Occupational stressors of dental hygienists in the United States

Abstract

BACKGROUND:

Demand of the work environment can cause stress. Stress can cause anxiety, depression, reduced productivity, job dissatisfaction, and health issues. Unfortunately, little attention has been placed on the stressors of dental hygienists.

OBJECTIVE:

The purpose of this study was to examine occupational stressors related to personal, environmental, and physical stressors and their relationship to job satisfaction and burnout of dental hygienists.

METHODS:

Survey research was conducted with a convenience sample of practicing dental hygienists (n = 763). The survey instrument consisted of 10 scales from the New Brief Job Stress Questionnaire and four questions related to burnout.

RESULTS:

Job satisfaction was affected by work overload, anxiety, depression, and emotional demands. Leaving clinical dental hygiene in the next year was affected by physical stress (p < 0.05), and burnout was related to the emotional demands (p < 0.05).

CONCLUSIONS:

Dental hygiene has a significant emotional component to the profession and these emotional demands were more likely to lead to burnout and affect job satisfaction. Physical demands were related to dental hygienists leaving clinical dental hygiene. Attention needs to be paid to these stressors to enhance retention and job satisfaction of dental hygienists.

Keywords

Burnout dental hygienist job satisfaction occupational stress

1 Introduction

Stress, on its own, can contribute to emotional, psychological, and physical health conditions [1]. Not only can anxiety and depression be an outcome of stress, but so too can cardiovascular disease, insomnia, digestive problems, and headaches [2]. Stress in the workplace can cause reduced productivity, absenteeism, and job dissatisfaction [2]. In the United States, one-third to one-fourth of surveyed workers reported having high levels of stress while at work [3]. Forty percent of workers in the United States also consider their job to be very stressful, with 26% of the workers saying their work causes them to be stressed or burned out [3].

Due to the demands of the work environment, pressures at work are unavoidable [4]. There are some pressures that help to keep individuals motivated and alert, but when those pressures become excessive, stress results [4]. Poor work organization, poor management, a lack of support, and unsatisfactory working conditions lead to stress at work [4]. However, stress is not something that has to come with a job; it can be prevented or managed [3]. The first step is to identify the stressors, so they can be properly addressed.

In the health professions, nursing has a substantial body of literature on occupational stress suggesting it is an issue [5 , 7]. Nurses face time pressure, excessive noise, enclosed atmospheres, inability to make a mistake, unpleasant sights, and standing for hours [5]. Even with training for these factors, stress takes its toll and causes emotional exhaustion [5]. Physicians have similar stressors in that there are increasing patient admissions, environmental stressors, increasing responsibilities, and emotional burdens [8]. In the dental field, dentists are constantly faced with new technologies, new methods, and new treatment techniques that require further education to provide the best possible care for their patients [2]. In the dental hygiene profession, stressors often arise from wanting to provide high quality preventive oral health services and the least amount of discomfort for the patient, all while being in a fast-paced work environment [1]. Also, low control over the various job functions, lack of support from co-workers, low job satisfaction, no work breaks, and anxiety from role competition with a dentist cause dental hygienists stress while on the job [1]. Identifying the occupational stressors would make it possible to develop intervention strategies such as stress management training and adjustments to the work environment to prevent burnout in the profession [9, 10]. Dental hygienists will also be able to recognize their own stressors, decrease their need for medical attention, and improve their daily lives [11]. Further research is necessary in all aspects of occupational stress, but particularly in dental hygiene as most studies use a small convenience sample size, and there is a need to extend the research to a national sample [1, 12].

The purpose of this study was to examine the relationship between occupational stressors in regards to the personal, environmental, and physical effects on the job satisfaction and burnout of dental hygienists. The personal effects are those that cause emotional responses and include anxiety, depression, and emotional demands [13]. The physical effects are those that can lead to poor health or injury [13]. The physical effects may include dizziness, joint pain, headaches, stiff neck or shoulders, back pain, eyestrain, shortness of breath, intestinal problems, loss of appetite, diarrhea, or inability to sleep well. Environmental stressors are those related to working conditions and include job overload, poor physical environment, workplace where people complement each other, career opportunity, and work engagement [13].

