Dental Hygiene Case Study

Developing and Pretesting Case Studies in Dental and Dental Hygiene Education: Using the Diffusion of Innovations Model

  1. Deborah L. Cragun, M.S.⇓,
  2. Rita DiGioacchino DeBate, Ph.D., M.P.H., C.H.E.S.,
  3. Herbert H. Severson, Ph.D.,
  4. Tracy Shaw, M.A.,
  5. Steve Christiansen, B.A.,
  6. Anne Koerber, D.D.S., Ph.D.,
  7. Scott L. Tomar, D.M.D., Dr.P.H.,
  8. Kelli McCormack Brown, Ph.D.,
  9. Lisa A. Tedesco, Ph.D. and
  10. William D. Hendricson, M.A., M.S.
  1. Ms. Cragun is Graduate Research Assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Dr. DeBate is Associate Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Dr. Severson is Senior Research Scientist, Deschutes Research, Inc.; Ms. Shaw is Senior Research Scientist, Deschutes Research, Inc.; Mr. Christiansen is Media Director, InterVision Media; Dr. Koerber is Associate Professor of Pediatric Dentistry, College of Dentistry, University of Illinois at Chicago; Dr. Tomar is Professor of Community Dentistry, College of Dentistry, University of Florida; Dr. Brown is Professor, College of Health and Human Performance, University of Florida; Dr. Tedesco is Vice Provost for Academic Affairs, Graduate Studies, Dean of the James T. Laney School of Graduate Studies, and Professor, Rollins School of Public Health, Emory University; and Mr. Hendricson is Assistant Dean for Educational and Faculty Development, Dental School, University of Texas Health Science Center at San Antonio
  1. Direct correspondence and requests for reprints to Ms. Deborah L. Cragun, Department of Community and Family Health, University of South Florida, 13201 Bruce B. Downs Blvd., Tampa, FL 33612; 813-466-4111 phone; 813-974-5172 fax; deborahcragun{at}
  • Received May 12, 2011.
  • Accepted August 29, 2011.


Case-based learning offers exposure to clinical situations that health professions students may not encounter in their training. The purposes of this study were to apply the Diffusion of Innovations conceptual framework to 1) identify characteristics of case studies that would increase their adoption among dental and dental hygiene faculty members and 2) develop and pretest interactive web-based case studies on sensitive oral-systemic health issues. The formative study spanned two phases using mixed methods (Phase 1: eight focus groups and four interviews; Phase 2: ten interviews and satisfaction surveys). Triangulation of quantitative and qualitative data revealed the following positive attributes of the developed case studies: relative advantage of active learning and modeling; compatibility with a variety of courses; observability of case-related knowledge and skills; independent learning; and modifiability for use with other oral-systemic health issues. These positive attributes are expected to increase the likelihood that dental and dental hygiene faculty members will adopt the developed case study once it is available for use. The themes identified in this study could be applied to the development of future case studies and may provide broader insight that might prove useful for exploring differences in case study use across dental and dental hygiene curricula.

Several calls for change have been issued regarding the future direction of dental and dental hygiene curricula.1–4 Consistently advocated changes include increasing students’ exposure to patients’ oral-systemic health issues early on and throughout their entire training1,5 and increasing the utilization of computer-based and web-based information technology.2,4 Moreover, the American Dental Education Association Position Paper on the roles and responsibilities of academic dental institutions in improving the oral health status of all Americans recommended creating more effective mechanisms to prepare dental students to provide oral health services to diverse populations and patients with special needs.6 Similar recommendations have been made regarding dental hygiene education.5

Case-based learning may provide the opportunity for students’ exposure to oral-systemic health issues they may not encounter in their clinical training, thereby increasing students’ experiences in differential diagnosis, patient-provider communication, and patient-specific treatment plans. Case-based learning typically consists of relevant clinical case scenarios, accompanied by structured questions that relate directly to the case and require students to synthesize and apply knowledge.7 The term “case-based learning” is sometimes used interchangeably with “problem-based learning” (PBL) even though distinctions have been made; PBL, for instance, is usually less structured than case-based learning and is not typically used to augment didactic learning experiences.7

Surveys of dental and dental hygiene students reveal positive overall ratings of case-based learning.8,9 Dental hygiene program directors have reported the following faculty perceptions of case-based learning: it is more effective than conventional learning, and it prepares students to problem-solve.10 Despite demonstrated benefits of case-based learning,7,8,11,12 teacher-directed instruction still predominates in many dental schools and dental hygiene programs.8,10,13 Additionally, a survey of North American dental schools suggested that the use of case-based learning decreased slightly from 2003 to 2009, although reasons for this trend were not explored.2,14 Therefore, additional research evaluating the perceptions of dental and dental hygiene faculty members may detail specific characteristics of case-based learning that can influence the adoption of this pedagogical method.

The purpose of the current study was twofold: 1) to identify characteristics of case studies that would increase adoption among dental and dental hygiene faculty members, and 2) to develop and pretest interactive web-based case studies on patient communication of sensitive oral-systemic health issues. The case study that was developed utilizes video clips to model a nonconfrontational method for identifying, communicating with, and treating patients presenting with various oral findings associated with disordered eating behaviors. Active participation is elicited via questions interspersed throughout each case. The multiple-choice questions require students to generate differential diagnoses, communication strategies, and treatment plans specific to each case.

