBC, and educational Institutions In th e d e v elo p m en t an d utilization of new a v e n u e s of Information a c c e s s . As Curtis e t ai. (1993) sta te d , training s e s s io n s m u st b e tailored to th e au d ien ce an d their specific n e e d s. Education an d training in th e new er m ethods of Information a c c e s s could help overcom e m any o f th e barriers Identified by respo ndents. R e sp o n se to th e 1993 CDA Fluoride G uidelines A s show n In this study, th e majority of dental hygienists In northem British Colum bia did a c c e s s Information on th e 1993 CDA fluoride guidelines. A c c e ss to this Information h a s led this group to c h a n g e their opinions ab o u t fluorides, m ak e c h a n g e s In their u s e of fluorides In practice, an d c h an g e recom m endations on fluorides to patients. Northem dental hygienists received this Information from a variety of m ethods, but m any re sp o n d e n ts Indicated th at they hav e further q uestions and points of confusion ab o u t 66 th e guidelines an d p ro p er u se of fluorides. Therefore, th e re is still a n e e d for continued dissem ination of information on fluorides and their appropriate u s e for c arie s reduction. T h e CDA 1993 fluoride guidelines sta te d th at fluorides su c h a s dietary su p p lem en ts an d in-office topical applications should b e given to individuals a t high risk for caries. Clark (1993, p. 277) acknow ledges th at " . . . difficulty a ris e s w hen attem pting to define high risk." P resently th e re is no generally a cc ep ted or a c c u ra te screen in g te s t th at predicts caries risk (Clark, 1993). Therefore, prediction of caries risk is highly d e p e n d e n t on th e know ledge and ex perience of practitioners (Clark, 1993). Several re sp o n d e n ts com m en ted th at they w ere not com fortable identifying individuals a t high risk for caries. This could b e d u e to their lack of professional e x p e rie n c e sin c e nearly 60 % of th e re sp o n d e n ts have less than five y ears ex p erien ce a s den tal hygienists, With limited experience, dental hygienists a re likely to b e m ore d e p e n d e n t on information to help them m ake decisions about fluoride reco m m en d atio n s. T his study sh o w s th a t th e information m ust b e directly d issem inated to den tal hygienists. At this tim e, continuing educatio n co u rses, journal articles and m ailings from th e professional asso ciatio n and licensing body s e e m to b e th e b e st m eth o d s to tran sm it information to dental hygienists in th e workforce. R e sp o n se s from recen t g ra d u a te s sh o w s th at dental hygiene program s h ave b e e n su ccessfu l in educating their s tu d e n ts a b o u t th e CDA 1993 fluoride guidelines. This survey h a s show n th at dental hygienists a re un aw are of th e re s p o n s e s o f o th er organizations to th e 1993 CDA fluoride guidelines. T hey a re a lso u n aw are o f th e potential for conflicting information to b e given to patien ts by different health c a re providers. By not being aw are of this conflict, dental hygienists m ay not b e a b le to resp o n d effectively to patient's questions. 67 G iven th e historical controversy regarding fluoride, th e investigator had ex p ec te d to find th a t dental hygienists received m any q u estio n s on fluoride from their p atien ts. However, th e results su g g e st th at general public concern ab o u t fluoride m ay not b e a s high a s thought by th e investigator. O n e m ust b e cautious ab o u t this conclusion for two re a s o n s . First, th e information w a s obtained through a se co n d party an d not directly from a study of th e general public. Secondly, perceptions an d c o n c e m s a b o u t fluorides of p eo p le who s e e k dental c a re could b e different th an th o se of th e g en eral public. Of th o s e p atien ts w ho a sk ed q u estio n s ab o u t fluoride, safety w as th e primary issu e . T h e last question in th e section on th e 1993 CDA fluoride guidelines w a s a n o p en e n d e d opportunity for re sp o n d en ts to m ake any com m ents they would like regarding the 1993 CDA fluoride guidelines. T h e com m ents covered a broad ran g e of id e a s an d c o n c e m s. S everal th e m e s em erg ed in th e com m ents recorded for this q u estio n . First, so m e re sp o n d e n ts w ere c o n cem ed th a t not all dental personnel, including dentists, d en tal hygienists and dental a ssista n ts w ere familiar with th e CDA 1993 fluoride guidelines. This perception is reinforced by th e fact th at five of th e re sp o n d e n ts to this survey ch eck ed th a t they did not know about th e guidelines and a sk e d th a t a copy b e s e n t to them . Similarly it is likely th a t oth er dental hygienists and dental a ss is ta n ts m ay not know ab o u t th e guideline c h an g e s. T he CDSBC only se n t a direct mailing to d e n tists which g a v e den tists th e responsibility to sh a re th e information with th eir e m p lo y ee s. This m ethod of information dissem ination did not a p p e a r to b e very su c c e ssfu l with th e dental hygiene resp o n d en ts. It is unknown if dental a s s is ta n ts receive information on th e revised fluoride guidelines from their em ployers. T heir in d e p e n d e n t a c c e s s to information is probably le s s th an th at of dental hygienists. Yet, dental a s s is ta n ts typically apply m any of th e in-office fluorides, sin ce th ey s e e 68 th e majority of children an d te e n -a g e patients on a regular basis. Secondly, re sp o n d e n ts w ho p ractise in m ore rural a re a s and a re a s without fluoridated w ater supplies w ere co n ce m e d about th e future caries rate. A m ajor concern with th e guidelines is th a t th e reduced u se of fluoride su p p le m e n ts m ay in crease th e c aries rate in g en eral an d especially th e baby bottle c aries rate. This w as a concem from both private practise and community health dental hygienists. A possible rise in c aries ra te s a s a result of reduced u se of fluoride su p p le m e n ts w a s the arg um ent p rese n te d by Dr. Jo h n O sterm an, a comm unity health officer in th e article "MDs Call for More Study Before Endorsing D entists' New R ecom m end atio n s on Fluoride” by R efu se (1993). Thirdly, th e topic of fluorosis w a s also raised in th e com m ents. W hile several hygienists com m ented th ey now have an increased a w a re n e ss of looking for fluorosis, o th ers do not believe th e level of fluorosis is th at high. This c o rresp o n d s with Burt's (1995) co m m en ts on th e varying professional viewpoints on th e prev alen ce and im portance of fluorosis. Limitations of th e Studv T here a re limitations to th e d esig n an d findings of this study. 1. T he study population w a s limited to dental hygienists. A study of dental hygienists, den tists and dental a s s is ta n ts would have allowed com parisons of information seeking m eth o d s an d a w a re n e s s of th e 1993 CDA fluoride guidelines. 2. T here could b e a re s p o n se bias. W hile a re sp o n se rate of 81.5 % w a s obtained, th e opinions of n o n -resp o n d en ts a re unknown. T here m ay b e differences betw een resp o n d en ts an d n o n -resp o n d en ts with resp ec t to th e variables u n d e r 69 consideration. 3. W hen su b je c ts know th e y a re participating in a study, they m ay give w hat th ey think a re e x p ec te d professionally an d socially a c c ep tab le a n sw e rs. W hile a se lf adm inistered questio n n aire provides a d e g re e of anonym ity, th e findings m ay still b e influenced by social desirability factors. However, b a s e d on th e ran g e of re s p o n se s, th e a u th o r h a s a ssu m e d th a t th e re s p o n se s a re both valid an d reliable. 