The research questions were: what are the occupational stressors dental hygienists experience from personal, environmental, and physical sources, as well as job satisfaction and burnout? What are the predictive relationships of stress sources on job satisfaction and burnout? What demographic variables are related to stress, burnout, and job satisfaction? Limited research has been conducted in regards to the occupational stressors of dental hygienists; further research is needed to better understand the stressors to help improve job satisfaction and maintain the health of dental hygienists.

2 Methods

This study design used survey research to collect numeric descriptions of trends, opinions, and attitudes of a population by studying a cross-sectional sample of dental hygienists [14]. The predictor variables were the occupational stressors of the dental hygienists. The outcome variables were job satisfaction and burnout. In this study, the subscales from the stress survey were utilized to predict job satisfaction and the reduction or intent to reduce work or leave the profession.

2.1 Research participants

The data was collected utilizing a web-based survey tool with the help of state dental hygiene associations, as well as through four dental hygiene professionals’ Facebook pages. A priori power analysis for this study was conducted using G*Power [15]. Using 80% power, with a medium effect size (f2 = 0.15) and alpha = 0.05 as parameters the target sample size for regression testing is 77.

Participants for this study were a convenience sample, and only licensed dental hygienists with at least one year of experience practicing in a private or public clinical setting from the United States were included. The participants were excluded if they were not a licensed dental hygienist, were retired, had less than one year of clinical practice experience, or were not currently practicing in a clinical setting.

2.2 Instrument

The study was deemed exempt in accordance with 45 CFR 46.101(B)(2) by the Massachusetts College of Pharmacy and Health Sciences University’s Institutional Review Board due to the research involving survey collection that carries minimal risk to the participants. The survey instrument was a questionnaire previously developed and validated called the New Brief Job Stress Questionnaire along with additional questions to address job satisfaction and burnout [16]. The standard version of the New Brief Job Stress Questionnaire consisted of 141 questions, with 49 different subscales, all on a four-point Likert scale [16]. Most of the scales from the New Brief Job Stress Questionnaire have shown high internal consistency reliability (Cronbach’s alpha > 0.70) [16]. The 10 subscales from the New Brief Job Stress Questionnaire utilized in this survey research included: quantitative job overload, poor physical environment, anxiety, depression, physical stress reaction, emotional demands, workplace where people complement each other, career opportunity, work engagement, and job satisfaction. The reported Cronbach’s alpha scores for the 10 subscales used in this research can be seen in Table 1 and range from 0.752 to 0.905. These specific subscales were chosen to answer the study’s research questions. It was important to explore the emotional, environmental, and physical stressors while still keeping the survey at a reasonable length. Content validity was conducted for additional questions related to burnout. Content validity feedback was evaluated by a panel of experts (n = 6) and were shown to be relevant with a S-CVI (summary content validity index) and I-CVI (individual content validity index) score of 1.

Table 1
Subscale validity

Subscale Cronbach’s alpha

Quantitative job overload 0.770

Poor physical environment Not calculated

Anxiety 0.773

Depression 0.885

Physical stress reaction 0.839

Emotional demands 0.860

Workplace where people complement each other 0.905

Career opportunity 0.848

Work engagement 0.752

Job satisfaction Not calculated

Subscale	Cronbach’s alpha
Quantitative job overload	0.770
Poor physical environment	Not calculated
Anxiety	0.773
Depression	0.885
Physical stress reaction	0.839
Emotional demands	0.860
Workplace where people complement each other	0.905
Career opportunity	0.848
Work engagement	0.752
Job satisfaction	Not calculated

Note. Cronbach’s alpha was not calculated because it was a one-item scale [14].

The final survey instrument consisted of 48 questions. The sections making up the survey included the following: demographics (7 items), emotional stressors (12 items), physical stressors (11 items), environmental stressors (12 items), job satisfaction (1 item), and burnout (5 items).

Pilot testing of the survey instrument then took place by individuals (n = 10) who met all of the study’s inclusion criteria. The participants were asked for feedback on the length and ease of comprehension of the survey. The results from the pilot testing were not included in the final study results.

2.3 Procedure

The state dental hygiene associations were contacted through email or telephone to request distribution of the link to the study’s questionnaire in Survey Monkey^® to members via member mailing lists, social media, or on their website. The state dental hygiene associations that participated included Alaska, New Hampshire, New Jersey, Tennessee, Washington, and West Virginia. The dental hygiene professionals’ Facebook pages included Dental Hygiene Professionals, Dental Hygiene Network, Dental Hygiene Life with Andy RDH, and Dental Hygienists Talk. The participants from the professional dental hygiene’s Facebook pages clicked a link provided in a post inviting them to participate. The survey took approximately 5–10 minutes to complete. There was a reminder to complete the survey one to two weeks after the original invitation to participate. No incentives were offered to the participant for survey completion.