This research is part of a larger study pertaining to the adaptation and evaluation of a web-based training program on secondary prevention of eating disorders for use in dental and dental hygiene curricula. Focus group data were obtained from the larger study that explored factors for increasing adoption of e-courses among dental and dental hygiene faculty participants.15 Thus, in the current study, qualitative data from focus groups are triangulated with data from the interviews and surveys. Furthermore, the content of the current research is distinct and focuses on case-based learning and the process of developing case studies that possess characteristics important for their adoption by faculty participants.

Diffusion of Innovations16 served as the conceptual framework for the current study. Diffusion of Innovations is the process by which an innovation (e.g., web-based case study) is diffused into an environment (e.g., dental and dental hygiene curricula) and is ultimately adopted by its members (e.g., dental and dental hygiene faculty members).16 According to Diffusion of Innovations, certain innovation attributes (e.g., relative advantage, compatibility, complexity) increase the likelihood that an innovation is adopted by a targeted population.16 If an innovation is too complex for the adopter to use, for example, then the likelihood of adoption is reduced. We have interpreted these attributes as they pertain to the adopter (i.e., dental and dental hygiene faculty members) and the innovation (i.e., case-based learning) (Table 1).

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Methods and Results

An exploratory assessment of online case-based training among dental and dental hygiene faculty members was conducted using mixed methods. The University of South Florida’s Institutional Review Board granted approval for the study that spanned two phases: Phase 1, faculty input and case study development; and Phase 2, pretesting and refining. The methods and results are described as they relate to each phase.

Phase 1a: Faculty Input

The first step of Phase 1 entailed soliciting input from potential innovation adopters (dental and dental hygiene faculty members) regarding attributes of case studies. Eight ninety-minute focus groups (three dental and five dental hygiene) representing six universities/colleges were conducted with a convenience sample of dental and dental hygiene faculty members at collaborating schools in the Eastern, Southeastern, Midwestern, and Pacific regions of the United States. Participants were recruited via an e-mail invitation sent by the contact person at each collaborating dental school and dental hygiene program participating in the larger study. Details regarding recruitment of focus group participants can be found in a previous study.15 Four focus group participants (two dental and two dental hygiene) also agreed to participate in a one-hour, follow-up semistructured interview.

Based on innovation attributes (Table 1), a semistructured focus group moderator’s guide and semistructured interview guide were developed by the principal investigator (author R.D.D.), with input and feedback from the research team and expert panel. Questions were developed following Gorden’s guidelines, which involve the organization of questions to allow for a funneling effect.17 The questions began with a less structured approach resulting in free discussion, moving toward a more structured format with specific questions pertaining to the conceptual framework. Specific questions and probes were originally included in the focus group and interview guides (Table 2). However, as is often the case in semistructured focus groups/interviews, additional spontaneous probes were used to further explore topics that arose.17

The principal investigator and one member of the research team, both experienced with focus group and interview procedures, moderated all focus groups and interviews. Prior to each focus group and interview, each participant was asked to read and sign a consent form; the procedures and purpose were explained by the moderator; and participants were given an opportunity to ask questions. All focus groups and interviews were audiotaped and later transcribed verbatim (with the exception of identifying information) by an experienced transcriptionist. All transcriptions were reviewed by the principal investigator to verify that the transcripts were accurate and reflective of the focus groups and interviews.

Two independent coders initially hand-coded the focus group and interview transcripts. Focus group and interview transcripts were then imported into NVivo 2.0 (QSR International, Melbourne, Australia), where axial coding was performed to identify overarching themes and subthemes. Lastly, a working conceptual framework was developed that describes attributes identified by the dental and dental hygiene faculty members for increasing adoption of case studies.

Table 2

Key questions from Phase 1a focus groups and interviews

Phase 1a: Results

A total of fifty participants were involved in the eight focus groups (twenty-seven dental faculty members and twenty-three dental hygiene faculty members). The majority of participants self-reported as female (84 percent), non-Hispanic (92 percent), and white (78 percent). The mean age of the participants was forty-three years. Two dental faculty members and two dental hygiene faculty members from the focus groups also participated in the in-depth interviews. All four interview participants were female. Three were Caucasian, and one was Asian-American.

A number of themes emerged from the focus groups and interviews pertaining to characteristics necessary for increasing adoption of case studies in dental and dental hygiene curricula (Table 3, columns A and B). All themes emerged from both dental and dental hygiene participants with little diversity across the two groups. The description that follows presents findings that support the themes associated with innovation adoption characteristics.

Relative advantage

Notably, the participants did not report any direct advantages that case-based learning might provide them as instructors. However, three themes emerged as representing relative advantages for students in case-based instruction. Illustrative quotes from participants are included with each theme.

Develops critical thinking skills was the first theme. One dental faculty member made these comments: “As an educator, I think it [case-based teaching] is a good way to teach the student about thinking well, to look at the whole picture, be able to analyze the different contributing factors, and be able in a professional way to work with your patient’s physician, patient’s medical doctor, and help the patient achieve something for their life. I like it.” Similar, a dental hygiene faculty member said, “I think it’s good because it [case-based teaching] allows the students to use their synthesis of a thought, their ideas, their incredible thinking skills and being able to relate one aspect into another and to integrate all of their knowledge together. And to me, a case-based type scenario whether you’re testing or even learning is the best way to put it on there.”

Provides active learning was the second theme. The following comment by a dental hygiene faculty member exemplifies this theme: “I think they [case studies] are awesome because it just keeps it interactive and engaging and makes a student think without the teacher having to divulge everything. They have to sort of figure it out in order for them to be able to move along.” In the words of another dental hygiene faculty member, “It [case-based teaching] makes it much more interesting and kind of interactive for the student other than a lecture and same-ole-same-ole. I just think I like cases and anything that has to do with the computer, Internet-based, or anything like that.”