4. Only o n e a re a of British C olum bia w a s surveyed. W hile th e re s p o n se rate (81.5% ) allows for generalizations for th e north, o n e should b e careful a b o u t m aking g eneralizations from this study to o th er pa rts of the province o r to C a n ad a . im plications of th e Findings T h e findings of this re se a rc h h av e implications for individual m em b ers of th e dental hygiene profession, CDHBC th e licensing body. BCDHA th e professional asso ciatio n , an d ed u catio n institutions. Im plications for m em b ers of th e profession. Dental hygienists h av e a professional responsibility of lifelong learning to rem ain cu rrent in practise. T o d ay 's environm ent offers m any options to a c c e s s information for lifelong learning. However, m any d ental hygienists a re still d e p e n d e n t on th e m ore traditional information so u rc e s which will prove to be in ad eq u ate in th e future. This is esp ecially true if continuing educatio n requirem ents b e co m e m ore self-directed. Dental hygienists m u st leam to ta k e a d v a n ta g e of th e nontraditional information so u rc e s and m o d em technology for im proved information a c c e ss . T hey m u st b e willing to leam new skills and m ak e both a tim e a n d financial investm ent. Improving their co m p u ter literacy 70 would b e a n appropriate ste p in becom ing m ore self-directed in continued learning. D ental hygienists who live in rem ote locations m u st b e willing to a d d re s s th eir own information n e e d s a s th ey c an n o t b e d e p e n d e n t on o th ers to provide opportunities for th em . T h ere a re m any potential w ays for d en tal hygienists in rem ote locations to a c c e s s information: involvem ent in a study club, e-m ail discussion groups, th e Intem et, b e tte r u s e of libraries an d literature indices, a b stra c t services, and continued c o n ta c t with d en tal hygiene program s after graduation. D ental hygienists w ho do n o t leam how to a c c e s s information in to d ay 's environm ent will quickly fall behind in providing optim um c a re for patients. Given th e changing know ledge b a s e of fluorides, individual den tal hygienists m u st e n s u re th a t th ey continue to a c c e s s information on this topic to rem ain current. T h e intent of th e 1993 CDA fluoride guidelines is to continue to m aintain a low c a rie s rate, while reducing th e risk of dental fluorosis. T h ere is a n e ed to closely m onitor th e effects of th e fluoride guidelines on th e oral health of th e g en eral public. T his is an u nique opportunity for dental hygienists to participate in rese a rc h on th e effects o f th e c h a n g e s. im plications for CDHBC. D ental hygiene b e c a m e a self-regulating health occupation u n d er th e British C olum bia H ealth P ro fessio n s Act in 1995. CDHBC is th e govem ing body of d en tal hygienists u n d e r this Act with th e prim e m a n d a te of protection of th e public. CDHBC h a s a n u m b er of o th e r duties and objectives th at a re outlined in th e R eg istran ts' H andbook. T h e objective "...to estab lish a n d m aintain a continuing co m p e te n cy program to p rom ote high practice sta n d a rd s a m o n g st registrants" (R egistrants' 71 H andbook, 1995, p. 13) is of relevance to this thesis. CDHBC h a s a responsibility to su p p o rt d en tal hygienists* efforts to a c c e s s information. At this time, den tal hygienists se e m to s e e information a c c e s s and continuing ed ucation a s sim ilar concepts. T he CDHBC could help dental hygienists recognize th e differences betw een th e s e two c o n ce p ts and develop their ability to a c c e s s new er nontraditional information sources. O n e way m ay be to allow a limited n um ber of continuing educatio n credits to be obtained from non-dental topics such a s com puter co u rses. T h e CDHBC is in a position to facilitate a variety of m eth o d s by which dental hygienists can ach iev e lifelong leam ing. CDHBC should continue to monitor th e m andatory continuing education system to e n su re it is th e b e st way to e n co u rag e lifelong leam ing. T hey should look for m ethods of m easuring continuing leam ing other th an by th e num ber of continuing education co u rses taken. If a self-directed CE program is initiated, CDHBC should help facilitate dental hygienists in gaining th e skills to o p e ra te in su ch a system . CDHBC se rv e s a s a n information source. CDHBC should continue to supply information through m ailings a s this study h a s shown th at it is a well utilized m ethod of information for dental hygienists in northem British Columbia. Im plications for BCDHA. BCDHA is th e professional association of dental hygiene with a m an d ate to serv e its m em bers. O n e of th e functions of both the provincial and local com ponents of the a sso ciatio n h a s b e e n to sp o n so r continuing education program s. They can also help facilitate a variety of m ethods by which dental hygienists can obtain continuing 72 ed u catio n credits such a s supporting th e reinstitution of te lec o n fere n es. However, BCDHA should also help dental hygienists recognize th e professional im portance of . lifelong leam ing and th at inform ation-seeking is m ore th a t ju st attending continuing ed ucation co u rses. O ne m ethod could be to provide a b stra c ts of re s e a rc h articles an d refe ren c e lists on timely topics or help support dental hygienists w ho would like to develop a b u sin e ss in providing th a t type of information. BCDHA shou ld continue its su pport of study clubs an d could initiate a pilot project of an e-m ail d isc u ssio n club. BCDHA should investigate how th ey could provide information via th e Intem et. BCDHA could offer a continuing education c o u rse on how to a c c e s s information. T hey could co n sid er sponsoring th e co u rse throughout th e province an d underw rite so m e of th e c o sts, if n ecessary . T he northem com ponent, NBCDHS, should a lso ex am in e how they c a n support the northem m em bers in leam ing how to b etter a c c e s s information. . A c o u rse on fluorides would also b e timely. BCDHA se rv e s a s information so u rc e and should continue to supply information through m ailings a s this study h a s show n th at th ey a re a well utilized m eth o d of information for dental hygienists in northem British Columbia. Im plications for educational institutions. T h ere a re implications in two a re a s for educational institutions. O n e is in re s p e c t to th e curriculum for b asic den tal hygiene education an d th e o th er is providing continuing ed ucatio n for practising dental hygienists. Given th e growing and changing know ledge b a s e o f dental hygiene, th e m ost im portant skill th a t stu d e n ts can le a m to d ay is how to a c c e s s information for lifelong leam ing. Joshi an d D ouglass (1992) s u g g e s t th a t d ental curricula should d e-em p h asize factual content an d expand on information retrieval and 73 problem solving skills. C olleges with dental hygiene program s should e x am in e their curricula to e n s u re th at stu d e n ts a re familiar with; (a) b a sic com puter literacy skills, (b) electronic m eth o d s of information a c c e s s ; and (c) how to u se a library, esp ecially th e indices to literature. C om puter literacy is e ssen tial for today’s health c a re provider to help them c o p e with rapid c h a n g e s in th e know ledge b a s e . This is particularly critical for health c a re practitioners who live in m ore rem ote a re a s and practise in isolation. Currently, a c ro ss C a n a d a th ere is a wide variation in th e design an d lenght o f d en tal hygiene educational program m es. Yet, all dental hygiene curricula should b e preparing stu d e n ts for th e challenge of lifelong leam ing. T here is d e b a te on how this c a n b e s t occur. L addered program m es an d two y e ar program s already ex p erien ce lim itations on how m uch m ore can b e a d d e d to th e curriculum. T h ere a re several options th a t a re currently con sid ered to provide m ore tim e in a program m e: (a) shifting so m e co m p o n e n ts of th e program m e to prerequisites, (b) an additional se m e ste r, o r (c) a c h a n g e in th e mix of didactic and clinical hours with le s s e m p h a sis on clinical training. T h e dental hygiene program m e a t th e C ollege of New C aledonia h a s recently m oved th e an ato