2.4 Statistical analysis

All data was analyzed for descriptive statistics (mean, median, standard deviation, and frequency) and examined for assumptions of normality and linearity. Subscales for Likert scale responses in the questionnaire were calculated by averaging item scores for each subscale to create a single score. Missing data responses were analyzed, and responses were weighted when necessary to adjust for data missing at random.

Associations between all variables were examined using Spearman and Pearson correlations where appropriate and chi-square tests of independence. A test of internal reliability assessed the interrelationships of items for each subscale using Cronbach’s alpha [17]. Regression was used to determine the predictive relationship between subscales and burnout questions. Depending on assumptions of normality, either linear, logistic, ordinal, or multinomial regression was used [18]. All statistical hypothesis testing for this study used an alpha level of 0.05 and reported 95% confidence intervals (95% CI), as well as all other effect size statistics where appropriate [19].

3 Results

A total of 972 people attempted to take the survey and 848 of those completed it for a completion rate of 87.2%. Missing data analysis resulted in 78 cases being removed for more than 80% of the responses missing. Of the remaining participants, 6 were removed for either reporting 0 hours of work per week or 0 years work experience and 1 was removed for living outside of the U.S., suggesting they did not meet the inclusion criteria. The final sample size for analysis was n = 763. All analysis was conducted using Statistical Package for the Social Sciences (SPSS^® 23).

The sample consisted of 758 females (99.3%) with a mean age of 41.6 (SD = 12.7), a mean number of hours worked per week of 31.0 (SD = 8.2), and a mean number of years in practice of 15.56 (SD = 12.9). Table 2 shows the demographic information and descriptive information for survey responses to burnout items: “In the last year I have reduced my clinical work schedule,” “I will reduce my clinical dental hygiene work schedule,” “I plan to leave the clinical dental hygiene field,” and “If you indicated you will leave the clinical dental hygiene field, what is the primary reason(s).”

Table 2
Demographic information, job satisfaction, and burnout responses (n = 763)

Mean SD 95% CI M

Age 41.6 12.8 40.7–42.5

Work week, hrs 31.0 8.2 30.4–31.6

Practice, yrs 15.6 12.9 14.7–16.5

Job satisfaction 3.01 0.9 3.0–3.2

Frequency % 95% CI

Leaving field within a year 36 4.7 3.3–6.5%

Cause: burnout 93 12.2% 10.0–14.7%

	Mean	SD	95% CI M
Age	41.6	12.8	40.7–42.5
Work week, hrs	31.0	8.2	30.4–31.6
Practice, yrs	15.6	12.9	14.7–16.5
Job satisfaction	3.01	0.9	3.0–3.2
	Frequency	%	95% CI
Leaving field within a year	36	4.7	3.3–6.5%
Cause: burnout	93	12.2%	10.0–14.7%

Note. SD = standard deviation of the mean, 95% CI M = 95% confidence interval of the mean. For frequencies, % = frequency/n^*100, 95% CI = 95% confidence interval of proportions.

Table 3 contains response central tendencies for all occupational stress questions and derived scales. Each variable was either reverse coded or retained the original value for consistency of interpretation. After reverse coding, there were higher values for individual occupational stress and burnout items to indicate higher values of those constructs (e.g. 4 on the anxiety scale indicates higher occupational anxiety than 3, 2, or 1). Each scale was evaluated and showed acceptable internal consistency (work anxiety, Cronbach’s alpha = 0.81 to work depression, Cronbach’s alpha = 0.93) except the two work engagement (0.42), therefore, each were retained as single items. Scales were developed according to Inoue et al.’s (2014) recommendations and calculated using the mean score of all items for each scale.