Reflects real-world application was the third theme. “If you want to make it like the real world, I think a case study would probably be ideal,” said one dental hygiene faculty member. Similarly, a dental faculty member commented as follows: “if you had a . . . case scenario of a child sitting down and sort of evaluating and then the assessment and then bringing the parent in, having a conversation. So you’re sort of modeling this process through an actual presentation but help[ing] contextualize, so that for the dentist, they’re not just hearing about this disorder, but they’re actually seeing how it would be experienced in their environment.”


Two faculty members from one dental school indicated that their school would be changing to an entirely case-based format in the near future. Most of the other participants reported that case studies are currently used in at least one course in their dental or dental hygiene curriculum. Other areas of compatibility centered around three themes.

The first theme was that case-based learning reflects the format of national board exams and trends in curricula. One dental hygiene faculty member noted, “They [the students] have those [cases] on their board exam, and that’s what we ultimately teach to is their board exam, so they can take it and pass it. So if you put different case scenarios about eating disorders in there that they could utilize to learn for their boards, I think that would be excellent.” Another dental hygiene faculty member said, “That’s the trend in the learning is evaluating the case scenario.”

The second theme was that case-based learning is compatible with students’ preference for online format. “Students today want everything on the Internet,” stated a dental faculty participant. “They want lectures on the Internet and they want PowerPoint and everything so that they can utilize it themselves.”

Online case studies appear to be highly compatible with dental and dental hygiene curricula, board examinations, and student preferences. However, there were a few exceptions as noted in one additional theme: that case-based learning is incompatible with some programs/courses. For example, one dental hygiene faculty member commented, “I don’t personally use cases in my courses because what I teach, there is nothing case-based that I have found.” A dental faculty member noted that “it’s just our curriculum is not built for that. We still haven’t found a way to incorporate more of the case studies.”


A few dental and dental hygiene faculty participants mentioned the complexity of creating case studies. This theme is illustrated by the following representative quote from a dental faculty member: “So those would be real cases most of those, rather than invented cases, and so they have the actual blood work and photographs that all hold together nicely. That’s the problem: it is so hard to synthesize a case. . . . it is so hard to get all the details exactly right.”


A number of dental hygiene faculty members mentioned the importance of knowing that students had completed the case by including some type of quiz or assessment. Representative comments from dental hygiene faculty members were the following: “That’s why if we do the cases, to have the assessment as part of the case”; “I like the idea of the quizzes. A short one for each one [case]”; and “having a quiz would make them read.”

Quizzes were also described as a way to provide students with feedback regarding learning outcomes. This was illustrated in the following quotes from dental hygiene faculty members: “I would probably put more quiz-type questions in there at smaller intervals of the learning experience just to give [students] feedback, and then prepare them for the next section”; and “What would be a nice feature is if when you chose an incorrect answer, it gave some type of an explanation or rationale for why that’s an incorrect answer.”

This theme was not as prevalent among dental faculty members. Although some felt quizzes might be useful, not all dental faculty members agreed, as indicated in the following two quotes: “I don’t know how that works from a faculty perspective when you get the results of the quizzes if it’s like coursework where you can kind of get a gauge for what people are grasping and what they’re not, so that’s kind of a nice feedback for faculty from a data perspective. I would imagine it’s quicker to tell you that up on a computer submission”; and “But in terms of that quiz, I mean how valid is that? The students can access it and do it together.”


A few faculty members expressed concerns about the ability of online learning to effectively transmit information. This concern was illustrated in the following quote from a dental faculty member: “I do feel that if you’re doing clinical teaching, it’s very difficult to be able to do that online. . . . how do you teach someone to talk to a patient, to care about—you know, those are things that you can’t teach someone off a computer screen.”

Despite a few concerns regarding the effectiveness of this teaching method, many faculty members acknowledged that the Internet provides an easy and convenient method for transmitting information. The participants also reported that online content may improve learning because the content can be reviewed repeatedly and at the student’s own pace. One dental hygiene faculty member commented, “I think from that perspective it [a web-based format] is good, and I think we can give them access maybe to a lot more material quicker.” Likewise, a dental faculty member noted that “one good thing for the students: [a web-based format] allows them to repeat things and so they get more than one opportunity to listen to things that they might’ve not gotten on the first time.”


Two themes emerged reflecting time as a barrier to using case studies. The first theme was the recognition that it is time-intensive to develop case studies. “I actually tried to develop a couple case studies on my own for an exam and it was very time-consuming,” said one dental hygiene faculty member. A dental faculty member noted, “You see how long it takes to get a case together: it is way more difficult. I mean for faculty it is way more time-consuming. Just like with online courses.” The second theme was the related recognition that it is time-intensive to complete case studies. One dental hygiene faculty member identified the “biggest challenge” as “when you are going over a case study, they are time-consuming, and unfortunately a lot of our lectures are only an hour long.” A dental faculty member commented, “I think it would have to be kind of a general change in the curriculum because the way that our curriculum is designed, there’s no time to have those cases.”

Table 3

Faculty-reported themes regarding attributes of case-based learning (columns A and B) and translation of themes to case development (C)

Phase 1b: Translation to Case Development

We developed the case studies after triangulating those themes that represented positive and negative attributes of case-based learning. The steps involved were these:

  1. A dentist and a dental hygienist collaborated in writing the case study script.

  2. The script was reviewed and edited by the research team.

  3. The script was evaluated by two dental and two dental hygiene faculty members who previously took part in the focus group. Feedback was elicited with regard to accuracy, realism, and the types of questions they would like included.