m y an d physiology co u rse from first y ear dental hygiene to a prerequisite c o u rse for adm ission into th e program . Several possiblities a re being co n sid ered to fill th a t tim e su ch a s: (a) increased com m unications, (b) com puter literacy, a n d (c) health informatics. T h ere is a long standing d e b a te with re sp e c t to w hether dental hygienists should received a four y e a r b a cc alau re ate training which would provide g ra d u a te s with a n underpinning of b asic an d social sc ien c es, instill a b etter understanding of enquiry an d re se a rc h m ethods, an d in crease their appreciation of lifelong leam ing. A cro ss th e country dental hygiene educators, accrediation bodies, licensing bodies an d 74 p rofessional a sso ciatio n s continue to d e b a te th e issu e s surrounding th e appropriate ed cu atio n level for entry level dental hygienists. T h e findings of this research also h a s im plications for educational institutions in reg a rd s to practising dental hygienists. As co lleg es an d universities look to providing continuing education opportunities for com m unity users, they could look to th e information n e e d s of practising dental hygienists. T hey could develop group continuing ed u catio n c o u rse s or offer individual tutoring in how to a c c e s s information an d improve their co m p u ter literacy. As continuing education c o u rses a re developed, education institutions should explore other m eth o d s of offering continuing educatio n b e sid e s th e traditional lecture co u rse. If possible, continuing education c o u rs e s should also b e delivered by teleco n feren ce to a ssist dental hygienists living in sm aller cen tres. Dental hygiene program s should also m ake th em se lv e s available a s a n information so u rc e to practising dental hygienists. Libraries a t th e educational institutions should exam ine why th e re is u n d e r u s e of their se rv ices by practising dental hygienists a n d other health c are providers. Dental hygienists a re interested in leam ing how to a c c e s s nontraditional infonnation so u rces. Libraries could offer c o u rse s or individual tutoring for practising health providers in electronic information a c c e s s . T hey could develop m ethods to e n su re th a t health p ro fessio n als a re aw are of th e services th a t a re offered. A c ce ss to th e literature indices should b e “u s e r friendly” and a c c e ssib le to health professionals o utside of Prince G eo rg e. Libraries m ust continue to extend th em se lv e s beyond their physical facilities. 75 Future R e se arch 1. A replication of this study on dental hygienists’ information a c c e s s should b e co n d u cted throughout British Columbia. T here could b e similarities or differences in problem s of information a c c e s s for dental hygienists in o th er “rem o te” a re a s of British Columbia, su ch a s th e K ootenays and up p er V ancouver Island, a s well a s in th e Lower Mainland. A larger and m ore in-depth study on th e inform ation-seeking m ethods of dental hygienists would be helpful to CDHBC and/or BCDHA for th e developm ent of a strategic plan for improved information a c c e s s . 2. A stu d y of a larger population could uncover differences in inform ation-seeking m eth o d s a n d a w a re n e ss of th e 1993 CDA fluoride guidelines by other variables su c h a s y e ar of graduation, school of dental hygiene graduation, a d v an c ed education, a g e or type of practice setting. 3. T h ere should be continued follow-up re sea rch on the knowledge level an d p ractices o f dental hygienists in resp ec t to fluorides. A study of th e re sp o n se by d en tists and dental a ssista n ts to th e 1993 CDA fluoride guidelines should a lso b e conducted. 4. A stu d y of oth er health c a re providers su ch a s dentists, nurses, or physiotherapists, in northem British Colum bia could help determ ine if their information a c c e s s p a tte rn s and problem s a re similar. 5. T his study h a s show n a rapid growth in th e supply of dental hygienists in o n e a re a o f British Columbia. Are other a re a s of th e province experiencing sim ilar grow th? Further research should look a t th e n eed for n um bers of d en tal hygienists in British Columbia. This would h ave implications for educational 76 institutions an d CDHBC. C onclusion "D ental hygienists function within a constantly changing Information environm ent" (G ravois, 1993, p.3). In o rd er to b e current In th e practise o f th eir p rofessio n , d en tal h ygienists m u st know how a n d w here to acquire Information. This exploratory stu d y h a s sh o w n th a t dental hygienists In northem British C olum bia a re primarily d e p e n d e n t on traditional so u rc e s of Information. To overcom e th e geographic restrictions th a t this g ro up fa c e s for Information a c c e s s , they will n e e d to d o several things: (a) u n d erstan d their p erso n al responsibility to s e e k out a n d leam how to a c c e s s non traditional information so u rc e s, (b) b e c o m e m ore c o m p u ter literate, (c) leam to co m m u n icate with o th e r den tal hygienists via e-m ail a n d th e Intem et. and (d) b e tte r utilize th e literature indices. W hile d ental hygienists In northem British Colum bia h a v e a n Individual professional responsibility to a c c e s s Information, th ey c a n b e supported In their efforts by various o rganizations. T he implications of th e findings o f this stu d y will b e s e n t to CDHBC, BCDHA and th e Continuing Education D ep artm en t of CNC. 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Medical E ducation. 25 (31. 191-195. Joshi, A., & D ouglass, C.W . (1992). An introductory co u rse in dental com puting an d re se a rc h m ethods. Joum al of Dental Education. 56 (11), 757-761. Kot, N., & H asselback, P. (1993). Fluoride an d vitamin supplem entation in R egina children. C an ad ian Joum al of Public Health. 8 4 (2), 88-89. Kunzel, C., & Sadow sky, D. (1991). D entists' so u rc es of information ab o u t patient m edications a n d other issu e s of m edical m an ag em en t. Joum al of Dental Education. 55 (5), 322-326. Levy, S. M., (1992). A review of fluoride e x p o su re s a n d ingestion. P a p e r p resen te d a t th e C anad ian W orkshop on Fluorides, Toronto, Ont. April 9 -1 1 ,1 9 9 2 . 79 Levy, S.M., Kiritsy, M.C., & W arren, J.J . (1995). S o u rc es of fluoride intake in children. Journal of Public Health Dentistry. 55 ML 39-52. Lewis, D.W., Banting, D.W., B urgess, R.C., Ismail, A., Clark, D C., & Leake, J.L. (1994). R ecom m endations regarding total daily fluoride intake for C an ad ian s. Joum al o f th e C anadian Dental A ssociation. 60 (12). 1050-1060. L undeen, G.W ., Tenopir, C., & W erm ager, P. (1994). Information n e e d s of rural health care practitioners in Hawaii. Bulletin of th e Medical Library A ssociation. 82 (2), 197-205. M arshall, J.G . (1992). T he im pact of th e hospital library on clinical decision making: th e R o c h este r study. Bulletin of th e Medical Library A ssociation. 80 (2). 169-178. Meskin, L.H. (1995). Information, p le a se . Jo u m al of th e A m erican Dental A ssociation. 126 (May), 540.542, 544-546. Mullaly-Quijas, P., W ard. D.H.. & Woelfl. N. (1994). Using fo cu s groups to discover health professionals' information n e ed s: a regional m arketing study. Bulletin of th e Medical Library Association. 82 (3), 305-311. N ash, D A. (1994). T he life-long leam ing im perative ...e n d s an d m e a n s. Joum al of Dental Education. 58 MOL 785-790. Neidle, E. (1990). On the brink - will dental education b e ready for th e future? Journal of Dental Education. 54 (9). 564-566. Norton, L.A., & Y aeger, J.A. (1992). P ractices an d p refe ren c es for leam ing am ong C onnecticut d en tists and University of C onnecticut d ental alum ni. Jo u m al of C onnecticut S ta te Dental Association. 68. 28-31. Nourjah, P., Horowitz. A.M.. & W agener. D.K. (1994). Jo u m al of Public Health Dentistry. 54 (1). 