Pathogenesis, diagnosis and management of dentin hypersensitivity: an evidence-based overview for dental practitioners.

Though dentin hypersensitivity (DHS) is one of the most common complaints from patients in dental clinics, there are no universally accepted guidelines for differential diagnosis as well as selection of reliable treatment modalities for this condition. The neurosensory mechanisms underlying DHS remain unclear, but fluid movements within exposed dentinal tubules, i.e., the hydrodynamic theory, has been a widely accepted explanation for DHS pain. As several dental conditions have symptoms that mimic DHS at different stages of their progression, diagnosis and treatment of DHS are often confusing, especially for inexperienced dental practitioners. In this paper we provide an up-to-date review on risk factors that play a role in the development and chronicity of DHS and summarize the current principles and strategies for differential diagnosis and management of DHS in dental practices. We will outline the etiology, predisposing factors and the underlying putative mechanisms of DHS, and provide principles and indications for its diagnosis and management. Though desensitization remains to be the first choice for DHS for many dental practitioners and most of desensitizing agents reduce the symptoms of DHS by occluding patent dentinal tubules, the long-term outcome of such treatment is uncertain. With improved understanding of the underlying nociceptive mechanisms of DHS, it is expected that promising novel therapies will emerge and provide more effective relief for patients with DHS.

Knowledge, attitudes and behaviours of patients regarding interdental deplaquing devices: A mixed-methods study.

OBJECTIVES: This mixed-methods study assessed patients' oral health literacy, motivation level and barriers regarding interdental plaque control. METHODS: Participants (n = 49) from a study comparing the use of Glide® Pro-Health Floss Original (F) or GUM® Curved Soft-Picks® Advance (SP) completed daily diaries and questionnaires regarding motivation, tiredness, confidence and satisfaction for their deplaquing method. The Mantel-Haenszel chi-square test was utilized. Data were also collected from 19 participants who attended focus group discussions regarding their oral health habits, knowledge, motivators and barriers with interdental plaque control. Discussions were digitally recorded, transcribed and imported into ATLAS.ti 7.5.15 to identify themes. RESULTS: There were no statistically significant differences between the two groups in relation to age, sex or ethnicity. F users reported statistically significant higher agreement about ability to remove food/debris (P = 0.01), cleaning thoroughly (P = 0.02) and clean feeling of the mouth (P = 0.01). SP users reported higher ease/efficiency of use (P = 0.01), convenience (P = 0.003), easy to hold (P = 0.0001) and easy use away from home (P = 0.008). Daily diaries revealed higher motivation and compliance/ease of use (SP). During the focus groups, some reported that they did not feel clean unless they deplaqued interdentally; however, most reported that they lacked motivation due to constraints on time, no desire due to lack of immediate or tangible rewards, and lack of knowledge on proper use of interdental devices or the benefits of using them. CONCLUSION: This study showed that the lack of compliance may be due to poor literacy and lack of motivation in patients due to gaps in patient education.

Improving periodontal outcomes: merging clinical and behavioral science.

New data indicate that periodontal diseases are much more prevalent than previously thought, which means that there are large numbers of patients who will need to be diagnosed and treated for periodontal disease in a general dental practice. Oral hygiene procedures performed by patients between office visits are important for gingival health. No particular type of toothbrush has consistently been shown to have superior plaque-removal ability over another. Although studies on powered brushes have shown evidence for efficacy of biofilm removal and increased patient compliance, they are of short duration, making evaluation of long-term effects difficult to achieve. Interdental cleaning with dental floss can be effective but it is technique-sensitive. Interdental brushes have been shown to be superior to floss in plaque index scores, but not in gingival inflammation reduction. A systematic review of oral irrigation reported a beneficial adjunctive effect on bleeding and gingival indices and pocket depth. Antimicrobials in mouthrinses and toothpastes have shown significant reductions in plaque and gingivitis when used correctly. Even though it is considered essential for patients to utilize biofilm-removal techniques on a frequent basis, studies on adherence show that approximately 30-60% of health information is forgotten within 1 h, and 50% of health recommendations are not followed. Incorporating psychosocial aspects of behavioral change, including well-established counseling strategies, such as motivational interviewing, may elicit improved patient outcomes.

Empowerment through mentorship and leadership.