  4. Modifications to the script were made by the primary researchers based on feedback obtained in step 3.

  5. Questions were generated by the primary researchers with substantial input from two dental and two dental hygiene faculty members. The questions assessed basic knowledge regarding physical signs of disordered eating behaviors as well as procedural knowledge pertaining to the following: appropriate ways to approach the patient about this sensitive topic; how to determine patient readiness to address this sensitive issue; and how to develop and implement an appropriate treatment plan that is tailored to the patient’s stage of readiness.

  6. Questions were interspersed at appropriate points throughout the case to make the case study more interactive.

  7. Pictures were taken and the script was audiorecorded to make the online case study prototype more interesting.

  8. The prototype was pretested as described in detail below.

  9. After the initial round of pretesting was complete, the case was filmed to create a live-action video to better model patient communication. (See Figure 1 for a screenshot of the video with a segment of the dialog—in the conversation bubble—and a sample question.)

Figure 1

Screenshot from developed case study

Throughout the development and revision process, findings from Phase 1 were translated into features of the case study to ensure that identified adoption characteristics were incorporated (Table 3, column C). To address the aspect of complexity and time involved with the creation of case studies by faculty members, a total of four interactive case studies were developed by the researchers and expert panel. Although the initial case study remains the primary focus here, all of the case studies capitalize on advantages identified in Phase 1 of this study. For example, videos were used to model communication by dentists or dental hygienists with diverse patients (male, female, adult, and pediatric) who present with a variety of clinical findings, are at varying stages of readiness to address their underlying issues, and therefore require various treatment plans. In addition, questions were interspersed throughout the cases to engage active learning. These strategies allow students to observe real-life patient-provider communication and to apply critical thinking skills.

To increase cultural compatibility with dental and dental hygiene programs, the research team structured case study questions in a fashion that is similar to cases presented in national board exams. Additionally, although the cases were specifically for identifying and treating patients with signs of disordered eating behaviors, they can be applied in a variety of courses, and the skills that are gained can be used for communicating about a variety of sensitive oral-systemic topics. Lastly, cases were also developed to be used online by students. In addition to being compatible with student preferences, online cases give the instructor flexibility to use the case in class or assign the case as homework. Thus, online cases can address the concern that case studies require too much time in class.

We utilized two strategies to address aspects of observability. The first was to include instant feedback regarding the accuracy of students’ responses to questions. Second, the inclusion of a personalized certificate of completion provides feedback to both the instructor and the student to enable the cases to be completed outside of the classroom.

Phase 2a: Pretesting

Pretesting is a data-driven, iterative process in which materials (e.g., web-based case studies) are tested and revised over a series of rounds until they communicate effectively with the intended audience (e.g., dental and dental hygiene faculty members).18 For the current study, participants were provided with a link to the case study prototype for review prior to the interview. A semistructured interview guide, based on characteristics of innovation adoption, was developed by members of the research team following Gorden’s guidelines, which involve the organization of questions to allow for a funneling effect.17 The interview guide included questions designed to elicit feedback on the case study specifically regarding the characteristics of adoption (Table 4). Data collection and analysis followed the same procedures described for Phase 1.

Table 4

Key questions from Phase 2a pretesting

Phase 2a: Results

Participants for the pretesting were dental (n=6) and dental hygiene (n=4) faculty members from three accredited dental schools and dental hygiene programs in the Eastern, Midwestern, and Pacific regions of the United States. The age of the participants ranged from twenty-eight to sixty-seven years. The majority identified themselves as female (90 percent) and Caucasian (70 percent). Teaching experience ranged from three to forty years, but only four reported routinely using case studies as an instructional method.

The participants identified themes pertaining to both faculty and students (Table 5). The same themes were identified by both dental and dental hygiene faculty members. The vast majority of the participants expressed positive feedback regarding attributes of the case study as exemplified by the following representative quotes. Two dental faculty members made these comments: “I think it’s well presented. I think the subject matter is very important and it really tunes them in to looking at the patient beyond just teeth, so I like that”; and “[the case] includes everything so I don’t have to worry about forgetting some details or not being able to go back and see what I gave them.” A dental hygiene faculty member noted, “I think the case study, the modeling, really helps the students see a realistic type of way of managing it.”

The participants did express minor concerns or recommendations for improving the case study with regard to decreasing complexity, increasing observability, and limitations to modifiability. Regarding the recommendation to decrease complexity, the comments of some participants demonstrated that making certain the case study is easy to use and decreasing the likelihood of technical problems were critical to adoption. One dental faculty member stated, “I think the most important thing is that I would want to know that it’s easy for students to navigate because I think that I wouldn’t want them to give up on something.” A dental hygiene faculty member made a similar point regarding faculty use of the case study: “If I’m going to have a lot of problems with it . . . I mean if I can easily click and click, and it doesn’t do anything, that’s a thing that would stop me and frustrate me and make me say, ‘Oh my God. I’m not doing this. This is too hard or too challenging.’”

Regarding the recommendation to increase observability, the case study provides for students and instructors to be able to observe and for faculty members to evaluate whether students completed the case study. However, as illustrated in the following quotes, some faculty members expressed the desire for additional feedback or evaluative measures. “I thought maybe it would be nice to get some comments,” said one dental hygiene faculty member. “When I did it first, then it was all correct and I thought, well, what if I get it incorrect. So when I did it the second time, I did it incorrectly, and then I wanted maybe something more.” A dental faculty member asked, “Is there a way that if you take the test how it could be scored or not? I mean how that could be documented?” Another dental faculty member commented, “In all honesty I think it would work, but if I was the clinical instructor and I was basing it on whether or not students were turning their certificates in, I don’t know if that would be the best way to indicate to me that they truly did read through it and they truly did get something out of it.”