Table 3

Mean score for each occupational questionnaire scale (n = 763)

	Mean	SD	95% CI
Negative
Work overload	2.6	0.7	2.6–2.7
Anxiety	2.4	0.8	2.4–2.5
Depression	1.9	0.8	1.8–2.0
Physical stress	2.2	0.7	2.1–2.3
Emotional demands	2.5	0.8	2.4–2.6
Positive
Work complement	2.4	0.9	2.3–2.5
Career opportunity	2.7	0.9	2.6–2.8
Work engagement	3.0	0.7	2.9–3.1

Note. SD = standard deviation of the mean, 95% CI = 95% confidence interval of the mean.

To examine the predictive relationship of occupational stress scales and job satisfaction and burnout, three regression models were created. Intention to leave the field was dichotomized into those who intend to leave within the next year and everyone else, while reason for leaving the field was dichotomized into participants who selected burnout and everyone else. Before conducting the regression models, Pearson’s correlations for each of the occupational stress scales (including two work engagement items) were calculated with job satisfaction, intention to leave the field, and burnout as the reason to leave the field, Table 4. The scale scores were significantly correlated with each other but appeared to be distinct constructs based on moderate correlation coefficients.

Table 4

Correlation matrix for occupational scales and outcome variables (n = 763)

	1	2	3	4	5	6	7	8	9	10	11	12	13	14
1 Overworked	–
2 Anxiety	0.22	–
3 Depression	0.16	0.56	–
4 Physical	0.18	0.55	0.64	–
5 Emot. demands	0.34	0.36	0.31	0.25	–
6 Complement	–0.21	–0.25	–0.19	–0.29	–
7 Opportunity	–0.08	–0.22	–0.17	–0.15	–0.23	0.56	–
8 Engagement	–0.08	–0.27	–0.26	–0.22	–0.22	0.34	0.49	–
9 Poor environment	0.29	0.23	0.16	0.20	0.26	–0.30	–0.28	–0.28	–
10 Job satisfaction	–0.27	–0.38	–0.37	–0.28	–0.47	0.42	0.40	0.46	–0.38	–
11 Past reduced	0.02	0.04	–0.01	0.01	–0.05	0.02	0.04	0.06	–0.07	0.02	–
12 Future reduce	–0.07	–0.03	–0.10	–0.12	–0.11	0.01	0.05	0.08	–0.08	0.11	0.25	–
13 Leave 1 year	0.01	0.13	0.08	0.13	0.07	–0.06	–0.06	–0.08	0.12	–0.14	–0.17	–0.32	–
14 Burnout	0.13	0.18	0.18	0.14	0.20	–0.15	–0.18	–0.19	0.14	–0.28	–0.11	–0.30	–0.24	–

Note. All correlations coefficients are Spearman’s rank order rho. Emot. = emotional. Bolded coefficients are significant at p < 0.001.

A multiple linear regression was calculated to predict job satisfaction based on occupational stress scales. The model was significant (F(5, 757) = 62.07, p < 0.001) with an adjusted R² of 0.29. The results indicated.

Job satisfaction = 4.95 + (–0.12)*overworked + (–0.19)*anxiety + (–0.17)*depression + (0.04)*phy-sical stress + (–0.37)*emotional demands (1).

A one unit increase in predictor variables resulted in a decrease of between 0.12 (work overload) and 0.37 (emotional demands) in job satisfaction scores. All predictors were statistically significant (p < 0.001) except the physical stress scale (p = 0.47), Table 5.

Table 5

Multivariable linear and logistic regression models (n = 763)

	B	SE B	β	R²	F
Job satisfaction				0.29	62.06^**
Work overload	–0.12	0.04	–0.09^**
Anxiety	–0.19	0.04	–0.17^**
Depression	–0.17	0.05	–0.16^**
Physical stress	0.04	0.06	0.03
Emotional demands	–0.37	0.04	–0.34^**
	β	SE β	e^β	C statistic	95% CI
Intention to leave within 1 yr				0.71^**	0.62–0.79
Work overload	–0.21	0.26	0.81
Anxiety	0.53	0.28	1.70
Depression	–0.17	0.27	0.85
Physical stress	0.72	0.34	2.01^*
Emotional demands	0.20	0.24	1.23
Cause of leaving: burnout				0.72^**	0.67–0.77
Work overload	0.26	0.17	1.30
Anxiety	0.31	0.18	1.36
Depression	0.27	0.18	1.30
Physical stress	0.07	0.23	1.01
Emotional demands	0.57	0.16	1.78^*

Note. ^*p < 0.05. ^**p < 0.001.

