Development of a Needs Assessment for Low-income Seniors in Cleveland Ohio: A student-driven Interprofessional Approach.

BACKGROUND AND OBJECTIVE: Older persons with low socioeconomic status in the United States have different and unique health needs compared to younger persons. As part of a student-led, interprofessional partnership, we performed a needs assessment of community dwelling older persons with low socioeconomic status in an urban location within Ohio, USA. METHODS: Three entities participated in the needs assessment: a student-run health clinic, a Federally Qualified Health Center, and an apartment complex of the study population. Health professional students from medical, dental, nursing, social work, nutrition, and physician assistant programs led the needs assessment process. The process consisted of multiple phases, which included preliminary literature review, survey development, data collection, and analysis. The final survey was multidisciplinary, with six content areas covered in 37 items. RESULTS: One hundred nineteen survey responses were received, and multiple areas of need were identified including food insecurity, dental care access, and mental health. 93% of participants had at least one unmet health need and 39% of respondents met our classification for high need. The needs of the local study population had key differences from previously published data in more generalized populations of older community-dwelling individuals in the United States, notably lower utilization of dental care (43% vs. 66%), increased prevalence of possible food insecurity (30% vs. 17%), and increased use of age-appropriate preventive cancer screening services. CONCLUSIONS: Multiple areas of need were successfully identified through a student-led interprofessional needs assessment. Future student teams can address the identified needs, again through interprofessional collaborations. This process may have unique benefits to help build robust community-academic partnerships, while fostering interprofessional collaborative opportunities among healthcare students.

The uses of 3-dimensional printing technology in orthodontic offices in North America.

INTRODUCTION: The purpose of this study was to examine the use of orthodontic 3-dimensional (3D) printing technology in North America and to understand why orthodontists are, or are not, incorporating 3D printing technology in their practices. METHODS: A survey questionnaire was delivered on a secure online platform, RedCap (Case Western Reserve University Clinical and Translational Science Award; no. UL1TR002548). The survey consisted of 14-34 items with branching logic. The association between participant demographics and in-house 3D printing was assessed using a chi-square test of independence. RESULTS: A total of 518 responses were recorded. The highest number of responses came from respondents in the 36-45-year age group. Most of the respondents were practice owners; 46.9% had 3D printers in their office. Chi-square tests of independence were performed on the data to see which associations existed. The strongest statistical associations with using an in-house 3D printer are seen with patient load, practice type, years since residency, and orthodontist's position. CONCLUSIONS: Approximately 75% of orthodontists use 3D printing technology in some capacity in North America. Major factors that influenced orthodontists to incorporate 3D printing technology into their office were self-interest and research. Major factors that have prevented orthodontists from not incorporating 3D printing technology into their office were space for equipment/ventilation and digital workflow training deficit. Orthodontists use their 3D printers mostly to make plastic retainers from printed models. The strongest associations with using in-house 3D printers are seen in patient load, practice type, years since residency, and orthodontist position. Increasing patient load and being in private practice increases the likelihood of having a 3D printer.

Sleep disordered breathing in children seeking orthodontic care.

INTRODUCTION: Our objective was to evaluate the prevalence of high-risk factors for sleep disordered breathing (SDB) in an orthodontic population of children. SDB is a spectrum of breathing disorders ranging from primary snoring to obstructive sleep apnea. METHODS: The sample included 303 healthy children between the ages of 9 and 17. High risk of SDB was assessed using the Pediatric Sleep Questionnaire, a validated instrument that consists of 22 questions, and high risk is defined as positive answers to 33% or more of the questions answered. Sixteen randomly selected patients repeated the questionnaire 1 month after the initial survey for reliability. RESULTS: In this sample, high-risk status on the Pediatric Sleep Questionnaire was not associated with sex, age, or race. The percentage of patients who were screened as high risk was 7.3% (95% confidence interval, 4.7%-10.6%). CONCLUSIONS: The results of this study suggest that approximately 7% of adolescent orthodontic patients may be at a significant risk for some form of SDB.

The feasibility, acceptance, and key features of a prevention-focused oral health education program for HIV+ adults.