Some participants also expressed concerns about limitations on modifiability. Despite the inability for instructors to modify the case study, these faculty members reported a few different ways in which the case study could be used. “I mean, you could try to give them something open-ended to write a paragraph about what you thought were the biggest challenges in a case like this or something like that, you know, if you really wanted to get into how much they absorbed it,” suggested one dental faculty member. A dental hygiene faculty member noted, “But even with these more sensitive topics, role playing would be good to implement, . . . you know, divide them into teams and each team has to present their own role-playing scenario.” Another possibility was raised by a dental faculty member: “I think it’s a good overview, and it would sort of lend itself to giving a good lecture based on this information.”

Table 5

Emergent themes from faculty members regarding attributes of the developed case studies that are expected to increase or decrease the likelihood of adoption

Phase 2b: Case Refinement

Based on information gathered in the pretesting phase, the research team with input from the expert panel made revisions to the cases to ensure they supported attributes that the participants had mentioned would increase the likelihood of adoption. For example, to decrease complexity, we revised the instructions for questions that required multiple correct responses because it was confusing for the participants. Additionally, several case study questions were revised to improve clarity and accuracy.

To increase observability, two revisions were made in the case study. First, if the student gets a question incorrect, a link appears that will take him or her to the section of the training program that describes the related content. This enables the student to review the material again to increase understanding of the information. Second, the certificate of completion was revised to include the percent of questions answered correctly on the first try.

Once revisions were made, a second round of pretesting was implemented with four faculty members (three dental and one dental hygiene) who had participated in the first round of pretesting. One additional dental hygiene faculty member who consented to the second round of pretesting was unable to complete it due to unforeseen circumstances. These participants were asked to review the revised case study and then complete an eight-item Likert-type web survey to assess final characteristics of intervention adoption. The percentages of participants who “strongly agreed/agreed” with specific intervention adoption characteristics were as follows:

  • provides a more practical experience on how to address sensitive topics with patients than is currently available for use in dental education (75 percent);

  • is tailored specifically for dental and dental hygiene students (75 percent);

  • is easy to navigate (100 percent);

  • is understandable (100 percent);

  • is realistic (100 percent);

  • would fit well in my school’s curriculum (75 percent);

  • questions are appropriate for dental and dental hygiene students (75 percent);

  • accurately represents patient-provider interactions regarding sensitive issues (100 percent);

  • provides a better teaching method to learn about recognizing and approaching patients who present with sensitive issues than other educational methods currently used (75 percent);

  • would be useful for dental/dental hygiene students to learn patient-provider communication (100 percent); and

  • if available, I would recommend using the cases in my school’s curriculum (75 percent).

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The two primary purposes of this study were to 1) engage dental and dental hygiene faculty members in identifying key aspects of web-based case studies that would increase the likelihood of adoption in dental and dental hygiene curricula and 2) apply that information to the development of web-based case studies as part of a larger intervention study. Public health articles have suggested that adoption of new evidence-based interventions by target populations rarely exceeds 1 percent.19–21 Real-world conditions include many factors that can interact with or moderate the reach, adoption, delivery, impact, or sustainability of an intervention.22 Barriers to successful dissemination and adoption of interventions include failure to consider the necessary steps to secure dental and dental hygiene faculty participation in intervention development and other factors needed to sustain the intervention over time (e.g., is it applicable, compatible, understandable, “fit” for many settings, feasible, and affordable?).19,23–25

Attributes of case studies that would likely decrease the likelihood of adoption include being too “topic-specific” so they could not be used in a variety of courses and adding additional information into already packed courses.13 In developing cases, we paid attention to these concerns and made sure that the cases were examples of patients presenting with oral findings related to eating disorders, but broad enough that the cases could be used in a variety of courses. In addition, the web-based nature of the cases, with built-in evaluation feedback, enables the cases to be completed by students outside of the classroom with minimal effort required on the part of the instructor.

The results of this study provided additional key input that shaped the development of case studies so dental and dental hygiene faculty members would be more likely to incorporate them into their current courses once they become available. Negative attributes that were identified by faculty members in Phase 1 (e.g., time and complexity in creating, completing, and evaluating case studies) were eliminated in Phase 2 by the development of comprehensive case studies. More specifically, negative attributes were addressed by including questions and a certificate of completion to provide a simple mechanism by which faculty members can track which students completed the case and evaluate student performance. These self-contained characteristics allow instructors to utilize the case study in their courses with little time needed for planning and evaluation.

The limitations of this study stem primarily from the use of a relatively small convenience sample, thus affecting the ability of generalizing these results to other faculty members. However, we were able to reach saturation,26 meaning that additional focus groups and/or interviews would be unlikely to reveal substantially different themes or other major recommendations for altering the case study. Nevertheless, the sample may have been biased due to self-selection of participants and overrepresentation among female dental faculty members.