A five-predictor logistic model was fitted to the data to test the relationship between occupational stress scales and likelihood of leaving the dental hygiene field in the next year. Predicted logit of (leaving field 1 year) = –5.82 + (–0.21)*overworked + (0.53)*anxiety + (–0.16)*depression + (0.73)*phy-sical stress + (0.20)*emotional demands. (2).

The higher the physical stress score, the more likely it was that a dental hygienist indicated it was their intention to leave the field in the next year (p < 0.05; Table 5). An increase in physical stress scores were 2.01 times more likely to endorse leaving the field within a year.

A five-predictor logistic model was fitted to the data to test the relationship between occupational stress scales and likelihood of selecting burnout as the reason for leaving the dental hygiene field in the future.

Predicted logit of (burnout) = –5.77 + (0.26)*overworked + (0.31) * anxiety + (0.27) * depression + (0.07)*physical stress + (0.57)*emotionally deman-ding. (3).

According to the model, a participant endorsing burnout was significantly related to emotional demands scores (p < 0.05; Table 5). The higher the emotional demands scale score, the more likely it was that a hygienist would cite burnout as their reason for leaving. Holding all other scales constant, a one unit increase in emotional demands scores results in being 1.78 times more likely to endorse leaving the field within a year.

The analysis of correlations to assess the relationship between occupational stress and outcome variables found age was negatively correlated with leaving the DH field (r(763) = –0.27, p < 0.001) and the number of hours worked per week was positively correlated with reducing work schedule (r(763) = 0.24, p < 0.001), intention to delay leaving the DH field (r(763) = 0.17), and job satisfaction (r(763) = 0.14). All other correlations were non-significant (p > 0.05) or r < 0.10.

4 Discussion

This study examined occupational stress and its relationship to job satisfaction and burnout in practicing dental hygienists. When looking at the first research question to determine the stressors dental hygienists experience, there was no single predictor variable that scored outside the neutral zone of 2-3 on a 4-point Likert scale, except depression. The findings also suggest work overload, anxiety, depression, and emotional demand all affect job satisfaction, while physical stress, instead, was related to leaving the field within one year. Next, the emotional demands subscale related to burnout. Also, the results indicated the demographic variables were unrelated to leaving the clinical dental hygiene field within one year and leaving due to burnout.

Previous research using the New Brief Job Stress Questionnaire showed an average score for most scales being between 2.0 and 3.0 on a scale of 1 to 4, except depression (3.27) and physical stress reactions (3.22) [16]. The current research found similar findings: the predictive variables mean score ranged from 2.2 to 3.0 with a higher score of 4 and a lower score of 1 on the Likert scale, except depression (1.9). For positive factors, participants reported in order of most to least work engagement (3.0), career opportunity (2.7), and an environment where employees complement each other (2.4). Given the mean score on most scales in this study were between 2.2 and 3.0, depression was the exception. The participants reported being less depressed especially when compared to the other variables.

When reviewing the second research questions, the predictive relationship of stress sources on job satisfaction found workload to have an effect, while emotional demands had the greatest effect. A study by Tür et al. (2016) found workload was the biggest stressor for physicians. Physicians tend to have a number of patients in various exam rooms at one time, while dental hygienists tend to have one patient at a time, so even though work overload can affect job satisfaction for dental hygienists, emotional demand is greater because of the one-to-one time with each patient. This study suggests dental hygienists become emotionally upset about their work, emotionally involved in work, and feel an emotional burden. Similar to a study by Bretherton et al. (2016) where dentists reported feeling a strong sense of responsibility and professionalism to their patients leading to occupational stress. The sharing of emotions and concern about causing the patient pain are two other occupational stressors also shown to affect the emotions of the dentist [10]. These stressors coincide with those of dental hygienists as both work chairside with a patient. Dentists and dental hygienists both feel a connection to the patient in the effort to help them achieve good oral health. These findings and those of Bretherton et al. (2016) show there is a need to intervene to help decrease the emotional demands on those in the dental field.

Not only are work overload and emotional demands two variables found to affect job satisfaction in this research, but anxiety and depression were found to have an effect on job satisfaction, as well. Lang and Gilpin (1990) found dental hygienists suffer from depression and anxiety. Lopresti (2014) noted that depression and anxiety, along with other factors, may result from risk factors such as demanding work schedules and lack of organization within the office. Further, depression and anxiety could result from stress, and elevated rates of anxiety and depression has been linked to occupational stress [1, 20]. Even though this study found depression and anxiety to be factors that affect job satisfaction, the mean score of depression was that of being less depressed in this study (mean = 1.9). This is inconsistent with findings from the other studies as they found depression to be higher in dental hygienists [9, 12].