UNLABELLED: Leadership is vital to future growth and change in the dental hygiene profession. BACKGROUND AND PURPOSE: As health care reform emerges, state practice acts expand and new models of dental hygiene practice are created and implemented, dental hygienists will assume leadership positions that may be quite different from the more traditional leadership roles they assume today. These dental hygienist leaders will envision, creatively design and implement oral health care programs to improve the oral health of the public. Mentoring, a vital component of leadership development, is critical for dental hygienists to acquire knowledge, guidance, and growth. METHODS: This paper provides a literature-supported overview of leadership and mentoring principles applicable to dental hygienists in their personal and professional lives. Opportunities for dental hygienists to assume leadership roles are also described. CONCLUSIONS: Dental hygienists are poised to become leaders and vital members of the professional team promoting and integrating oral health care as a part of general health. Consequently, the dental hygienist's leadership roles are likely to expand and can be strengthened through mentoring relationships and mentoring teams. Ultimately, this can increase professional growth and career satisfaction for the dental hygienist as well as improve oral health care for the public.

The power of coaching: Developing leaders and beyond.

In recent decades, the application of coaching for career development and supporting faculty in leadership roles has greatly expanded in higher education. Coaching can offer transformational and life-changing experiences, inspire critical reflection in early career decisions, and (re)ignite passion and commitment at all career stages. While coaching focuses on transforming individuals, it also has the potential to impact organizations and professional environments. The power of coaching deserves appropriate recognition within dental education and scholarship. In this article, the authors discuss the potential for career coaching as a tool for developing future leaders in dental education. After differentiating between coaching and mentoring, coaching for professional development is reviewed as an evidence-based approach that can enhance traditional leadership and professional development programs. Although this article was inspired by programming supporting the development of female leaders, coaching applies to all leaders and may be particularly helpful in supporting the development of diverse leaders including but not limited to individuals from different backgrounds, national origins, gender, racial, socioeconomic, and cultural distinctions. After a review of existing coaching initiatives in dental education, a variety of coaching strategies for faculty, staff, and trainees will be described that can be implemented by oral health educational institutions. Examples of coaching strategies range from developing internal coaching programs to contractual agreements with external coaching groups. Step-by-step guidelines are included.

Adoption and implementation of policies to support preventive dentistry initiatives for physicians: a national survey of Medicaid programs.

OBJECTIVES: We determined the number of state Medicaid programs adopting initiatives to support preventive dental services provision by nondental health care professionals, their perceived attributes, and implementation barriers. METHODS: We used Qualtrics to conduct a cross-sectional survey in 2008 of Medicaid dental program managers to determine organizational stage of adoption classified according to the Transtheoretical Model of Behavior Change with 3-year follow-up. We assessed perceptions of the influence of 18 initiative attributes on the decision to adopt, drawn from Roger's diffusion of innovations theory. Stage and date of adoption are presented descriptively. Attributes and barriers were analyzed by stage of adoption by using analyses of variance or χ(2) statistics. RESULTS: By 2011, 42 states had adopted a policy. Only 9 states included a comprehensive set of preventive services, the most common being fluoride varnish. Adoption was affected by perceived initiative simplicity and its compatibility with other Medicaid programs. Administrative barriers were the most common among the 15 studied. CONCLUSIONS: State Medicaid policies to reimburse nondental providers for preventive dental services are becoming widespread. Interventions are needed to ensure oral health services delivery at the practice level.

100 Years of Dental Hygiene Research: Progress and possibilities.

During the last century, the role of dental hygienists as leaders in the recognition, prevention, and treatment of oral diseases has grown, reflecting the ever-evolving knowledge base of the profession. The American Dental Hygienists' Association (ADHA) has contributed to and supported research that has formulated the scientific basis for the profession to inform education and practice. Progress has been made across multiple priority areas identified on the National Dental Hygiene Research Agenda, including educational research examining the impact of curriculum models on teaching and learning; health services research projects documenting workforce issues and cost-effectiveness of practice models; and public health initiatives expanding access to care to provide oral health care services for diverse patient populations. The Journal of Dental Hygiene, established in 1927, has played a significant role in disseminating scientific evidence to the global dental hygiene and professional communities. Collaborative efforts both within dental hygiene and externally with interprofessional partners and key stakeholders have positively contributed towards building the research infrastructure to support the profession. The number of dental hygienists who are actively engaged in research has increased, as has the value for research as part of the research culture. Focused research priorities and training efforts have encouraged collaborations across the globe to conduct and promote the science supporting dental hygiene education and practice. Development, testing and validation of theoretical frameworks is essential to drive all professional activities. Building a community of scholars who will continue to define the dental hygiene discipline through scholarship is critical to promote a scholarly identity for the profession.