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The use of Diffusion of Innovations as a guiding framework helped elicit perceived characteristics of web-based case studies by dental and dental hygiene faculty members. The results from this study provided valuable and practical information that was used to inform the development of case studies for an ongoing research project aimed at increasing dental and dental hygiene students’ capacity to identify, communicate, and treat patients with signs of disordered eating behaviors. Using the Diffusion of Innovations model as the theoretical framework allowed us to capitalize on positive characteristics of case studies that may increase the likelihood that instructors would incorporate them into existing dental and dental hygiene courses. Although the purpose of this study was to provide input on innovation adoption for the development of case studies, the actual adoption of case studies is part of a future evaluation study. Nonetheless, the adoption themes identified in this study can be applied to the development of case studies regarding a variety of topics, and our results suggest that Diffusion of Innovations may prove to be a useful framework for exploring differences in case study use across dental and dental hygiene curricula.


  1. American Dental Education Association. ADEA position paper: statement on the roles and responsibilities of academic dental institutions in improving the oral health status of all Americans. J Dent Educ2011;75(7):988–95.

Table 1

Attributes of case-based learning that may influence its likelihood of adoption by dental and dental hygiene faculty members

By Lauren Wilgenbusch, Minnesota State University, Mankato
May 7, 2013

Tooth avulsion is among the most common and serious dental injuries. According to the American Academy of Pediatric Dentistry, it is defined as “the complete displacement of a tooth out of its socket.” It is responsible for up to 16% of all dental injuries in the permanent dentition. Healing of an avulsed tooth often presents a challenge and depends on the vitality of the cell layers along the root surface. Immediate replantation at the accident site is the most critical determinant for the survival of avulsed teeth. Delay in replantation will perpetually result in root resorption and loss of the tooth (Kenny, 2006).

Complications after replantation of avulsed teeth are common and have conveyed incidence rates ranging from 57% to 80% (Nesiama & Sinn, 2010). Complications may arise during the next several years of regular dental exams, including ankylosis, excessive mobility of the tooth, and resorption. Other complications that can emerge consist of discoloration, infection in the pulp, and reinclusion of the tooth as a result of root replacement resorption and ankylosis (Emerich & Wyszowski, 2010). Most replanted teeth will be lost in five to seven years even if root canal therapy has been done after replantation (Nesiama & Sinn, 2010). 

The patient, a 13-year-old female, was seen for emergency treatment in July 2005. The child was catapulted over the handlebars of a bicycle, resulting in the avulsion of the right and left permanent maxillary central incisors. The avulsed teeth were left dry in the palm of her hand for 10 minutes until she reached the hospital where the teeth were placed in milk. Other oral injuries included a laceration on the right side of the philtrum, which was sutured. Examination of the avulsed teeth revealed that the crowns were intact but the mesial incisal edges of both were fractured. Treatment options were explained to the parents and replantation of the avulsed teeth was chosen. She was referred to a local dentist to have the teeth replanted. The roots of the teeth were planed to remove any debris and were then reinserted into the alveolar socket and secured with a splint for six weeks. During the next year the patient had root canals done, followed by metal posts and PFM crowns placed on the avulsed teeth (Figure 1).

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Figure 1

Due to the patient’s age at the time of trauma, the crowns were replaced five years later with lava crowns, which are porcelain crowns with a zirconia framework inside (refer to figure 2a and 2b).

Figure 2a

Figure 2b

One year after the crowns were replaced, the teeth became mobile. The patient went in for an appointment and radiographs confirmed external root resorption had occured around the reimplanted teeth (refer to figure 3).

Figure 3

The root resorption in this case was most likely due to PDL damage. Treatment options were explained and the decision was made to extract the teeth and place dental implants. She was referred to a Mankato, Minnesota oral surgeon for the implants.

Implants in the anterior region signify a particular challenge for oral surgeons. The ideal outcome is normal, natural-looking teeth, but that is not always a possibility. Many considerations need to be made in order for the implants to look as natural as possible, such as the need for bone and tissue grafting (Block, 2001).

When extracting a tooth with intentions of replacing it with an implant, the decision needs to be made whether to do an immediate implant placement or delayed placement. In this case, infection was not present, so implants were able to be placed immediately.

In the case of the patient, bone grafting was needed and was performed at the same time as extraction and implant placement. Most anterior maxillary tooth sites have insufficient bone and soft tissue, requiring both bone and soft tissue augmentation (Block, 2001).

The oral surgeon, Dr. Richard Kim, D.D.S., M.D., explained how the procedure went. “When the patient first came in, she was put to sleep with intravenous general anesthesia. When she was asleep, I removed teeth numbers eight and nine. For immediate extraction with implant placement, the first initial pilot hole is placed a little bit lingually from the extraction site. You want the top of the implant to come out where the tooth cingulum would be so that more porcelain can be placed toward the buccal of the crown. After this, you go in with a 2-millimeter wide twist drill, then a larger tapered twist drill, and keep increasing the diameter of the drill until you reach the desired size, which was 4.3 mm in this case. I used Tapered Groovy Titanium Nobel Biocare implants for the patient at a size of 4.3 mm in diameter. The implants had threads which made it a little wider so it could engage the bone. I then used a torque wrench to tighten the implant into the bone and I was able to obtain a force of 45 Ncm2, which tells you the primary stability of the bone. I then placed bone allograft, which included BMP-2, to promote bone regeneration. The last step was securing the healing abutments, suturing up the tissue, and adjusting the flipper to fit.” (Refer to figure 4.)

Figure 4

As previously stated, the gingival flap performed on the patient during the implant surgery resulted in blunted papillae on all four of the maxillary incisors, revealing one millimeter of cementum on the lateral incisors and shrinking the tissue making the healing abutments visible over the flipper. Composite was added to the apical portion of the flipper to mimic tooth structure and conceal the abutments (refer to figure 5).

