Running head: TRAINING DENTAL HYGIENE STUDENTS

Training Dental Hygiene Students To Perform Intraoral/Extraoral Cancer Examinations

Susan Brown
California State University Monterey Bay

Running head: TRAINING DENTAL HYGIENE STUDENTS

Introduction
A thorough examination of the head, neck and oral cavity is an essential
component of patient care in the dental hygiene appointment. A small change in the
tissue structures of the mouth may be an early indicator of disease in other regions of
the body. For example, diseases that may first show up in the mouth include human
immunodeficiency virus (HIV) infection, leukemia, diabetes, and nutritional
deficiency. Other orofacial lesions are more common. 10% of patients have some type
of abnormal orofacial artifact. Most of these can be categorized as atypical, but some
can be abnormal or even fatal. It is the responsibility of the dental hygienist to
identify these changes in the oral cavity and to inform the dentist so the condition can
be diagnosed. Sometimes a referral to a specialist, such as an oral surgeon may be in
order. This simple action may be the thing that saves a patient from an early death, as
some cases of cancer can be rapid growing. Dental hygienists must be familiar with
all aspects of normal anatomy of the head and neck in order to recognize when
something is abnormal.
Beyond attendance in dental hygiene school, California licensed dental hygienists
are required by the California Dental Board of Examiners to complete 25 units of
continuing education per year. Accepted courses in the delivery of dental services to
the patient or the community include courses in preventive services, diagnostic
protocols and procedures, including physical evaluation and charting of the oral
conditions. An online course reviewing the extraoral exam procedure therefore would
be of benefit not only to current dental hygiene students, but to practicing dental

Running head: TRAINING DENTAL HYGIENE STUDENTS

hygienists as well. A refresher course in examination protocols is not only beneficial

to the education of the dental community, but has the potential of being life saving to
their patients as well.

Training Methods
Training for dental hygienists occurs over a two year period with clinical
instruction in a supervised setting, either in a dental school or a dental hygiene clinic
overseen by a dental school. The average dental hygiene program in California has a
class size of 20-25 students. Therefore, there may be up to 50 students utilizing one
clinic per year. With limited one-on-one supervision, instructors rely on book
learning, lecture slides and chairside video tutorials for instructional aid. Currently,
the Foothill Dental Hygiene Program located in Los Altos Hills, California has only
two textbooks for training in oral exams. The director of the clinic, Phyllis Spragge,
RDH, MA has communicated a need for adjunctive visual aids. In the clinic there
exist computers with 22 monitors mounted on each light fixture, within clear view of
both operator and patient. This provides a delivery method for instruction utilizing
electronic deliverables, such as slide shows and videos. Development of a training
module using Storyline2 offers a viable solution for the Foothill Dental Hygiene
Program.
Education for oral exam begins with book learning on the topics of oral facial
anatomy. The landmarks of the head and neck must be identified in order to be able to
locate the areas to be examined. This information is usually covered in a prior classes
on head and neck anatomy. The student is assumed to know this already. New

Running head: TRAINING DENTAL HYGIENE STUDENTS

information on the steps involved for a thorough intraoral and extraoral examination
are covered extensively in two separate texts. The main text used at this institution is
Dental Hygiene: Theory and Practice. (Darby, 2015). Included in the text are color
photos of performance of the extraoral exam with each step pictured. There are nine
such steps. In a clinical setting, where sterile technique must be adhered to, it is
impractical to have an open textbook in the working area, where blood splatter may
occur. Therefore, it is helpful to have the exam steps available to students viewable on
the screen in the operatory utilizing the monitor available at each chairside setting.
Students are able to review the visual materials in advance and may use a summary
screenshot as a guide or job aid for reference.
Note: For the purposes of this paper, only the extraoral exam will be discussed, as
the intraoral exam is rather lengthy and beyond the scope of the capstone project
referenced herein.
The extraoral exam begins with a visual assessment of the patient overall. The
instructor conveys this information to the student through lecture and description of
possible abnormalities that may be perceived upon visual inspection of the physical
appearance of a patient once seated in the treatment area. The color of the skin,
appearance of the eyes, demeanor, and responsiveness can all be indicators of a
physical illness or condition.
The physical performance of the oral exam is a mostly tactile procedure involving
discernment of various hard and soft tissues. This is often described by the instructor,
with the help of slides. More often, live observation of the procedure is the norm, but
there is no other way to learn palpation of tissue other than by doing. Tactile

Running head: TRAINING DENTAL HYGIENE STUDENTS

feedback, and technical vocabulary to describe the findings are necessary to

document a proper assessment of tissues. Instructors must observe the performance of
the students exam in action to provide feedback as to the accuracy and thoroughness
of technique implemented.
Once the extraoral exam is complete, documentation is required. In the Foothill
Clinic, Eaglesoft brand software is used. The results of the exam are typed into the
patient record freestyle.