Periodontal-systemic disease education in U.S. and Canadian dental schools.

Research has proliferated in recent years regarding the relationship of oral disease to systemic conditions. Specifically, periodontal disease has been studied as a potential risk factor for multiple conditions such as cardiovascular disease (CVD) and adverse pregnancy outcomes, while other research focuses on exposures or behaviors associated with oral disease. However, few articles have been published reporting how this information is integrated into schools of dentistry, both in the classroom and clinical curriculum. For our study, a thirty-three-item survey and cover letter were electronically mailed to academic deans at sixty-five accredited dental schools in the United States and Canada in the fall of 2007. The response rate was 77 percent. According to the responses to this survey, the primary topics covered in the didactic curriculum regarding periodontal oral-systemic disease are aging, CVD, diabetes, and tobacco use. Eighty-eight percent of the respondents reported that their students are knowledgeable about the role of inflammation and its impact on oral-systemic conditions. Forty-eight percent of the respondents said they provide formal training for their students in how to discuss or communicate aspects of periodontal oral-systemic disease with patients. Only seven schools reported teaching didactic content to dental students intermixed with other health professions students, and only two schools reported conducting joint projects. Only 9 percent of the respondents said they think nurses and physicians are knowledgeable about oral-systemic disease. The findings indicate that dental schools are confident about the knowledge of their students regarding oral-systemic content. However, much work is needed to educate dental students to work in a collaborative fashion with other health care providers to co-manage patients at risk for oral-systemic conditions.

The relationship of periodontal disease to diseases and disorders at distant sites: communication to health care professionals and patients.

BACKGROUND: The body of research defining relationships among periodontal disease and certain systemic diseases and disorders has been expanding, and questions have been raised regarding what information should be conveyed to health care professionals and patients. METHODS: Representatives from dentistry, medicine, the academic community and the insurance industry convened a two-day workshop July 23 and 24, 2007. RESULTS: The workshop participants achieved general consensus on a number of issues, including the need for greater cooperation between the health care professions. This cooperation should translate into improved clinical care as physicians refer patients for dental care, and dentists are proactive in regard to the general health of their patients. CONCLUSION: Communication to health care professionals requires a multifaceted approach that includes publication of research findings in medical and dental journals, cooperation among professional organizations and initiatives at the local level such as presentations at medical grand rounds. Dental schools should play a role in their health science centers. Communication with patients may improve through the use of targeted informational brochures in the offices of medical specialists, appropriate media campaigns and efforts led by local dental organizations. PRACTICE IMPLICATIONS: It is too early to provide specific recommendations regarding the treatment of periodontal disease to improve specific health outcomes, but dentists can become advocates for a general health promotion and disease prevention message. The lifestyles approach includes an improved diet, smoking cessation, appropriate hygiene practices and stress reduction. These strategies can improve oral and general health outcomes.

Periodontal-systemic disease education in United States dental hygiene programs.

The relationship between periodontal disease and systemic disease has gained much attention in recent years in the dental profession and from national health care agencies. Two third-party providers are now modifying their dental reimbursements for patients who have periodontal disease and are pregnant or have cardiovascular disease. However, there are few reports in the dental or dental hygiene literature about how students are taught this information and how it is incorporated into the didactic and clinical aspects of the curriculum. A thirty-item survey and cover letter on these subjects were emailed to the directors of the 286 accredited dental hygiene programs in the United States in 2007. The response rate was 63 percent. According to these responses, the three most emphasized topics regarding oral-systemic disease are diabetes, tobacco use, and cardiovascular disease. Most programs (90 percent) use journal articles for instructional content, and 87 percent use the American Academy of Periodontology website for reference. Only 4 percent have content taught jointly with nursing, medical, or allied health students. The majority of directors (87 percent) indicated they could use more evidence-based educational materials to help teach the concepts to students. Only 9 percent of survey respondents thought that nurses and physicians are knowledgeable about the relationship of oral health to systemic disease. The findings indicate that dental hygiene program directors are confident about the education on oral-systemic content provided to their dental hygiene students, but would like additional evidence-based materials to help their students learn this topic.