Figure 5

The patient and oral surgeon agreed to do a cosmetic procedure called a subepithelial connective tissue graft to correct the problem. The subepithelial connective tissue graft produces exceptional color matching at the recipient site and should be considered whenever soft tissue grafting is recommended in an area of esthetic concern (Sclar, 2003). This patient received a closed bilateral palatal subepithelial connective tissue graft one month after the implants were placed. The procedure went as followed: A horizontal incision was made on the palate approximately three millimeters apical to the premolars and ranged from the mesial of the first premolar to the distal of the second premolar. A second incision was then made, which determined the thickness of the donor site. The tip of the scalpel was then reinserted inside the second incision, parallel to the palatal tissue and another incision was made, which created a subepithelial pouch. Following, vertical incisions were made within the pouch through the connective tissue to define the width of the donor site. An incision was made at the most apical portion and the connective tissue was then dissected from the subepithelial pouch. Donor tissue is composed of connective tissue, epithelium, fat, and periosteum. It was instantaneously taken and placed over the recipient bed, where it was then adjusted and sutured into place. The recipient site was prepared beforehand by revealing some connective tissue and obtaining a blood supply for the donor tissue. An absorbable collagen dressing (CollaPlug) was then placed in the subepithelial pouch to fill the dead space and aid in hemostasis. The wound was then sutured closed and healed by secondary intention (Sclar, 2003).

The patient was healing well until a week after the surgery, when a suture became unfastened, mobilizing the tissue and exposing the facial and mesial root surfaces of number seven. The patient returned for a post-op appointment and the area was examined. The oral surgeon (Dr. Kim) attempted to repair it at the appointment. The patient was anesthetized with local anesthesia, a connective tissue bed was made at the recipient site, and Alloderm was positioned over the exposed root surface of number seven and immobilized with sutures. Alloderm connective tissue grafts are composed of freeze-dried human cadaver skin with all immunogenic cellular components removed (Sclar, 2003). A coe-pak periodontal dressing was then placed over the surgical site to provide protection, help prevent postsurgical bleeding and assist in shaping newly formed tissue. The allograft failed and the mesial and facial root surfaces of number seven were exposed once again.

The patient was then referred to a periodontist with optimistic expectations of a successful tissue graft. She was seen for a consult and a treatment plan was developed. The patient had a mucogingival defect at the facial and mesial surfaces of number seven; each presented three millimeters of recession.  The papillary tissue between numbers seven and eight was absent, which presented a particular challenge for the periodontist since lost papillary tissue previously could not be regenerated. The patient returned for surgery two weeks later. Local anesthesia was used on the patient. A connective tissue bed was made on the recipient site. To receive a decent color match, the donor tissue was taken from the attached gingiva on the buccal side of teeth numbers two and three; the papilla was included in the donor tissue. It was then transplanted onto the connective tissue bed and sutured into position with the donor papilla replacing the missing papilla between teeth numbers seven and eight. A periodontal dressing was placed over the donor site to aid in healing and the patient was dismissed. The patient returned for a post-op appointment two weeks after the procedure and a good response was shown with a wide band of keratinized soft tissue support, partial facial root coverage, and regeneration of a mesial papilla.

After healing of the epithelial graft, the patient returned to her general dentist to have the abutments and crowns placed. The healing abutments were removed, impressions were taken and shades were matched and sent to the lab (refer to figures 6a and 6b).

Figure 6a

Figure 6b

The patient returned two weeks later for the crown fitting. The doctors were successful in regenerating some of the tissue on tooth number seven but were not efficacious in restoring the tissue apical to the implants. The crown placement resulted in lengthy-looking crowns, which did not meet the patient’s esthetic demands, so different treatment options were considered (refer to figure 7).

Figure 7


It was agreed to use pink porcelain crowns. The use of gingiva-colored ceramics in addition with a fixed prosthesis has been recommended for treatment of gingival recession (Capa, 2007). It can be challenging to achieve natural gingiva color so a gingival shade guide was sent to the office and used to match the tissue. An intraoral photograph was taken to assist the technician in providing the proper gingival color (refer to figure 8).

Figure 8

Pink porcelain was added to the crowns and shaped to accommodate with the anatomical contours of the maxillary incisors and completed with a glaze. They were returned to the office for the patient to evaluate. She was satisfied so they went ahead with treatment. The maxillary lateral incisors still consisted of inadequate tissue coverage (refer to figure 9), so composite material was placed on the facial and mesial surfaces to coronally extend the crown of the teeth.

Figure 9

The abutments were then secured into the implant site and the pink porcelain crowns were cemented into place. Radiographs were taken to confirm adequate crown placement and photographs were taken of the final result (refer for figures 10, 11a and 11b).


Figures 10, 11a, 11b

Dental hygienists play a key role in maintaining the replacement of avulsed teeth. They are faced with the challenge of treating patients who have avulsed teeth and educating them with proper oral hygiene instruction so they last for years to come, whether they are reimplanted or replaced with dental implants. Patients that have successfully undergone dental implant surgery should receive treatment modifications during dental care. All patients with dental implants should be treated with plastic instruments in the affected area because stainless steel or titanium instruments may scratch the surface of the implant promoting the growth of plaque biofilm; the use of ultrasonic machines should also be avoided (Todescan, Lavigne & Kelekis-Cholakis, 2012).

Individual treatment modifications may also have to be considered depending on the past periodontal health of the patient. Several studies have shown that prior periodontal infections are a significant source of periodontal pathogens and may proliferate to the dental implant. Other factors that put patients at greater risk include the presence of diabetes mellitus, poor plaque control, and cigarette smokers. Patients with any of these qualities should be closely monitored on a regular basis in hopes of extending the life of their dental implants (Todescan et al, 2012).