Poor oral health is common in HIV+ adults. We explored the feasibility, acceptance, and key features of a prevention-focused oral health education program for HIV+ adults. This was a pilot substudy of a parent study in which all subjects (n = 112) received a baseline periodontal disease (PD) examination and provider-delivered oral health messages informed by the Information-Motivation-Behavioral Skills (IMB) Model. Forty-one parent study subjects were then eligible for the substudy; of these subjects, a volunteer sample was contacted and interviewed 3-6 months after the baseline visit. At the recall visit, subjects self-reported behavior changes that they had made since the baseline. PD was reassessed using standard clinical assessment guidelines, and results were shared with each subject. At recall, individualized, hands-on oral hygiene coaching was performed and patients provided feedback on this experience. Statistics included frequency distributions, means, and chi-square testing for bivariate analyses. Twenty-two HIV+ adults completed the study. At recall, subjects had modest, but nonsignificant (p > 0.05) clinician-observed improvement in PD. Each subject reported adopting, on average, 3.8 (± 1.5) specific oral health behavior changes at recall. By self-report, subjects attributed most behavior changes (95%) to baseline health messages. Behavior changes were self-reported for increased frequency of flossing (55%) and toothbrushing (50%), enhanced toothbrushing technique (50%), and improved eating habits (32%). As compared to smokers, nonsmokers reported being more optimistic about their oral health (p = 0.024) at recall and were more likely to have reported changing their oral health behaviors (p = 0.009). All subjects self-reported increased knowledge after receiving hands-on oral hygiene coaching performed at the recall visit. In HIV+ adults, IMB-informed oral health messages promoted self-reported behavior change, subjects preferred more interactive, hands-on coaching. We describe a holistic clinical behavior change approach that may provide a helpful framework when creating more rigorously designed IMB-informed studies on this topic.

A longitudinal study of the survival of interproximal root caries lesions restored with glass ionomer cement via a minimally invasive approach.

The prevalence of gingival recessions and the number of root surfaces exposed to the oral environment both increase with age. In turn, these increases place the older population at increased risk for caries; it is estimated that 23.7% of those over the age of 65 have root caries.1 Glass ionomer (GI) seems particularly suitable for restoring root lesions, as it has good esthetic and anti-cariogenic properties, allows for chemical bonding to teeth, and has gained wide acceptance. This article describes a minimally invasive approach for restoring interproximal root caries lesions with GI; in this study, 66 such lesions were restored and followed for up to 80 months. The results show that the radiographic quality score was the single most important predictor for restoration survival. High-quality restorations survived an average of 74 months (SE = 2.7), with a cumulative survival rate of 77.4% at 80 months. Age, gender, and periodontal status were unrelated to restoration survival.

Prevalence of oral lesions in the dental office.

Comprehensive head and neck examinations provide the best opportunity to carefully evaluate the oral cavity for the presence of disease. For this study, 40 dental professionals in 20 dental offices in Northern Ohio received a three-hour standardization course on oral pathology, performed head and neck examinations on all adult patients over a three-week period, and recorded the presumptive identification of all observed oral lesions. Lesion-positive and lesion-negative patients were compared on patient age, gender, tobacco usage, denture status, and the type of provider (dentist or hygienist) making the observations. Providers performed head and neck examinations on 3,182 adults, 847 (26.7%) of whom had 1,073 lesions. Lesion-positive and negative patients were similar in terms of age and gender, although patients with lesions were almost twice as likely to use tobacco and more than 2.5 times as likely to wear dentures. Most lesions were classified as white (36.6%), followed by red (17%), ulcerated (14%), pigmented (14%), and soft tissue enlargements (12%). Leukoplakia and erythroplakia were observed in 1% of the screened adults, although patients were not aware of the presence of these conditions. Overall, the prevalence of lesions in dental patients (26.7%) was similar to national estimates (27.9%), but the prevalence of some specific lesions varied.

A provider-observed tool to assess Oral Hygiene Skill Mastery (OHSIM) in human immunodeficiency virus-positive (HIV+) adults.