47-54. Nowjack-Raymer, R E.. Selwitz. R.H.. Kingman. A.. & Driscoll. W .S. (1995). T he prevalence of dental fluorosis in a sch o o l-b ased program of fluoride mouthrinsing. fluoride tablets, an d both pro ced u res com bined. Jo u m al of Public Health Dentistry. 55 (3). 165-170. Pendrys, D.G. (1991). Dental fluorosis in perspective. Jo u m al of th e A m erican Dental A ssociation. 122 (Sept), 63-66. Pettengill, M M.. Gillis, D A.. & Clark. C.C. (1994). F actors encouraging and discouraging th e u s e of nursing re sea rch findings. Im age: Jo u m al of Nursing Scholarship. 26 (2). 143-147. 80 R afu se, J. (1993). MDs call for m ore stu d y before endorsing d en tists' n e w reco m m en d atio n s on fluoride. C anadian Medical A ssociation Joum al. 149 f12V 18201822. R iordan, P .J. (1993). Fluoride su p p le m e n ts in caries prevention; a literature review an d p ro p o sal for a new d o s a g e schedule. Jo u m a l o f Public Health Dentistry. 5 3 (3), 174-189. Strother. E.A., & L ancaster, D M. (1986). Information n e e d s of practicing d e n tists. Bulletin of th e Medical Library A ssociation. 74 (3), 227-230. T ietze, M.F., & Huber, J.T . (1995). Electronic information retrieval in nursing. Nursing M anagem ent. 26 (7). 36-42. Zem ik, J.M. (1994). Electronic study club on Intem et. Am erican Jo u m a l of O rthodontics a n d D entofacial O rthopedics. 106 (5), 21A-22A. 81 APPENDICES 82 A ppendix A T he C anadian Dental A ssociation 1993 Fluoride Guidelines R E P O R T O F T H E W O R K IN G G R O U P O F T H E C A N A D IA N W O R K S H O P O N T H E E V A L U A T IO N O F C U R R E N T R E C O M M E N D A T IO N S C O N C E R N IN G F L U O R ID E S P A R T IC IP A N T S Dr. David W. Banting University o f Western Ontario Ms. Lorraine Boomhour. President-Elect Canadian Dental Hygienists’ Association Dr. Jean-Marc Brodeur Ecole de médecine dentaire Université Laval Dr. Ralph C. Burgess Head. Preventive Dentistry Faculty of Dentistry University of Toronto Dr. Dan Haas Canadian Dental Association Mr. Brian Henderson Canadian Dental Association Dr. Rita Hurley Faculty o f Dentistry McGill University Dr. Amid 1. Ismail Faculty o f Dentistry Dalhousie University Dr. David W. Johnston Faculty o f Dentistry University of Western Ontario 83 Dr. Donald J. McFarlane Senior Denial Consultant Ontario Ministry of Health Dr. Alan R. Milnes Department o f Pediatric Dentistry University of Toronto Dr. Gordon Nikiforuk Faculty o f Dentistry University o f Toronto Dr. Olva Odium Faculty o f Dentistry University o f Manitoba Dr. Arthur Schwartz Canadian Dental Association Dr. Brian A. Burl Program in Dental Public Health School of Public Health The University of Michigan Dr. Daniel Kandelman Faculté de médecine dentaire Université de Montreal Dr. Ron Smith Canadian Dental Association Dr. Robert Charland Responsable. Dentisterie pediatrique Université de Montreal Dr. James L. Lcake Faculty o f Dentistry University of Toronto Dr. George K. Stookey School o f Dentistry Indiana University Dr. D. Christopher Clark Faculty of Dentistry University o f British Columbia Dr. Jack Lee Director o f Dental Services City o f Toronto Dr. Gordon W. Thompson Faculty o f Dentistry University of Alberta Dr. Colin Dawes Faculty of Dentistry University o f Manitoba Dr. Steven Levy College of Dentistry University o f Iowa Dr. Jim J. Tynan College o f Dentistry University o f Saskatchewan Dr. Neil A. Farrell. President Canadian Society of Public Health Dentists Dr. Don W. Lewis Faculty o f Dentistry University o f Toronto Dr. Jcan-Guy Vallee Community Health Department Pointe-Claire. Quebec Dr. Pierre Gagnon Pediatric dentistry Université Laval Dr. Hardy Limeback Faculty o f Dentistry University of.Toronto Dr. Malcolm F. Williamson Ministry o f Health Province of British Columbia In tro d u c tio n Canada, and the Medical Research Council of Canada. Fluoride has been proven lo be an cffccii vc and inexpensive way of preventing tooth decay, and its introduction into community water Purpose of the W orkshop supplies, toothpastes, rinses and other products has contributed to a dramatic decrease in the development o f tooth decay for all ages of The purpose o f this workshop was to determine the appropriateness people. In a continuing attempt to realize these benefits, a National o f the current recommendations made by the Canadian Dental Workshop on Fluorides was held in Toronto on April 9-11. 1992. Association concerning the concentration o f fluoride compounds, where dental public healdi and pediau’ic dcntisu'y specialists, and the amount used, and the frequency o f use for the various method­ dental scientists from across North America reviewed and evaluated ologies of fluoride administration that are currently available in current literature on the utilization of lluoridcs. The workshop was Canada. The Workshop also sought to determine whether currently sponsored by Proctor and Gamble of Canada. Health and Welfare recommended dosages need to be adjusted to ensure an optimal dosage from all sources sufficient to sustain the current level of I 84 I prevention of denial caries wiiljoni increasing die risk ol denial riiiorosis. Ueasons lor (lie Chanircs In reviewing die procedures used lor caries control wliich involve the uscof lluoridcs, die goal ofilie Workshop was to develop revised recommendations which would keep the exixisure to Huoride at the lowest possible level consistent widi caries control. This Workshop recognized the principle that concentrations o f fluoride in the materials used and die dosage regimens which were estab­ lished when fluoridation was first introduced may no longer be appropriate at present when most Canadians are exposed to fluoride from more than one source. Since dicre is now a wealth of informa­ tion available, decisions regarding the recommendations were based upon scientific or empirical evidence, or public health needs. As these considerations change in the future, further revisions will undoubtedly be needed. One of the signs that fluoride consumption has reached opti­ mum levels is thatchildrcn protected by lluoridcs may exhibit nearly undetectable dental fluorosis or mottling which is a sensitive indicator of exposure to fluoride from all sources before the child reaches the age o f six years, the most critical period being from birth to three years. When fluoride in liie drinking water was the only significant source o f fluoride, about 12% o f children exhibited the mildest forms o f dental fluorosis. Currcndy, with exposure to fluoride from other sources, such as toothpastes, dietary supple­ ments. processed foods and beverages, and drinking water, the I prevalence o f the mildest forms of dental fluorosis has increased both in fluoridated and in non-fluoridatcd communities. Although this increase pertains to mild fluorosis, there is a slight increase also in the moderate to severe forms in fluoridated communities. While current levels of fluorosis in North America do not constitute a health problem, dental fluorosis may become a public health issue in the future, and the value o f fluoride for controlling dental caries may be undermined by the public concern. Sum mary of R ecom m endations The Workshop developed a number of recommendations. The most important is a recommendation reaffirming the role of community water fluoridation as an equitable, effective and economical means of delivering fluoride to groups and individuals, especially to those who have litde or no access to other sources of fluoride or other preventive technologies. The Workshop empha­ sized that there is no evidence that fluoridation at current recom­ mended dosages represents a risk to general health. However, it was suggested that there should be periodic re-evaluation o f recom­ mended fluoride concentrations in the context o f the total potential fluoride intake. The Workshop also proposed significant changes to the current recommendations on fluoride supplements which were first intro­ duced to provide a systemic source of fluoride to infants and children living in non-fluoridated areas. While supplements can prevent dental caries, they are not very effective because compliance with the daily regimen is low, and, moreover, the children who use diem are usually from