Putting job satisfaction aside, the second research question also observed the predictive relationships of stress sources on burnout. When assessing whether a dental hygienist was going to leave the field in the next year, the most prominent variable was the physical stress score. The physical stress score relates to feeling dizzy, joint pain, headaches, stiff neck and/or shoulders, lower back pain, eyestrain, heart palpitations or shortness of breath, stomach and/or intestinal problems, loss of appetite, diarrhea and/or constipation, and inability to sleep well. A combination of these factors determined if a dental hygienist was going to leave the clinical dental hygiene field in the upcoming year. Based on the results, the more these factors were felt, the greater the chances of the dental hygienist leaving in the next year. Nurses have also reported headaches and fatigue in relation to physical stress [5]. Lopresti (2014) noted that headaches and gastrointestinal problems could be symptoms of stress. Further, stress can cause cardiovascular disease, type 2 diabetes, and a compromised immune system [9]. These outcomes of stress need to be prevented through work breaks, exercise, meditation, or relaxation [5].

Further, this research found an emotionally demanding job was the most significant factor when a dental hygienist is planning to leave clinical dental hygiene due to burnout. Dental hygienists are constantly pushing themselves to find ways to minimize the pain they may cause to their patients while also trying to find the best, individualized, treatment plan [1]. It is a challenge for dental hygienists to avoid causing pain while still completing treatment, all while having developed a personal relationship with the patient [1]. Even more so, when no oral health improvement occurs, the dental hygienist will take it personally [1]. These emotional demands increase burnout, and it is important to address these to keep dental hygienists in the clinical field.

When reviewing correlations between demographic variables for the third and final research question, there was a low percentage (4.7%) of dental hygienists leaving clinical dental hygiene within one year. Of those participants, the cause of leaving due to burnout was 12.2%. The results also showed older dental hygienists were less likely to leave the field.

More research is needed to identify why and how these stressors occur and to determine the connection between emotional demands and burnout. The occupational stressors were related to job satisfaction and not burnout, but burnout and job satisfaction were associated. The complex link between occupational stress, job satisfaction, and burnout is valuable to understand and future studies would benefit from identifying how each variable interacts. There are many sources of occupational stress and this study only focused on more common examples. Further research is needed to determine what other occupational stressors or other factors influence a person’s decision to leave the field and experience burnout.

4.1 Limitations

There are a number of limitations that could have occurred with this study. The first limitation is dependent upon the type of sampling: convenience sampling. Unfortunately, convenience sampling limits generalizability beyond the study sample; however, the study had a very large sample size making the results important to note [21]. There are also limitations in the use of the web-based survey. The state dental hygiene associations could have had undeliverable emails to their members, technical difficulties, or potential participants could have lacked the technical expertise to complete the survey [22]. If the location has limited access to technology, they would be unable to take the survey [22]. These could all lead to non-response bias.

The chosen predictor variables may also not answer the research question posed. There are various job stressors, and this survey only tested nine independent variables, and two different outcome variables. The original survey examined 49 different subscales included in job demands, job resources: task-level, job resources: workgroup-level, job resources: company-level, and outcomes [16]. Because of this, there is a possibility other job stressors not included in the study’s survey are causing the participant to feel burned-out at work, causing him or her to want to reduce hours or leave the field, or have feelings of being unsatisfied with work.

5 Conclusion

This study explored occupational stressors of dental hygienists in relation to personal, environmental, and physical sources as well as job satisfaction and burnout. Job satisfaction is related to anxiety, depression, work overload, and, most prominently, emotional demands. Burnout being the reason for leaving is also closely related to emotional demands. However, leaving within the next year is related to the physical stress reaction over all other scales. The findings of this study could help employers and workers recognize the causes of stress to avoid or minimize the adverse effects [2]. Knowing these stressors can help to decrease the need for medical attention and improve quality of life, as well as help determine when and how to intervene to prevent stressors for dental hygienists [11].

Conflict of interest

The authors declare that they have no conflict of interest.

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