AIMS: Periodontal diseases (PDs) affect nearly half of Americans ≥30 years old and are common in human immunodeficiency virus-positive (HIV+) adults. A validated measure of oral hygiene skill could improve tailored prevention-focused health communication. METHODS: We developed Oral Hygiene Skill Mastery (OHSIM), a provider-observed measure of toothbrushing and flossing ability. We examined OHSIM's inter-rater reliability (IRR) and concurrent validity using a blinded, cross-sectional study design with a convenience sample of HIV+/- adults. Clinical outcome measures included bleeding on probing (BOP) and abbreviated plaque and gingival indices. Analyses included IRR and, after identifying relevant predictor variables for each outcome, backward elimination regression and structural equation modeling (SEM) were used to demonstrate concurrent validity. RESULTS: We saw 173 research participants (reliability: n = 61; validity: n = 112). The average IRR was α = 0.73 for toothbrushing and α = 0.84 for flossing. Toothbrushing and flossing skill were moderately correlated (r = 0.49, P < 0.001). SEM analyses demonstrated that OHSIM toothbrushing significantly and independently predicted variance in plaque and gingival indices and BOP, while OHSIM flossing skill significantly and independently predicted plaque index and BOP. CONCLUSION: OHSIM is a provisionally reliable and valid provider-observed measure of toothbrushing and flossing skill. Most predictors of clinical outcomes were modifiable behaviors. Toothbrushing quality is a critical component of oral health.

Caring for African-American patients in private practice: disparities and similarities in dental procedures and communication.

UNLABELLED: OBJECTIVE. Disparities in oral health care among racial and low socioeconomic groups have been reported. The authors compared the communication behaviors and dental services to African-American and white patients in private dental offices. METHODS: and Subjects. The investigators directly observed office visits of 292 black and 1,552 white patients in 64 practices by using standardized checklists for the frequency of services provided and frequency and time of communication behaviors. From patient surveys, they constructed three communication scales and a patient satisfaction score. They examined the effects of provider-patient racial concordance on dental services and observed and perceived communication behaviors by using multiple regression analyses. RESULTS: Groups of black and white patients had similar demographic characteristics. Dental procedures were similar for black and white patients in offices with white providers. Compared with white patients, black patients with white providers reported lower ratings for how well the dentist knew them (P = .001), but patients' satisfaction with their providers was high and not affected by provider-patient racial concordance. After multivariate adjustment, odds of chatting were significantly lower between black patients and white providers than between racially concordant patients and providers (odds ratio = 0.38; P < .001), whereas odds of negotiation were lower among black patients regardless of the race of the provider. CONCLUSIONS: In this study sample, the investigators did not observe overt disparities in dental services on the basis of race. They noted that some communication behaviors were influenced by dentist-patient racial concordance, which suggests the possibility of more subtle disparities than usually are considered. CLINICAL IMPLICATIONS: Dental professionals could benefit from understanding their patients' perceptions of a range of interactions that occur during a typical dental visit.

Tuberosity versus palatal donor sites for soft tissue grafting: A split-mouth clinical study.

OBJECTIVE: To compare postoperative pain associated with palatal and tuberosity donor sites for soft tissue grafting, and to evaluate the outcomes in both the donor and recipient sites. METHOD AND MATERIALS: Twenty healthy nonsmokers requiring bilateral soft tissue grafts were recruited for the study. For the 10 patients who required free gingival graft (FGG), 10 epithelialized grafts were taken from the tuberosity and 10 from the palate. The other 10 patients who required coronally advanced flap (CAF) and connective tissue graft (CTG) received 10 de-epithelialized grafts from the tuberosity and 10 from the palate. A total of 20 receded areas were treated with CAF and CTG. A total of 20 mucogingival defects were treated by FGG. Pain level was reported by the patient using a subjective score on a scale of 0 to 10 (0 = no pain, 10 = very severe pain). The length, width, and thickness of the outcome was measured for the FGG group at 8 weeks. The percentage of root coverage along with the length, width, and thickness of the final outcome was measured for the FGG group as well as the CAF and CTG group. RESULTS: Pain level in the tuberosity donor site was significantly lower than in the palatal donor site during the first 2 postoperative weeks (2.6 ± 2.16 versus 5.9 ± 2.74 respectively, P < .001). Mean gingival thickness of the healed tuberosity donor graft was greater than of the palatal donor grafts in both groups; for CAF and CTG group 2.9 ± 0.5 versus 2.3 ± 0.6 mm, respectively (P = .016); for FGG group 2.7 ± 0.7 versus 2.1 ± 0.7, respectively (P = .026). No differences were observed in the length or width of both grafted sites at an 8-week follow-up. No significant difference in the mean percentage of root coverage resulting from tuberosity or palatal donor sites was noted (67 ± 12% versus 62 ± 13%, respectively, P = .102). CONCLUSION: Soft tissue grafts harvested from the tuberosity site might provide a better option than soft tissue donor grafts obtained from the palate in terms of function and less postoperative pain.