well-educated families who are also more preven­ tion oriented than tlie population at large. Tlie Workshop partici­ pants also concluded, af ter reviewing the current epidemiological studies, that fluoride supplements are associated with an increased risk of dental fluorosis. There is good evidence indicating tlia. fluoride supplements are of ten prescribed by physicians and dentists wifliout evaluating flic infant’s ingestion o f lluoride from drinking water at home and from inf ant feeding practices. Moreover, current research indicates that children, on average, consume about 30 percent of the tootlipaste that is used when they are three years old, and tills amount diminishes as they reach school age. With the increasing use o f fluoridated toothpastes by infants, a new source of systemic and topical fluoride is now available which was not widely available when die current guidelines on supplements were formu­ lated. To prevent a potential increase in moderate-to-scverc fluoro­ sis, the Workshop recommended new guidelines for the use of fluoride supplements and a new dosage schedule. The new regimen considers the critical periods during which dental fluorosis devel­ ops, especially on anterior teeth, and the increasing evidence that fluoride intake in early childhood m ay be derived from fluoridated dentifrices, foods and drinks. The proposed recommendations sug­ gest that supplements should not be prescribed for children less than three years o f age, and that they should be targeted only for individuals or groups at high risk to dental caries. The Workshop also favored reducing the fluoride concentrations tised with 3.4,and S-ycar old children from 0.5 to 0.25 mg F for children using fluoridated dentifrices. Fluoride dentifrices were endorsed as effective delivery sys­ tems, although many children under the age o f 6 tend to increase their intake of fluoride by swallowing the toothpaste. The Workshop accordingly recommended that children under the age of 6 should brush under supervision o f an adult no more than twice a day with a fluoridated ttrathpastc. Only a pea-sized amount of toothpaste should be dispensed, preferably by the supervising adult, and swallowing any toothpaste should be discouraged. The role o f professionally applied topical fluorides (solutions, gels and varnishes) was reviewed and their selective use with individual patients at risk for dental caries was endorsed. This topic was included for discussion, not because o f any evidence that professionally applied topical lluoridcs caused dental fluorosis, but because of the potential for gastric irritation from the ingestion of excessive fluoride. The Workshop, for practical reasons, recognized that a one minute application o f a professionally applied topical fluoride treatment may be appropriate given patient management considerations, however, it should be recognized that a one-minute procedure will not realize tlie same level o f benefits as a four-minute application. Finally, it was agreed that lluoridaied mouihrinscs were valu­ able in dental public health school programs for at risk groups, and use at home by individual patients who may be at moderate to highrisk to denial caries was also endorsed. 83 R c c o n in ie n d a tio iis : (îencrui consensus w;is achieved by the W orking G roup on the following statem ents: W ater Huoridation 1. Water Huoridation at recommended levels is endorsed and encouraged because: a) Water Huoridation is an cfllcacious/cflcciivc mea­ sure for preventing dental caries in all age groups. b) Water Huoridation equitably provides the greatest benefits for those who have limited access to other sources of Huoridc or other caries preventive technologies. c) At recommended doses, there is no evidence that water Huoridation presents a risk to general health. d) Water Huoridation is the preferable source o f sys­ temic and topical Huoride for prevention o f dental caries. 2. A scientific panel should be convened to review and evaluate the data concerning standards on the minimal, optimal and maxi­ mum concentrations of Huoridc in Huoridatcd communities, and the maximum allowable concentration of fluoride for naturally fluori­ dated water because of the: a) potential risk of dental Huorosis (a side effect which may or may not be an esthetic concern in the future but is not a major dental health problem at this time); b) increased exposure of the public to a variety of different sources of Huorides; c) evidence that increased exposure to Huorides has in­ creased the prevalence of Huorosis; d) impact of variations in ambient temperature and humidity, and the increased use of air-conditioning throughout Canada that need to be considered for the determination o f optimal Huoride concentrations. 3. Fluoride levels in community water supplies should be monitored and adjusted routinely to prevent wide Huciuations in Huoride concentrations. 4. Manufacturers should provide labelling on foods and bever­ ages to indicate the Huoride content of the product. 5. The Canadian Government should institute legislation re­ quiring manufacturers to provide information on tlic Huoride con­ tent of their products. 6. S tandards. e.g. milligramsof Huoride per unit volume, should be developed for reporting the Huoride conccnu-ations in products. 7. The Canadian Government should assign a senior dental officer as a spokesperson and expert to provide the official govern­ ment position, and to coordinate and help disseminate infonnation on issues relating to water Huoridation. Fluoride Supplements 1) Fluoride supplements: a) should nrg be recommended for children less than three years old; b) should be targeted only for individuals or groups at high risk to dental caries; c) should be sold in achewable or lozenge form only and as a behind-ihc-counier product; d) should noi be recommended in Huoridatcd areas; c) should be packaged with a written dosage regimen. 2) The use of Huoride supplements may be appropriate for targeted individuals and groups for children three years and older in areas with less than or equal to 0.3 ppm Huoride in the water. Evaluation of all Huoride intake from ingested Huids should be considered prior to their use. Dosage Schedule Age of Child Fluoride in Water Supply less than 0.3 ppm 3 .4 and 5 years 0.25 mg* 6 or more 1.00 mg * if there is not regular use of Huoridatcd toothpaste, then 0.5 mg is recommended 3) The estimation of the mean Huoride ingested from all fluid sources should include all home and child care water sources, and the possible impact o f water filtration devices within the home. 4) Commercial interests should be formally requested to formulate proper dosage regimens both for chewable Huoride and multivitamin supplements. Fluoride dentifrices 1. The following guidelines are proposed for children under 6 years o f age who use Huoridatcd toothpaste: a) brushing should normally be twice a day; b) brushing should be supervised by an adult; c) a pea-si/ed amount of toothpaste (or a single ribbon/strip o f dentifrice not to exceed half the length o f the head of a child-sized toothbrush) should be dispensed, pretcrably by the supervising adult; d) swallowing should bcdiscouragcd (after brushing spit out. rinse with water and spit out the rinse). 2. Tlie above guidelines should be made available to the public cither through product labelling on the package or by product inserts. 3. Product labelling or package inserts containing these guidelines should be included in the criteria for awarding the CDA Seal of 86 Rccogniiion for dentifrices containing fluoride in the I(XX) - 1 l(X) ppm range. 4. Studies to investigate the cfficacy/cffcctivencss of a iowcr-dosc fluoride dentifrice, i.e. 500 ppm, for use by children under 6 years of age should be encouraged. 