Description of applicable theories

It seems relevant to begin with the behaviorists such as Mager, Skinner, Thorndike
and Watson when contemplating learning. Behaviorist theory assumes that cognitive
processing has little to do with the learning involved in a task, but is simply learning
through rote memorization of facts that you need to know. Other behaviorists like
Gagn think that environment is key. Skinner and Thorndike influenced his early
research on memory transfer. Then came B.F. Skinner with operant conditioning
based on positive and negative reinforcement. All learning is grounded in this
collective theory like ingredients in a fruitcake. Whether one chooses to eat the
fruitcake or re-gift it is a matter of personal taste! The focus of behaviorism is on the
environment though, and in clinical training, learning is more environment-focused,
thereby begging a cognitive approach.
The complexities of a clinical dental education involve a mountain of new
information. Learning to perform an oral exam is only a small part of the overall
training of a dental hygienist, but it is largely based on prior knowledge of head and

Running head: TRAINING DENTAL HYGIENE STUDENTS

neck anatomy. It follows that a cognitive approach pioneered by theorists such Merrill
may be the desired method of instruction for this task. Lessons would also incorporate
an information processing model based on behaviorist theory, where learning happens
when new information is transferred form short term to long term memory. Since the
role of the instructor is to organize this information into a coherent format, in this
capstone project for oral exams, the procedural steps are laid out in sequence, with
photos depicting the area to be examined. This is easily followed utilizing a summary
diagram, of a job aid depicting all nine steps. This is a good example of utilization of
clumping, as the information necessary for the entire task is vast, memory is triggered
by the use of thumbnails of the procedural steps. Overall, student is tasked with
acquiring knowledge within the cognitive domain and exercising the skill by
application of the task in the psychomotor domain, by performing the exam hands on
in the clinic.
One must take into account the varying levels of proficiency of the students. Some
may have more experience than others, where other less experienced students may
need more practice and feedback, or active participation. For this reason, different
learning strategies may overlap at different times during the teaching process. Some
students may need more hands on instruction, while others will be comfortable to
proceed with only reference to the materials provided, such as the textbook
illustrations and a few videos.
In designing instruction for the task of teaching a group of learners with a variety of
skill levels, the prior knowledge must be taken into consideration as well as the
varying proficiency levels. This is where instructors may get into trouble by ascribing

Running head: TRAINING DENTAL HYGIENE STUDENTS

to only one specific learning theory, rather than blending others at different points in
instruction. For example, there may be a student who had prior experience as a dental
assistant before attending dental hygiene school. This student would have been
exposed to the procedure by assisting a doctor or hygienist in charting the procedure,
thereby observing the steps during multiple sessions over a period of time. This
hygiene student would have been able to commit the procedure to long term memory
prior to enrollment in the hygiene program at Foothill College. In contrast, a new
dental hygiene student with no prior dental experience would be witnessing the
procedure with new eyes, and require more repetition to master the task. This learner
would be best served by learning theory based on behavioral concepts, rather than
starting off with constructivist methods. This concept of how learning occurs with
respect to the role of memory is address in an article by Peggy Ertmer in the journal
Performance Improvement Quarterly. (Ertmer, 1993).
The role of the teacher is to first understand that any one group of students have a
variety of experiences they bring to the classroom, which can impact learning
outcomes. This will influence how the lesson plans are organized, because prior
knowledge and ability is assumed, especially in the case of dental clinic training. For
example, one cannot operate within the clinical setting without a knowledge of basic
sterile procedure, or everyone is at risk of cross contamination. And finally, an
instructor must arrange practice with feedback so that the new information is
effectively and efficiently assimilated and/or accommodated within the learners
cognitive structure. (Stepich & Newby, 1988).
Ultimately one major weakness of cognitivism as an approach is that it is unable to

Running head: TRAINING DENTAL HYGIENE STUDENTS

account for the varying skill levels and experiences of learners. (McLeod, 2003).
But, a strength of a cognitive-focused instruction is the potential to provide more
meaningful learning to the learner with a longer impact. Merriam and Caffarella
(1999, p. 254-255).