Revisiting comfort: strategies observed in the direct observation study.

The Surgeon General's 2000 report on oral health found that one-third of adults in the U.S. had not visited a dentist in the previous year. Fear of treatments received during a dental encounter can create a barrier to patients receiving care. Most studies of dental anxiety have focused on phobic patients; relatively few studies have explored attempts to provide comfort and alleviate anxiety among everyday patients. This study describes comforting strategies that were performed by dentists, dental assistants, and hygienists for their patient population as a whole. As part of the Direct Observation Study, 120 dental practices in Ohio were observed over a four-day period by trained research hygienists. Researchers observed and recorded 3,800 patient interactions with dentists and hygienists at 30-second intervals using 24 behavior-specific codes. In addition, observers composed qualitative notes detailing the patient visits and recorded in their notes specific comforting techniques performed by dentists, hygienists, and dental assistants.

Characteristics of the Cochrane Oral Health Group systematic reviews.

The Cochrane Oral Health Group (COHG) was formed in 1994 with the aim of producing systematic reviews that primarily include oral health randomized controlled trials (RCTs). The purpose of this cross-sectional study was to characterize reviews published by the COHG. In September 2013, the COHG database was accessed, and all publications were downloaded. Reviews with no studies identified according to the inclusion criteria were labeled "empty reviews." The complete Cochrane database included a total of 5,697 reviews, of which the COHG database included 142 reviews. Of these 142, 69 (48.6%) did not reach a conclusion, including 20 (14.1%) that were identified as empty reviews. Of the 122 non-empty reviews, 116 (95.1%) were based exclusively on RCTs. The median number of RCTs and patients included in the non-empty reviews were seven and 489, respectively. The median number of included RCTs and patients for reviews that reached conclusions were 12 and 934, respectively, and there were five RCTs and 211 patients for reviews without conclusions. Overall, the characteristics of the Cochrane oral health reviews (OH-CSRs) were similar to Cochrane reviews published in other disciplines (All-CSRs). The authors observed a significant difference in the median number of RCTs and patients included when reviews that reached conclusions were separated from those that did not. A greater proportion of empty reviews were present in OH-CSRs compared with All-CSRs. Turning the Cochrane reviews into a tool that is more relevant in clinical practice will require implementation of a methodology allowing inclusion of non-RCTs while controlling for possible bias.

Use of indoor tanning facilities by white adolescents in the United States.

CONTEXT: Indoor tanning is a risk factor for skin cancer, but the population-based prevalence of this behavior among adolescents is not clearly known. OBJECTIVES: To describe the prevalence of tanning booth use among white US adolescents and to assess its association with sociodemographic factors, health behaviors, and appearance. DESIGN, SETTING, AND PARTICIPANTS: A nationally representative sample of 6903 non-Hispanic white adolescents, aged 13 to 19 years, who participated in Wave II (between April 1, 1996, and August 31, 1996) of the National Longitudinal Study of Adolescent Health. MAIN OUTCOME MEASURE: Frequency of lifetime use of indoor artificial tanning facilities. RESULTS: With the data weighted to national levels, 36.8% of the white female adolescents and 11.2% of the white male adolescents have used a tanning booth at least once in their life, while 28.1% and 6.9% of the female and male adolescents, respectively, reported tanning booth use 3 or more times. The percentage of female adolescents using tanning booths 3 or more times increased with age, from 11.2% of the 13- to 14-year-olds to 47.0% of 18- to 19-year-olds and also increased with greater tanning ability, from 12.6% of the poor tanners to 38.1% of those with a strong tan response. After multivariate adjustment, those residing in the Midwest (adjusted odds ratio [aOR], 2.38; 95% confidence interval [CI], 1.53-3.68) or South (aOR, 2.91; 95% CI, 1.89-4.53), attending a rural high school (aOR, 1.80; 95% CI, 1.09-2.98), and reporting the use of 2 or 3 substances (aOR, 3.06; 95% CI, 2.44-3.82) were more likely to use indoor tanning facilities, as were dieters (aOR, 1.26; 95% CI, 1.01-1.57) regardless of their body mass index. Decreased odds of indoor tanning were observed among those with a college-educated mother (aOR, 0.68; 95% CI, 0.51-0.90) and greater cognitive ability (per 10-point score increase; aOR, 0.89; 95% CI, 0.82-0.96) while routine participation in physical activity significantly lowered the odds of indoor tanning only among female adolescents. CONCLUSIONS: Indoor tanning is prevalent, particularly among female adolescents, and aligns with other risk behaviors, appearance-related factors, and intentional sunbathing. The risks of artificial tanning need increased emphasis among adolescents, especially in the Midwest and South where extremes in the availability of natural light appear to send intentional tanners indoors.