5. Manufacturers should be discouraged from marketing toothpastes which, because of their taste or appeal, encourage swallowing or excessive use. Fluoride M outh rinses 1. The use. in dental public health school programs, of fluoridated mouthrinscs (currently 0.2% sodium fluoride administered weekly or biweekly) should be considered only in high-risk populations aged 6 years and over. 2. Self-applied, daily rinse programs using over-the-counter or specially-formulated fluoride mouthrinscs (0.05% sodium fluoride) should be used only in moderate to high-risk individuals who are aged 6 years and over. 6. Manufacturers should be discouraged from marketing toothpastes that have ‘extra strength’ fluoride content (i.e. greater than 1100 ppm). Professionally-applied Topical Fluorides (.solutions, gels and varnishes) 1. The selective useof professionally-applied topical fluorides (gels and varnishes) should be endorsed. The decision to use topical fluorides will be based on the assessment of caries risk of patients as determined by the dentist. 2. Scientific evidence from clinical trials indicates thaia prophylaxis prior to a professionally-applied topical fluoride application is not necessary, however, if a professional prophylaxis is performed selectively prior to the application of topical Huoride. a nonfluoridated prophylaxis paste is recommended. 3. Studies on the effectiveness of professionally-applied topical fluorides with a reduced concentration of fluoride should be pro­ moted. 4. The following procedures for the professional application of fluoride gels should be encouraged: a) Apply for 4 minutes in well-fitting trays with absor­ bent liners (custom U’ays). b) Use only a ribbon of gel in each tray, approximating 2.5 ml in each full-size tray but less in small trays for children. I c) If custom trays arc used, only 5-10 drops of gel should I be dispensed. d) Place the patient in an upright position during appli­ cation. I c) Use suction to remove excess saliva/gcl mixture j during and after the procedure. 0 Remove excess gel at the conclusion of the procc- dure. g) Instruct the patient to spit out as much of the material as possible following the removal of trays and not to rinse, eat or drink for 30 minutes after the procedure. 3. All over-the-counter fluoride mouthrinscs which are used daily (0.05% sodium Huoridc) should be labelled to indicate that they should not be used by children under the age of 6 years. 4. Manufacturers of over-the-counter fluoride mouthrinscs should be encouraged to develop alcohol-free products or products with a reduced alcohol content. Is th is f e a s ib le o r n e c e s s a ry ? 5. The Health Protection Branch of Health and Welfare Canada should reconsider its approval o f 0.2 % sodium Huoride mouthrinscs that can be purchased over-the-counter. Self-applied Fluoride Gels 1. Self-applied (tooihbrushing) Huoride gels should not be used in children under 6 years o f age and should not be routinely used by adults when regular toothpastes are used. 2. The daily use of Huoride gels in customized trays for individuals at high risk to dental caries may be appropriate. If gels are used by children under the age of 6 years, this should be done only on the direction of a dentist in order to minimize the risk of ingestion. If customized trays are used, only 5-10 drops of gel should be dis­ pensed. When customized trays can’t be used because of patient management considerations, the application of the gel with a tooth­ brush may be appropriate for high-risk individuals. This brushing should be closely supervised by an adulL 87 A ppendix B Approval of R e se a rc h from CDHBC 1 1 0 /1 8 /9 5 I ' MON 2 0 :4 7 FA I 604 363 4144 ■ ■■ CDHBC • gg . • "r C O L L E G E O F D E N T A L H Y G IE N IS T S O F B R IT IS H ■ ■ Suite 219, YnmiwBuildiaf 645 Fort Stteel C O L U M B IA Tt fcphow : (606) 383-4101 FiCiiBBilr (604) 3f?-4144 Vietovia, Britûh Cohmibia V8W1G2 October 16,1995 T o W h o m I t M a y C oocenL * T h is is t o a d v is e y o u t h a t th e B o a r d o f t h e C o lle g e o f D e n ta l o f B n tû h C o ta n b ia h a s n r ^ g p ifitif tn a p p T w v a n g t h e r d e a a e t o P a t r i c i a C o v m g t o o o f t h e a a i B C S a n d a d d i e i s c i , h a t n o t th e i n u i i h e « , o f A e r e g l s t r a u t s o f t h i a C o l l ^ e A r t h e p u r p o s e o f c o m d % K ta & g s p e c i f i c a c a d é m i e r e s e a r c h r e l a t i n g t o A e r e s p o a s e o f d e o t a l h y g i e m i s t s t o f l u o r i d e g w id c B n n s a d o p te d b y t h é C a n a d ia n D e n ta l A s s o c ia tio n m 1993, a d to h o w h y g ie m M s e e k a n d g a in h if iD im a tio n t o r e m a ia . c a r r e n t i n p r a o tio e . T h e B o a r d ’s i ^ x o v a l is c o n tin g e n t o n P a tric ia C o v m g to n c e s til^ q m g A a t t h e a rA n n rS n w t p r o v id e d t o h e r vw H n o t b e u s e d A r a y p o r p o a o & e r A a A a t a p e e iB e d . a tta d ie d . 1 tr u s t th is is s a tx s A c to ry , N a n c y H a rw o o d , D ^ D H , L L B R e g is tra r attachm at A c o p y o f t h is c e rtific a ti o n is XU/x.-''JO » v » ii «w.«f rn A . ww« 89 Cerdgcmdom of Uie of Pcnoiial Informatioii T PatrieiM raw ingeam liatiehy t h t T^ mmm Otm u t t i — —ii mÆÂwmmrmm |.piwpi I to me by the College ofDegW^ygMummfbf Aepwpo## on|y of cnodoctingtlie ipedfiad acadgmic rewMTrfi (w ayiwi» mf Ham*.: hygkmW#*m«km ky CDA'in 1993 andbowlqrgieniftsiedcflidgakBfiiaiiitioB tozenunocuncDtiopnctiGeX,Mpst ofisQTcoimnt cooise of soid^ at dw IMvenily ofNot^Bm Bridrfi Cobuflbia, aad thit I iwillaoc use die mfbnnatiaii, nor allow or caoae it to be aaad, for any pwpoae odier dun Aia acadaoie research. on ^ ^ . 1995. 90 A ppendix C C over L etter an d Q uestionnaire 91 THEUNIVERSITYOF NORTHERNBRITISHCOLUMBIA 3333 UniversityWay PrinceGeorge.B.C. Canada V2N 4Z9 Tel.:(604)960-5555 Fax:(604)960-5794 January 8, 1996 Dear Ms I am an instructor in the dental hygiene programme at the College of New Caledonia and also a graduate student in the Community Health Masters programme at the University of Northern British Columbia. My thesis topic is designed to assess how dental hygienists outside of the lower mainland access information to remain current in practice. This is always a challenge, but particularly for those of us who live in the north. I want to determine what are the preferred methods of accessing information and what other methods could be developed. I am asking you to help me with this task. I am particularly interested in the flow of information regarding fluorides. Your name and address were obtained from the College of Dental Hygienists of British Columbia by permission of the board. The survey takes approximately 3 0 minutes to complete. YOUR IN P U T 1 8 VERY VALUABLE. This information can help determine the needs of dental hygienists in northern British Columbia. Participation in this study is voluntary. All individual responses will be anonymous and kept confidential. The coding system is only for a second mailing and computer data entry. I will not have access to the master list. Recommendations based on the findings will be made to the Continuing Education Department of the College of New Caledonia, the College of Dental Hygienists of British Columbia, and the British Columbia Dental Hygienists Association as appropriate. If you have any concerns about this study or your rights as a research subject, please contact Dr. Bill Morrison, Dean of Graduate Studies at UNBC, (604) 960 5821. Your prompt response is appreciated. Please mail your completed questionnaire ON OR BEFORE JANUARY 2 4 , 1 9 9 6 . Thank you for your time and cooperation on this questionnaire. Sincerely, Patricia Covington, R.D.H., B.Sc. 2459 Lisgar Crescent Prince George, B.C. (604) 563 7430 covington@cnc.be.ca 92 C O D E # ________ SECTION A: DEMOGRAPHICS j T he following q u e stio n s a sk a b o u t your perso n al background an d experiences. This is simply to I s e e if p e o p le with different backgrounds m ight h a v e different opinions. Your a n sw e rs will b e j a n o n y m o u s a n d kept confidential. I I A1. Y e a r of birth: 19____ :] A3. A re you a m em b er of th e British Colum bia D ental Hygienists A ssociation? i I Y es (1) A4. A2. G ender: [ ] m ale (1) [ ] fem ale (2) No (2) Y e a r o f dental hygiene graduation Do not know (3) 19 S chool of dental hygiene g ra d u a tio n ______ In w h at province o r s ta te ________________ I AS. I W hat d e g re es, beyond th e dental hygiene diplom a, d o you h a v e? C heck th e h ig h est