A thorough understanding of the clinical signs on peri-implant diseases is critical to the prognosis of the implant. There are many clinical examinations that can be used to discover the health status of a dental implant. This includes a soft tissue assessment, plaque index, clinical probing depths, bleeding on probing, suppuration, stability of soft tissue margins, mobility, and bone levels (Todescan et al, 2012).

The soft tissue assessment entails checking for clinical signs of gingival inflammation, including edema, redness, and variations of delineation and uniformity. A plaque index measuring system should also be utilized during the clinical examination. Studies have shown that implants sprayed with titanium plasma that possess a rough surface have higher plaque retention rates than smooth surface implants. On the other hand, other studies have shown no correlation between the surface texture of an implant and plaque retention. However, caution is advised when monitoring rough surfaced implants because of the possibility of greater amounts of plaque accumulation (Todescan et al, 2012).

Probing is an essential and dependable diagnostic guideline in the longitudinal monitoring of peri-implant tissues. A plastic probe should be utilized at recall appointments to measure the midaspect of the mesiobuccal, buccal, distobuccal, mesiolingual, lingual, and distolingual surfaces of the abutment. At the initial appointment after the placement of the implant, baseline probing depths should be determined. Probing depths for traditionally placed implants with supraosseous platforms generally range from two to four millimeters. Intraosseous implants or implants placed at bone level may display slightly greater probing depths. Increase in clinical probing depths along with bleeding upon probing and suppuration are generally associated with loss of attachment and should be regarded as a peri-implant disease. The clinical assessment should also include monitoring the soft tissue margins in relation to the fixed dental implant. Apically migrating gingival tissue may expose the implant surface to bacteria, increasing biofilm accumulation. Any recession around the implant should be noted and monitored (Todescan et al, 2012).

Mobility should be routinely evaluated by means of manual examination or automated testing devices such as the Periotest dental measuring instrument or the Ostell instrument. The cause of any signs of mobility should always be determined if possible. Mobility may be due to failure of the prosthetic or osseointegration. If the implant device moves as a whole unit, failure has occurred and the device should be removed (Todescan et al, 2012).

If clinical signs imply peri-implantitis is present, radiographs should be taken to confirm the diagnosis.  At each recall appointment, an effort should be made to calibrate radiographic techniques so that the relationship between bone and implant can be well defined. It is also important to establish baseline bone levels after implant placement for comparison reasons (Todescan et al, 2012).

There are three diagnoses that can be made in regards to the health of dental implants. Healthy is when no clinical signs of inflammation are present. Implant mucositis is characterized as a localized inflammatory lesion within the soft tissue, and may be recognized by redness and bleeding upon probing. Peri-implantitis is identified by a localized inflammatory lesion which also includes attachment loss around an osseointegrated dental implant. It is often correlated with increased probing depths, suppuration, bleeding on probing, and loss of supporting bone (Todescan et al, 2012).

Daily plaque removal is the most critical factor in maintaining dental implants. Therefore, it is imperative the patient have a thorough understanding of their responsibility in preserving their implants along with proper at-home care techniques. An individualized oral hygiene regimen should be provided for the patient according to the condition of the soft tissues and extent of plaque accumulation and should be reviewed at every recall appointment. Home care devices that have been shown to aid in the maintenance of dental implants include soft toothbrushes, interdental brushes without metal wiring, end-tufted brushes, gauze, many types of floss, stannous fluoride gel, and chlorhexidine rinse (Todescan et al, 2012).

In conclusion, traumatic dental injuries such as avulsion can be accompanied by many complications and can also be time consuming and costly. In addition, they may affect many aspects of life such as function, appearance, and self-esteem. But with new technology and experts in their field, missing teeth and tissue can be esthetically replaced and maintained and the patient’s quality of life and self-esteem can be returned.


1. Block, M., (2001). Anterior aesthetic implant restorations: Surgical techniques for optimal results. Color Atlas of Dental Implant Surgery (pp. 109-158).  Philadelphia, PA: The Curtic Center.
2. Capa, N. (2007). An alternative treatment approach to gingival recession: Gingiva-colored partial porcelain veneers: A clinical report. The Journal of Prosthetic Dentistry, 98(2), 82-84. doi: 10.1016/S0022-3913(07)60040-7.
3. Emerich, K. & Wyszowski, J. (2010). Clinical practice: Dental trauma. European Journal of Pediatrics, 169(9), 1045-1050. doi:10.1007/s00431-009-1130-x
4. Kenny, D. (2006). Whether to replant avulsed permanent teeth. Dental Abstracts, 51(1), 9-10. Doi:10.1016/j.bbr.2011.03.031
5. Nesiama, J. & Sinn, D., (2010). Tooth avulsion. Clinical Pediatric Emergency Medicine, 11(2), 108-111. Retrieved from http://www.sciencedirect.comttwszfctfwftbxtsdwucawvtftsbdfdv
6. Sclar, A., (2003). Subepithelial connective tissue graft technique for dental implants. Soft Tissue and Esthetic Considerations in Implant Therapy. (pp.141-162). Carol Stream, IL: Quintessence Publishing Co, Inc.
7. Todescan, S., Lavigne, S., & Kelekis-Cholakis, A. (2012). Guidance for the maintenance care of dental implants: clinical review.  Journal of the Canadian Dental Association , 78(107), 1-8. Retrieved from


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