Is dentistry at risk? A case for interprofessional education.

The goal of interprofessional education (IPE) is to bring various professional groups together in the educational environment to promote collaborative practice and improve the health care of patients. Interest in IPE has been sparked by several factors in the health care system, including the increased awareness of oral-systemic connections, an aging population, the shift of the burden of illness from acute to chronic care, and lack of access to basic oral care. Increasingly, since the publication of the U.S. surgeon general's report in 2000, the dialogue surrounding IPE in dentistry has escalated. But how has dentistry changed regarding IPE since the report was released? This position paper argues that little has changed in the way dental students are taught and prepared to participate in IPE. The authors contend that academic dentistry and organized dentistry must take the lead in initiating and demanding IPE if dental students are to be prepared to work in the health care environment of the twenty-first century. Included are reasons why IPE is necessary and why dentistry must lead the conversation and participate in the solution to the oral health care crisis. It explores existing models and alternate approaches to IPE, barriers to implementation, and proposed strategies for academic institutions.

Dental Hygienists' Knowledge, Attitudes, and Comfort Level in Treating Patients with Dental Anxiety.

Purpose: Fear of dental treatment is a significant problem in the United States, impacting patients as well as oral health care providers. The purpose of this study was to identify the already-acquired knowledge, attitudes, and level of confidence of practicing dental hygienists with respect to the treatment of patients with dental anxiety.Methods: A paper survey was developed, pilot tested, and administered at a state-wide annual dental hygiene continuing education (CE) course in North Carolina. The survey domains studied included demographics, practice setting, practice behaviors, dental anxiety awareness, and opinions and attitudes. Item responses included multiple choice, a Likert Scale ranging from "extremely frequent to never" and "strongly agree to strongly disagree," and free response questions. Results were tabulated and descriptive statistics were performed.Results: Of the 157 attendees, 153 met the inclusion criteria (n=153) for a participation rate of 97%. Dental anxiety questionnaires were used "often" or "always" by 20% of the respondents. Less than half (43%) of the respondents stated that they knew the common signs and symptoms of a patient suffering from dental anxiety. However, 92% of the respondents (n=140) indicated confidence in their ability to perceive whether a patient felt stressed. A little more than half (58%) believed their dental hygiene education prepared them for treating patients with mild dental anxiety, 38% with moderate dental anxiety, and 22% with severe dental anxiety.Conclusion: Although the majority of dental hygienists in this study felt confident in their abilities to perceive stress in patients seeking dental care, they were less knowledgeable in recognizing the full range of signs and symptoms of dental anxiety. Questionnaires designed to specifically identify this population were used infrequently. Dental hygiene curricula and continuing education programs should include content on anxiety management for patients exhibiting all levels of dental anxiety.

Assessment of full-time dental hygiene faculty participation in clinical practice.

The purpose of this research project was to determine how many U.S. dental hygiene (DH) programs had full-time (FT) faculty members who provided direct patient care unrelated to the curriculum. Questions in this project also assessed attitudes and opinions of DH directors regarding clinical practice and opportunities for salary supplementation. A questionnaire of twenty open-ended and closed-ended questions was designed on Survey Monkey, an online survey engine. After IRB approval and pilot testing, 278 U.S. DH program directors received two emails with the survey link requesting their participation. A response rate of 69.1 percent (n=192) was achieved. Results revealed that 14.2 percent of the programs required FT DH faculties to participate in clinical practice settings unrelated to the curriculum, while 67 percent of the programs had faculties who also participated in clinical practice. Eighty-three percent of respondents reported faculties who participated in clinical practice were financially compensated. The majority (95.4 percent) of directors indicated maintaining clinical skills was an advantage to clinical practice, while 48 percent of directors indicated participation takes time away from being an educator. Overall, the majority of DH programs did not require FT faculties to participate in clinical practice; however, respondents were generally in favor of allowing faculties the opportunity to practice and thought that it enhanced their competency as clinical instructors.

Circulating Omentin-1 and Chronic Painful Temporomandibular Disorders.