level th a t applies to you. D e g re e Y ear g rad u ated B achelor (1) 1 9 _____ M asters (2) 1 9 _____ Ph D (3) 1 9 _____ Non applicable (4) A6. H av e you had an y m ajor b reak s in continuous dental hygiene practice sin ce g rad u atio n ? E x am ples would b e tim e off for infent o r child c are, extended illness, further education, o r u n a b le to find em ploym ent a s dental hygienist. P le a s e calculate TOTAL tim e off during d e n ta l hygiene career. N one (1) L ess th an 1 y e a r (2) 1-3 y e a rs (3) 4-6 y e a rs (4) O th e r____________________________________________________________ (5) - 1 93 A7. W h at is your category of current em ploym ent? P le a s e ch eck all th a t apply. O ne private practice office Two or m ore private practice offices Public health I Education I S a le s ^ Other, p le a se explain I Not em ployed a s dental hygienist a t this tim e If not p resently em ployed a s dental hygienist p le a se skip q u e stio n s 8-13, g o directly to q uestion #14. AS. How much a re you currently working? P le a se fill in th e num ber of d a y s to all categ o ries th at apply to your em ploym ent situation. N um ber o f d ay s p e r w eek in private practice I N um ber of d ay s p er w eek in public health N um ber o f d ay s p e r w eek in education N um ber of d ay s p er w eek in s a le s N um ber of d ay s p e r w eek in other a A9. A re o th er hygienists em ployed w h ere you w ork? A10. A re th e re o th er hygienists who practice in your com m unity? Y es (1) A ll. No (2) ______ No (2) Do not know (3) W h at is th e frequency of professional d isc u ssio n s th a t you h a v e with o th er d en tal hygienists? P le a s e ch ec k one. I Y es (1) daily (1) 1-2 tim es weekly (2) 1-2 tim es monthly (3) 1-2 tim es a y e ar (4) -2- A12. D o you c o n sid e r th a t you practice in a n isolated geo g rap h ic location? j I _______ ______ Y es (1) No (2) I I A13. Do you c o n sid e r th a t you practice in a n isolated practice situation? i '% I ______ Y es (1) No (2) II A14. W h a t is your h ealth unit region? A15. N orthern H ealth Unit (1) S k e e n a H ealth Unit (2) P e a c e River H ealth Unit (3) C ariboo H ealth Unit (4) Do n o t know (5) W h at is th e level o f y o u r com puter skills? P le a s e c h e c k all th a t apply. Little o r no co m p u ter skills G a m e s a n d en tertainm ent W ord p ro cessin g S p re a d s h e e ts C an su rf in th e Internet A ble to d o ow n program m ing A6. Do you ow n o r h a v e a c c e s s to an y of the following? P le a s e c h ec k all th a t apply. C om p u ter with fax m odem CD -Rom E-mail a cc o u n t T he Internet N one of th e a b o v e -3 - 94 95 SECTION B: FLUORIDES In 1992 a n d 1993, th e C an ad ian D ental A ssociation w ent through th e p ro c e s s o f evaluating a n d c h a n g in g th e fluoride guidelines. N ew recom m endations w ere m ad e during th a t p ro c e ss. T h e information h a s b e e n dissem inated to practitioners in various w ays. T he q u e stio n s in this section d eal with d ental hygienists’ re s p o n se s to th e 1993 guidelines. T here are no right o r w rong an sw ers. It is yo u r p erso n al opinions and e x p erien ces th at a re im portant All a n sw e rs will b e an o n y m o u s an d confidential. I B1. How did you find out a b o u t th e C anadian Dental A ssociations 1993 fluoride guideline reco m m en d atio n s? P le a s e ch ec k all th a t apply. U naw are o f 1993 CDA fluoride guidelines L earned while in d en tal hygiene program Mailings from w hom ? ___________________________________________________ Em ployer Continuing ed u catio n co u rse(s) R eading journals D iscussions with co llea g u es S a le s rep re se n ta tiv e s D ental e x c h a n g e s on Internet O th er m ethod p le a s e e x p la in ___________________________________________ 82. W hich of th e a b o v e c h o ic es w a s th e m ost valuable o r beneficial s o u rc e of information. 83. P le a s e indicate w hat ch a n g e s, if any, you have m ad e in your daily p ractice d u e to th e new recom m endations. a . Y our recom m endation of fluoride su pplem ents?____ Y es (1) _ No (2) b. T o w hom you give office fluoride treatm en ts? ____ Y es (1) _ _ No (2) c. Y our oral hygiene instructions on fluoride? ____ Y es (1) No (2) d. Y our d isc u ssio n s with p a tien ts on fluoride? ____ Y es (1) e . P le a s e explain a n y o th e r c h a n g e s ____________ _ -4 - - No (2) 96 B4. Have the new recom m endations influenced your opinion ab o u t fluorides? P le a s e indicate any c h a n g e s. a. W ater fluoridation? Y es f1) No (2) b. E fffectiveness of fluorides? Y es f n No (2) c. W ho should receive fluorides? Y es f n No (2) d. C oncern o v er fluorosis? Y es f1) No (2) e. P le a s e explain an y o th e r opinion c h a n g e s on fluorides. B5. 86. Approximately how m any tim es a w eek a re you questioned about fluoride by y o u r p atien ts? P le a s e ch eck o n e only. L ess th an 3 tim es a w eek (1) 4-6 tim es a w eek (2) 7-9 tim es a w eek (3) 10 o r m ore tim es a w eek (4) W hat a re th e a re a s o f p atien t concern regarding fluoride? P le a s e ch eck all th a t apply. Fluorosis Fluoride su p p le m e n ts S afety of fluoride W ater fluoridation T ype of fluoride th ey should u se E ffectiveness o f fluoride O ther P le a s e sp e c ify ___________________________________________________ O ver th e years, different organizations h ave m ad e various recom m endations on th e d o s a g e level of fluoride sup p lem en ts that should b e prescribed. This can lead to confusion for d en tal p ersonnel an d the g eneral public. P le a s e a n sw e r questions 7 a n d 8 b a se d on your current know ledge of th e reco m m ended d o s a g e s for fluoride supplem ents. 87. H as C a n ad a Health a cc e p te d th e 1993 C anadian Dental Association guidelines for fluoride? Y es (1) ______ No (2) Do not know (3) -5 - 97 H as th e C a n ad ian P aediatric S ociety a c c e p te d th e 1993 C an ad ian D ental A ssociation fluoride su p p le m e n t guidelines? Y es (1) ______ No (2) Do not know (3) W h at a re a s of fluorides do you n eed m ore information a b o u t? P le a s e ch ec k all th a t apply. Fluorosis Fluoride su p p lem en ts S afety of fluorides W ater fluoridation T ype of fluorides E ffectiveness of fluorides In office topicals S elf applied topicals O th er P le a s e sp e c ify ____________________________________________________ BIO. A re th ere any com m ents you would like to m ak e regarding th e 1993 CDA fluoride guidelines a n d how th ey h a v e /h a v e not affected your clinical practice? 6- 98 SECTION C: INFORMATION SEEKING There are many sources of information available to today’s health practitioner. I am interested in what information sources are tieing utilized in northern British Columbia and what ones could t)e better developed. There are no right or wrong answers. It is your personal opinions and experiences that are important All answers will be anonymous and confidential. D (daily) C l. W (weekly) M (m onthly) 5 5 5 Professional meetings/conventions Discussion with colleagues Discussions with sales representatives 2 2 2 3 Contact with dental hygiene teaching institutions Literature review study clubs 2 3 2 2 3 3 3 5 3 3 5 5 2 Continuing education courses (lecture format) Continuing education courses (clinical hands on format) C3. N (n ever) Which (if any) of the following do you participate in to access information? Circle the most appropriate level for each line. M JflL Clinical study clubs Educational video programs C2. O (o cca sio n a lly ) 2 2 3 3 5 5 5 Which of the following PRINTED information sources do you use? Circle the most appropriate level for each line. 12 Stf M Q N Textbooks 2 3 5 Dental Indexes to the literature Other Indexes to literature (such as CINAHL) 2 5 5 Journal articles Research abstract services (such as Perio Reports) 2 5 5 Product literature Mailings from professional associations 2 2 3 3 3 3 3 3 Mailings from licensing body 2 3 5 2 2 5 5 Which of the following ELECTRONIC OR COMPUTER INFORMATION SERVICES do you use? Circle the most appropriate level for each line. D W M