Treatment of noncarious cervical lesions by a subepithelial connective tissue graft versus a composite resin restoration.

This study compared two treatments for mild noncarious cervical lesions (NCCLs): a subepithelial connective tissue graft (CTG) versus a Class V composite resin restoration (CRR). Twenty-six sites with NCCLs were randomly assigned to be treated by CTG or CRR. Periodontal health parameters and dentinal hypersensitivity (DH) were recorded at baseline and 3 months postoperatively. Esthetics was also evaluated at 3 months. Results showed a significant improvement in all periodontal health parameters in the CTG treatment. The CTG treatment attained a mean 82% defect coverage with 75% of sites achieving complete coverage. Patients rated the CTG treatment to be significantly more esthetic (P = .03), while a clinician panel did not see an esthetic difference (P = .86). There was no difference in DH reduction between the two treatments (P = .81). In conclusion, the CTG treatment is superior to the CRR treatment for NCCLs based on periodontal health parameters. From a patient point of view, the CTG is the more esthetic treatment.

Evidence-based dentistry and clinical implementation by third-year dental students.

Over the last two decades, the concept of evidence-based medicine (EBM) has become the standard of medical care. Defined by Sackett et al. as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients," EBM recognizes that the practitioner should combine individual clinical expertise with the best available external evidence for optimal care. Consideration of the patient's needs and preferences is also an integral component of the clinical application. Dental educators have to account for the fact that not all dental treatment outcomes have been researched with randomized clinical trials. Dogmas in dentistry still exist regarding restorative treatments and methods taught to next generations of practitioners, while limited evidence is available. The purpose of this study was to determine how third-year dental students at one U.S. dental school select articles to provide supportive evidence related to treatment planning. The results show that knowledge provided in a three-week course in evidence-based dentistry (EBD) for first-year dental students was not efficiently applied when the students reached their third year. A significant percentage of the students perceived the use of literature as not beneficial for sustaining clinical aspects of a treatment plan, and they did not use appropriate tools to access best available resources. As a result of these findings, the article proposes incorporation of specific learning objectives related to EBD principles throughout the curriculum and a simplified method to search for best available evidence that has the advantage of not requiring knowledge and training in rigorous formulation of clinical questions.

Effect of Nadir CD4+ T cell count on clinical measures of periodontal disease in HIV+ adults before and during immune reconstitution on HAART.

BACKGROUND: The contribution of HIV-infection to periodontal disease (PD) is poorly understood. We proposed that immunological markers would be associated with improved clinical measures of PD. METHODS: We performed a longitudinal cohort study of HIV-infected adults who had started highly active antiretroviral therapy (HAART) <2 years. PD was characterized clinically as the percent of teeth with ≥ 1 site with periodontal probing depth (PPD) ≥ 5.0mm, recession (REC) >0mm, clinical attachment level (CAL) ≥ 4.0mm, and bleeding on probing (BOP) at ≥ 4 sites/tooth and microbiologically as specific periodontopathogen concentration. Linear mixed-effects models were used to assess the associations between immune function and PD. RESULTS: Forty (40) subjects with median 2.7 months on HAART and median nadir CD4+ T-cell count of 212 cells/µl completed a median 3 visits. Over 24 months, CD4+ T-cell count increased by a mean 173 cells/µl (p<0.001) and HIV RNA decreased by 0.5 log10 copies/ml (p<0.001); concurrently, PPD, CAL and BOP decreased by a mean 11.7%, 12.1%, and 14.7% respectively (all p<0.001). Lower nadir CD4+ T-cell count was associated with worse baseline REC (-6.72%; p=0.04) and CAL (9.06%; p<0.001). Further, lower nadir CD4+ T-cell count was associated with a greater relative longitudinal improvement in PPD in subjects with higher baseline levels of Porphyromonas gingivalis (p=0.027), and BOP in subjects with higher baseline levels of Porphyromonas gingivalis or Treponema denticola (p=0.001 and p=0.006 respectively). Longitudinal changes from baseline in CD4+ T-cell count and level of HIV RNA were not independently associated with longitudinal changes in any clinical markers of PD. CONCLUSION: Degree of immunosuppression was associated with baseline gingival recession. After HAART initiation, measures of active PD improved most in those with lower nadir CD4+ T-cell counts and higher baseline levels of specific periodontopathogens. Nadir CD4+ T-cell count differentially influences periodontal disease both before and after HAART in HIV-infected adults.