Specific Illustrations
An example of cognitive theory applied to the oral exam is the use of hypotheticodeductive operations, or Level III thinking when considering the number of possible
diagnoses from an oral inspection. The observations are deducible, but only from the
frame of reference of a compendium of knowledge based on oral cancer and other
abnormalities common to the oral cavity.
A learning strategy incorporated into the prepared module that is also a capstone
project, includes a summary page or job aid of the nine steps or nine areas that are to be
examined in the extraoral inspection. Thumbnail photos provide an action scheme for the
practice and performance of the psychomotor operations required in the clinical setting.
The actual job aid can be viewed at the following url:
http://susanbrownmistx.weebly.com/job-aid1.html

Target Audience
The intended target audience for training in the oral exam procedure is the dental
hygiene student and practitioner. A student learning the procedure for the first time, or a
seasoned professional seeking a refresher course may benefit from the review in the

Running head: TRAINING DENTAL HYGIENE STUDENTS

provided module. Dental hygienists must apply and be accepted into an accredited dental
hygiene program overseen by a dental school. Competition for acceptance into dental
hygiene programs in California is competitive, and GPAs are usually amongst the highest
ranges. Training of this typically adult learner consists of two years of college
prerequisites heavy in STEM coursework with two additional years in-program with
extensive clinical training hours. Hygiene education automatically includes all duties and
responsibilities inclusive of a dental assistant. After licensure, the average dental
hygienist practices for a length of only three years, which is surprising given the length of
training. The highest attrition rate is attributed to pregnancy.
Most students at Foothill College already have a bachelors degree upon entry.
Therefore, it is evident that the motivation to learn is present. Piaget (1973) identified the
source of motivation as that of need. This need can be physiological, affective, or
intellectual. In this case, the need may be described as intellectual.

Constraints
The real world constraints to this design would be the cost of development of the module.
The publisher has not provided supplemental video materials for the dental hygiene
manual to date. This capstone seeks to address that need. The Foothill Dental Hygiene
Program will be provided the module at no cost. Should this have been developed by the
publisher, a professional instructional designer would have to be hired, a
photographer/videographer, models, and a SME. The setting would have to be a clinic
with working dental equipment. If the office were to be shut down during patient hours,

Running head: TRAINING DENTAL HYGIENE STUDENTS

10

that would be at an hourly fiscal loss to the dental practice. In this particular instance, the
clinic at Foothill College was utilized during spring break, at no loss of time or money to
the school. The director offered her time to manage the event at no cost.
The benefits are real to the stakeholders, who in this case are the students and faculty
of Foothill College Dental Hygiene Program. Tangentially, patients who are diagnosed
with an illness are benefitting from the training of dental personnel as well. Early
detection of cancerous lesions can save lives. This has impact on not only the patient, but
their families as well. The lessons continue without video supplements, and supervision is
limited. Individual instruction is at a premium when there are up to twenty students
occupying the clinic at one given time. Clinical hours are usually three hours in duration,
so this leaves minimal time for individual instruction. The facility is state of art, having
undergone renovations in the past five years. Students are exposed to newer equipment
that is likely to be present in any dental office where they seek future employment.

Conclusion
In conclusion, the training of dental hygiene students is a complicated task. Over the
past thirty years there have been many changes in the clinic and the instructional
methods. Technology has advanced to the point where the instruments of choice are
completely redesigned for more ergonomic convenience and patient comfort. There is
an ongoing need for training when new instruments and equipment is unveiled in the
field. Often times the sales representatives are tasked with training on new products. A
dental office may schedule a lunch and learn for the staff to be trained on new

Running head: TRAINING DENTAL HYGIENE STUDENTS

11

materials or equipment. But this takes time away from productive office time and
personal time. It is much more cost effective to provide training via the internet.
Students or employees of a dental office can then receive training at their own
convenience via the web. This will ensure access to current information, maintaining
the quality of care and level of patient safety expected by the consumer public.
The supervision of such a dental hygiene program such as the Foothill College
Dental Hygiene clinic is a daunting task. The most precious resource in a live setting
such as this is the instructor. So it makes sense that the current director is looking into
the NanoCam as a means of live broadcasting clinical technique. This device allows
recording from the operators perspective with high definition video capture. It comes at
a price tag of over $5,000. Thankfully the director is an excellent grant writer. New
technologies such as the NanoCam, combined with instructional modules that give more
detailed instruction of textbook learning, will give the students of the Foothill College
Dental Hygiene Program a distinct learning advantage in their pursuit of educational
excellence.

Running head: TRAINING DENTAL HYGIENE STUDENTS

12

References

Clark N, Sandow P. Comprehensive oral cancer examination of the extra-oral and intraoral regions of the head and neck, MedEdPORTAL, 2012.
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Fehrenbach, MJ, Herring, SW: Illustrated anatomy of the head and neck. ed 4, 2012,
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McLeod, G. (2003). Learning theory and instructional design. Learning Matters, 2(2003),
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Merriam, S. B. (ed.). (2001). The new update on adult learning theory. Jossey-Bass.
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