Q H e-mail dental exchanges on the internet 2 Medline (CD Rom) CINAHL (CD Rom) Grateful Med Carl Uncover 2 2 2 2 2 -7- 3 3 3 3 3 3 S 5 5 5 5 5 99 I C4. How HELPFUL is e a c h of the following information so u rc es for keeping up to d a te in dental h y g ien e? Circle th e m ost appropriate level for e a c h line. Not helpful Very Helpful Professional meetings/ conventions Discussions with colleagues Discussions with sales representatives Dental hygiene teaching institutions Literature review study clubs Clinical study clubs 2 2 2 2 2 2 Educational video programs Lecture continuing education courses 2 Clinical continuing education courses 2 Textbooks Dental Index to the literature Other Indexes to literature 2 2 I Reading journal articles 2 I Research abstract services (such as Perio Reports) Reading product literature Mailings from professional associations Mailings from licensing body 2 E-mail Dental exchanges on the Internet 2 Medline (CD Rom) CINAHL (CD Rom) Grateful Med Carl Uncover Others (write in) 2 2 2 2 2 2 2 2 2 2 2 -8- 3 3 3 3 3 3 3 3 3 5 5 5 5 5 5 5 5 5 3 3 3 3 3 3 3 3 5 5 5 5 5 5 5 5 3 3 3 3 3 3 3 5 5 5 5 5 5 5 Never used 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 100 C5 . What are the BARRIERS you ^ ce vwhen trying to access information? Circle the appropriate level of difficulty for each line. High 06. Mod Low 5 5 5 5 5 Geographic isolation Practice isolation Lack of a study club 2 2 3 3 3 Lack of computer skills 2 3 Lack of access to electronic information sources Lack of access to journals Lack of access to library services 2 2 3 3 3 Lack of research analysis skills 2 3 Shortage of continuing education courses Shortage of time Costs 2 2 3 3 5 2 3 5 Other (write in) 2 3 5 2 2 5 5 5 S In order to improve your access to information, what methods would you prefer that the professional association, licensing body and educational institutions dedicate their resources to? Please check all that apply. Continuing education courses on computer skills Continuing education courses on how to access information Continuing education courses by teleconference Formation of e-mail study club Formation of e-mail groups for informal discussions on professional issues Formation of dental hygiene home page on the Internet Supplying research abstracts Packages of references and joumal articles on current topics Please write in any other suggestions c7 . O f all th e c h o ices in question num ber 6. p le a se indicate w hat would b e y o u r #1 choice. C8. A re th e re a n y com m ents you would c a re to m ak e regarding a c c e ssin g inform ation. 9- lü l C.9 A re th e re a n y com m ents you would c a re to m a k e regarding th e required continuing ed u ca tio n sy ste m in B.C.? 010. W ould you like a sum m ary report of this stu d y ? 0 a [ ] Y es (1) [ ] No (2) THANK YOU VERY MUCH FOR TAKING THE TIME TO REPLY! THANK YOU FOR YOUR PARTICIPATION IN THE MAIL SURVEY. Would you be willing to participate in further discussion with me by telephone on these issues? This would be strictly voluntary and all discussion would be kept confidential. If so. please read and sign the consent form. I,________________________________________ would be willing to participate in further discussion on the 1993 CDA fluoride guidelines and accessing information with Patricia Covington by telephone. I realize that this is strictly voluntary and not a requirement of participation in the mail survey. I understand that if I agree to participate in a telephone discussion, that I may withdraw from that part of the study at any time. All comments made in a telephone interview will be kept strictly confidential. Signature: Telephone numt>er P le a s e fold th e com pleted questionnaire, p lace into th e stam p ed , a d d re s s e d e n v elo p e, a n d return I to P atricia Covington. -10 - 102 A ppendix D UNBC R esearch Ethics C om m ittee Certificate of Ethics Approval 103 UNBC Research Ethics Committee Certificate of Ethics Approval Name of Researcher: Patricia Covington-----------------------Title of Research Project: A Pilot Investigation of the Information. Seeking Habits of Dental Hygienists and Their Response to thfiJ922— Canadian Dental AssociatioiLFhiQride Guidelines I certify that this project was given ethics approval by the UNBC Research Ethics Committee. - Signed: Pe— of K tn irrii me# Ci mdwe S w a n 104 A ppendix E Definition of T ernis BCDHA British Colum bia D ental H ygienists A ssociation, th e provincial professional asso ciatio n th a t dental hygienists m ay belong to on a voluntary b a sis. BCDHA is a provincial co m p o n en t o f th e C anad ian D ental Hygienists A ssociation.. CDHA C an ad ian Dental H ygienists A ssociation, th e national professional a sso ciatio n th a t d en ta l hygienists m ay join. CDHBC T h e C ollege o f D ental Hygienists of British Columbia, th e licensing body of den tal hygienists in British Colum bia, which w a s e stab lish ed March 1, 1995, by th e Health Professional Council. All practising d en tal hygienists in British Colum bia m u st b e registered an d licensed by this body. CDA C a n ad ian D ental A ssociation, th e national professional associatio n th a t d en tists m ay join. CD SBC T he College of D ental S u rg e o n s of British Columbia, th e licensing body of d e n tists in British Colum bia. All practising d en tists in British Colum bia m u st b e registered an d licensed by this body. CDSBC w a s previously th e licensing body of den tal hygienists in British Colum bia. C o m p e te n c e T he ability to apply th e profession's current know ledge b a s e to patient c a re with integrity (N ash, 1994). Continuing E ducation Education beyond th e b a sic preparation required for th e profession. T h e primary goal of continuing ed ucation is th e prom otion of optim al health se rv ice s through educational activities th a t refresh, update, and ex p an d th e know ledge and c o m p e te n c e of th e den tal hygienist (Hull & Darby. 1989). Continuing ed u catio n can b e on a voluntary or m andatory b a sis. T he CDHBC required d ental hygienists to obtain 75 cred its h ours of continuing education during a th ree y e a r cycle for re-licensure. D ental Hvoiene A health service discipline involving both theory a n d practice. T h e practice of dental hygiene c a n generally b e defined a s a collaborative relationship in which th e d ental hygienists w orks with th e client, o th er health c a re professions, a n d society in general, to a ch iev e and m aintain optim al oral health a s a n integral p art of well-being (CDHA S c o p e o f Practice, 1995). D ental Hvoienist A licen sed primary oral health c a re professional who p o s s e s s e s a unique body of know ledge, distinct expertise, recognized sta n d a rd s of practice an d a C o d e o f Ethics. As integral m em b ers of th e oral health c a re system , d ental hygienists 105 provide preventive, e d u catio n al, clinical and therapeutic se rv ice s (CDHA M an ag em en t of D ental Hygiene C are, 1992). Fluorosis Histologically, th is condition is defined a s th e p re s e n c e o f a hypom ineiiized su b su rfa c e zone, lying b e n e a th a well-minerilized enam el su rfa ce lay er (Pendrys, 1991). It is a a e sth e tic condition th a t c a n range in severity from faint white streaking or flaking a p p e a ra n c e to brow n staining a n d pitting (Pendrys, 1991). Mottled e n a m e l is th e original term for this condition. It is still u se d for th e m ore se v e re c a s e s of fluorosis. Health Informatics T he com bination o f technology a nd m ethodology which m a k e s p ossib le th e c o m p u te r-a ssiste d collection, storage, processing, retrieval, distribution an d m a n a g e m e n t of inform ation (Jo n e s, e t al., 1991). Information O rganized d a ta or know ledge th at provides a b a sis for decision m aking (Gravois, 1993). Lifelong Learning Form al a n d informal study intended to m aintain c o m p e te n ce . Lifelong learning is a b a sic te n e t of professionalism (CDHA S c o p e of P ractice, 1995). NBCDHS Northern British C olum bia D ental Hygienists Society, w hich is a local co m p o n en t of BCDHA.