Information-seeking behaviors of dental practitioners in three practice-based research networks.

Research on the information-seeking behaviors of dental practitioners is scarce. Knowledge of dentists' informationseeking behaviors should advance the translational gap between clinical dental research and dental practice. A cross-sectional survey was conducted to examine the self-reported information-seeking behaviors of dentists in three dental practice-based research networks (PBRNs). A total of 950 dentists (65 percent response rate) completed the survey. Dental journals and continuing dental education (CDE) sources used and their influence on practice guidance were assessed. PBRN participation level and years since dental degree were measured. Full-participant dentists reported reading the Journal of the American Dental Association and General Dentistry more frequently than did their reference counterparts. Printed journals were preferred by most dentists. A lower proportion of full participants obtained their CDE credits at dental meetings compared to partial participants. Experienced dentists read other dental information sources more frequently than did less experienced dentists. Practitioners involved in a PBRN differed in their approaches to accessing information sources. Peer-reviewed sources were more frequently used by full participants and dentists with fifteen years of experience or more. Dental PBRNs potentially play a significant role in the dissemination of evidence-based information. This study found that specific educational sources might increase and disseminate knowledge among dentists.

A prospective cohort study of periodontal disease measures and cardiovascular disease markers in HIV-infected adults.

The determinants of HIV-associated cardiovascular disease (CVD) are not well understood. Periodontal disease (PD) has been linked to CVD but this connection has not been examined in HIV infection. We followed a cohort of HIV-infected adults to ascertain whether PD was associated with carotid artery intima media thickness (IMT) and brachial artery flow-mediated dilation (FMD). We performed a longitudinal observational study of HIV-infected adults on HAART for <2 years with no known heart disease. PD was characterized clinically and microbiologically. Cardiovascular disease was assessed by IMT/FMD. Linear mixed models assessed cross-sectional and longitudinal associations between PD and FMD/IMT. Forty three HIV(+) adults completed a median of 24 (6-44) months on the study. Defining delta to be the change in a variable between baseline and a follow-up time, longitudinally, on average and after adjusting for change in time, CVD-specific and HIV-specific potential confounding covariates, a 1-log(10) increase in delta Porphyromonas gingivalis was associated with a 0.013 mm increase in delta IMT (95% CI: 0.0006-0.0262; p=0.04). After adjusting for the same potential confounding covariates, a 10% increase in delta gingival recession was associated with a 2.3% increase in delta FMD (95% CI: 0.4-4.2; p=0.03). In a cohort of HIV-infected adults, an increase in subgingival Porphyromonas gingivalis, a known periodontal pathogen, was significantly associated with longitudinal increases in IMT, while increased gingival recession, which herein may represent PD resolution, was significantly associated with longitudinal improvement in FMD. In the context of HIV infection, PD may contribute to CVD risk. Intervention studies treating PD may help clarify this association.

A multimethod investigation including direct observation of 3751 patient visits to 120 dental offices.

This report defines verbal interactions between practitioners and patients as core activities of dental practice. Trained teams spent four days in 120 Ohio dental practices observing 3751 patient encounters with dentists and hygienists. Direct observation of practice characteristics, procedures performed, and how procedure and nonprocedure time was utilized during patient visits was recorded using a modified Davis Observation Code that classified patient contact time into 24 behavioral categories. Dentist, hygienist, and patient characteristics were gathered by questionnaire. The most common nonprocedure behaviors observed for dentists were chatting, evaluation feedback, history taking, and answering patient questions. Hygienists added preventive counseling. We distinguish between preventive procedures and counseling in actual dental offices that are members of a practice-based research network. Almost a third of the dentist's and half of the hygienist's patient contact time is utilized for nonprocedure behaviors during patient encounters. These interactions may be linked to patient and practitioner satisfaction and effectiveness of self-care instruction.