AIMS: To investigate the relationship between omentin-1 levels and painful temporomandibular disorders (TMD). METHODS: In a case-control design, chronic painful TMD cases (n = 90) and TMD-free controls (n = 54) were selected from participants in the multisite OPPERA study (Orofacial Pain: Prospective Evaluation and Risk Assessment). Painful TMD case status was determined by examination using established Research Diagnostic Criteria for TMD (RDC/TMD). Levels of omentin-1 in stored blood plasma samples were measured by using an enzyme linked immunosorbent assay. Binary logistic regression was used to calculate the odds ratios (ORs) and 95% confidence limits (CLs) for the association between omentin-1 and painful TMD. Models were adjusted for study site, age, sex, and body mass index. RESULTS: The unadjusted association between omentin-1 and chronic painful TMD was statistically nonsignificant (P = .072). Following adjustment for covariates, odds of TMD pain decreased 36% per standard deviation increase in circulating omentin-1 (adjusted OR = 0.64; 95% CL: 0.43, 0.96; P = .031). CONCLUSION: Circulating levels of omentin-1 were significantly lower in painful TMD cases than controls, suggesting that TMD pain is mediated by inflammatory pathways.

North Carolina Cardiologists' Knowledge, Opinions and Practice Behaviors Regarding the Relationship between Periodontal Disease and Cardiovascular Disease.

PURPOSE: There has been an increase in awareness of the link between oral health and systemic health in recent years. While questions exist about the relationship of oral disease to cardiovascular conditions, no published study to date has addressed cardiologists' knowledge and opinions about this area of science. This study examined North Carolina cardiologists' knowledge, opinions and practice behaviors regarding periodontal disease and cardiovascular disease. METHODS: A survey was developed, revised, pilot tested and mailed to 625 licensed, practicing cardiologists' in North Carolina. A total of 3 mailings were conducted. Data were analyzed using descriptive statistics. RESULTS: The response rate was 19% (n=119). Respondents were mostly males (86%) and working in private group practice (48%) or academia (32%). Sixty three percent correctly identified the first sign of periodontal disease; however, only 18% choose the correct etiology of periodontal disease. Sixty percent of respondents stated that medical students and dental students should be trained to work collaboratively. Half of cardiologists' surveyed were unsure that treatment of periodontal disease can decrease a patient's risk for cardiovascular disease. The majority were interested in learning more about the relationship between cardiovascular disease and periodontitis. CONCLUSION: The majority of cardiologists surveyed were unclear about the etiology of periodontal disease and would like to have more information about the potential oral-systemic link regarding cardiovascular disease. It is important for educators and administrators in higher education to examine the need for interprofessional education and collaboration between medicine and dentistry. This study may provide valuable information about ways to implement more effective interprofessional education and collaboration between dental and dental hygiene professionals and cardiologists to improve oral health.

Knowledge, Perceived Ability and Practice Behaviors Regarding Oral Health among Pediatric Hematology and Oncology Nurses.

PURPOSE: Oral complications are common in children undergoing head and neck radiation and chemotherapy. The purpose of this study is to examine the knowledge, perceived ability and practice behaviors of pediatric oncology and hematology nurses in assisting with the various oral health care needs of pediatric oncology patients and to identify pediatric oncology nurses' previous training/education, practice types and other demographic characteristics that are related to their oral health competencies. METHODS: A survey of a convenience sample of Pediatric Oncology and Hematology Nurses was conducted during the Association of Pediatric Oncology and Hematology Nurses' (APHON) 36(th) Annual Conference and Exhibit. Descriptive analysis and the exploratory factor analyses were performed using SAS version 9.2 (SAS Institute, Inc., Cary, NC). RESULTS: Among the 300 surveys that were distributed, 235 surveys were completed (78% response rate) by pediatric oncology or hematology nurses who provide direct patient care in the U.S. Approximately 75% reported receiving less than 3 hours of oral health related education/training. Sixty percent did not have a clinical requirement regarding the assessment of the teeth and gums during their nursing school education. Bivariate analyses indicated that nurses who had clinical requirements regarding oral health assessment during nursing education/training presented greater overall oral health competencies including having greater confidence in examining oral complications than those who did not. CONCLUSION: Pediatric oncology nurses' knowledge, perceived ability and practice in assisting patient's oral hygiene care, preventing and managing oral complications vary by topic and might reflect their educational preparedness. This study may provide valuable information pertaining to the need and opportunity for interprofessional oral health care education and collaboration with nursing and dental professionals, in order to increase access to comprehensive oral care for pediatric cancer patients.

Dental and allied dental students' attitudes towards and perceptions of intraprofessional education.

Interprofessional and intraprofessional learning opportunities in health professions education are vital to emphasize evidence-based practice, quality improvement, and cost-effectiveness in patients' oral health care. The aim of this study was to assess dental, dental hygiene, and dental assisting students' readiness for intraprofessional education and to evaluate their attitudes towards and perceptions of intraprofessional teamwork, communication, respect, and understanding of professional roles. In 2013, students at one dental school (N=247) were surveyed, and focus groups were conducted for this convergent parallel mixed-methods study. Survey response rates were as follows: senior dental students 54.4% (N=43), senior dental hygiene students 100% (N=32), dental assisting students 95% (N=19), junior dental students 51.8% (N=42), and junior dental hygiene students 100% (N=33). The results showed that the dental hygiene students had more positive responses about intraprofessional education than the dental and dental assisting students (p<0.05). Most (94%, N=160) of the respondents in the combined groups agreed that intraprofessional learning would help them become more effective members of the oral health care team. The three focus group sessions (N=17) revealed consistency among the groups regarding the value of an integrated clinical design and intraprofessional education. These students were eager and positive about intraprofessional learning and agreed that a shared learning model can improve communication and respect among team members, provide a better understanding of roles, and ultimately enhance patient care.

Dentists' knowledge and opinions of oral-systemic disease relationships: relevance to patient care and education.

Population studies consistently support associations between poor oral (periodontal) health and systemic diseases such as cardiovascular disease (CVD) and diabetes. The aim of this study was to assess the knowledge of dentists and document their opinions regarding the evidence on oral-systemic disease relationships. A survey consisting of 39 items was developed and mailed to 1,350 licensed dentists in North Carolina. After three mailings, 667 dentists (49%) meeting inclusion criteria responded. The respondents were predominantly male (76.3%), in solo practice (59.5%), and in non-rural settings (74%). More than 75% of these dentists correctly identified risk factors like diet, genetics, smoking, obesity, and physical inactivity for CVD and diabetes. The majority rated the evidence linking periodontal disease with CVD and diabetes as strong (71% and 67%, respectively). These dentists were most comfortable inquiring about patients' tobacco habits (93%), treating patients with diabetes (89%) or CVD (84%) and concurrent periodontal disease, and discussing diabetes-periodontal disease risks with patients (88%). Fewer respondents were comfortable asking patients about alcohol consumption (54%) or providing alcohol counseling (49%). Most agreed that dentists should be trained to identify risk factors (96%) or actively manage systemically diseased patients (74%). Over 90% agreed that medical and dental professionals should be taught to practice more collaboratively. These data indicate that these dentists were knowledgeable about oral-systemic health associations, had mixed comfort levels translating the evidence into clinical practice, but expressed support for interprofessional education to improve their readiness to actively participate in their patients' overall health management.

Practicum Experiences: Effects on Clinical Self-Confidence of Senior Dental Hygiene Students.

PURPOSE: The purpose of this study was to determine the effects of a 3-week practicum experience on the clinical self-confidence of University of North Carolina (UNC) senior dental hygiene students. METHODS: A mixed methods approach was utilized. Before and after a 3-week practicum experience, UNC senior dental hygiene students (n=32) were asked to complete a 20-statement clinical self-confidence survey based on the dental hygiene process of care. Statements were Likert-scaled, ranging from "not at all confident" to "totally confident." The stratified Mantel Haenszel row mean score test with the subject as strata as a repeated approach was used to assess whether on average across subjects, the pre- and post-surveys had the same mean score. Students were also asked to submit reflective journal entries discussing critical incidents during their practicum experience. Representative comments from students' journal entries were selected as qualitative data to support survey results. RESULTS: Pre- and post-practicum surveys (31 and 32, respectively) were completed, and all 32 students submitted journal entries. The differences in the row mean scores from pre- to post-practicum survey were statistically significant (p<0.05), indicating an overall positive gain in clinical self-confidence from the practicum experience. Students' journal entries provided comments that supported the quantitative results. CONCLUSION: The results suggest that a 3-week practicum experience in dental hygiene students' final semester increased UNC dental hygiene students' clinical self-confidence in the dental hygiene process of care. Dental hygiene administrators may want to consider the benefits of requiring students to participate in a practicum experience if they do not already do so.