Health topics emerged from brief-motivational interviewing: A randomized clinical trial.

OBJECTIVE: The goal of this study was to analyse transcription of audio recordings to determine health topics that emerged from brief-motivational interviewing (MI) compared to traditional oral hygiene instructions (OHI). METHODS: Fifty-eight periodontal maintenance patients were randomized to a brief-MI or traditional OHI group for a longitudinal 1-year clinical trial. Both groups received four patient education sessions per their assigned group. Audio recordings were transcribed and coded. The overarching themes and subthemes emerged were quantified and reported as the number of instances per participant. Global scores and behavioural counts were compared across baseline, 4, 8, and 12-month research visits using mixed-effect models. RESULTS: Of the six overarching themes, the brief-MI group evoked more topics toward total health. Oral home care behaviours (15 vs. 10.2) and oral diseases/conditions (3.3 vs. 1.9) were discussed more in the brief-MI group compared to the traditional OHI group. This positive outcome for the average number of times a health topic was discussed in the brief-MI group compared to the traditional OHI group continued for the remaining major themes: lifestyle behaviours (1.0 vs. 0.4), nutrition (2.6 vs. 0.8), emotional/mental health (1.8 vs. 0.8) and general health (1.2 vs. 0.4). CONCLUSION: This study identified that brief-MI was a more successful communication approach to increase discussions of oral home care behaviours, oral diseases/conditions, lifestyle behaviours, nutrition, emotional/mental health and general health compared to traditional OHI in individuals with periodontitis.

Effect of scaling and root planing with and without minocycline HCl microspheres on periodontal pathogens and clinical outcomes: A randomized clinical trial.

BACKGROUND: This study tests the effects of scaling and root planing (SRP) versus SRP plus minocycline hydrochloride microspheres (SRP+MM) on 11 periodontal pathogens and clinical outcomes in Stage II-IV Grade B periodontitis participants. METHODS: Seventy participants were randomized to receive SRP (n = 35) or SRP+MM (n = 35). Saliva and clinical outcomes were collected for both groups at baseline before SRP, 1-month reevaluation, and at 3- and 6-month periodontal recall. MM were delivered to pockets ≥5 mm immediately after SRP and immediately after the 3-month periodontal maintenance in the SRP+MM group. A proprietary saliva test* was utilized to quantitate 11 putative periodontal pathogens. Microorganisms and clinical outcomes were compared between groups using generalized linear mixed-effects models with fixed effects and random effects terms. Mean changes from baseline were compared between groups via group-by-visit interaction tests. RESULTS: Significant reduction in Tannerella forsythia, Treponema denticola, Fusobacterium nucleatum, Prevotella intermedia, Parvimonas micra, and Eikenella corrodens were identified at the 1-month reevaluation after SRP+MM. Six months after SRP with a re-application of MM 3 months after SRP, Fusobacterium nucleatum, Prevotella intermedia, Campylobacter rectus, and Eikenella corrodens were significantly reduced. SRP+MM participants had significant clinical outcome reductions in pockets ≥5 mm at the reevaluation, 3- and 6-month periodontal maintenance, and clinical attachment loss gains at the 6-month periodontal maintenance. CONCLUSION: MM delivered immediately after SRP and reapplication at 3 months appeared to contribute to improved clinical outcomes and sustained decreased numbers of Fusobacterium nucleatum, Prevotella intermedia, Campylobacter rectus, and Eikenella corrodens at 6 months.

Functional Oral Health Literacy and Periodontal Health.

Purpose: Growing evidence associates low oral health literacy (OHL) with poor oral health outcomes. While nearly half of United States adults have periodontal disease (PD), there are conflicting results on association between OHL and PD. The purpose of this pilot study was to explore the association between functional OHL and periodontal health as defined by the American Academy of Periodontology (AAP) classification system.Methods: A cross-sectional study was conducted with a convenience sample of dental patients presenting for care at a Midwestern Federally Qualified Health Center. Functional OHL was measured using the Oral Health Literacy Adults Questionnaire (OHL-AQ), and periodontal health was measured clinically and categorized by stage and grade using the recently revised AAP classification system. Additional demographic factors and health history information related to periodontal health were collected. Descriptive analysis reported the median and range for ordered variables, and frequency and percentages for categorical variables. Wilcoxon rank sum test, Kruskal-Wallis test, and Spearman correlation coefficients were used to find association between functional OHL and periodontal health.Results: Among fifty-four participants, statistically significant associations were found between OHL-AQ scores and AAP staging and grading categories. Periodontal disease stage increased with age, and periodontal disease grades progressed among participants with diabetes. No associations were found between periodontal health and sex, race, ethnicity, education, insurance, or country of origin.Conclusion: Functional oral health literacy had a significant inverse relationship with both AAP periodontal disease staging and grading. A larger study is needed to confirm the findings of this pilot study.

Impact of Brief Motivational Interviewing on Periodontal Clinical Outcomes: A randomized clinical trial.

Purpose: Patient education and oral hygiene instruction (OHI) communication play a key role in the dental hygiene process of care. The purpose of this study was to determine whether brief motivational interviewing (BMI) was superior to traditional OHI in improving periodontal health. Chairside time needed to deliver traditional OHI as compared to BMI was also compared.Methods: A convenience sample of 60 participants were randomized into two groups. The control group received traditional OHI and the test group received BMI. Periodontal indicators of disease were collected by a blinded examiner. Interventions for both groups and data collection occurred at four time points over a 12-month period. Periodontal outcome measures were plaque score, bleeding on probing (BOP), and gingival index (GI).Results: Both groups showed significant reductions in plaque score, BOP, and GI over time. The control group had an improvement in plaque score compared to the test group at visit three (p=0.05) and at visit four (p=0.03). The test group had an improvement in GI score compared to the control group at visit four (p=0.03). Chairside time was shorter in the control (OHI) group at each time point (p<0.01).Conclusion: Both traditional OHI and BMI patient education communication methods improved periodontal outcomes measured by plaque score, BOP, and GI. The inclusion of BMI in patient education sessions was demonstrated to be feasible within the time constraints of the dental hygiene recare appointment.

Dental hygienists' use of motivational interviewing and perceptions of effectiveness in changing patient behaviors.

BACKGROUND: The University of Minnesota (UMN) Dental Hygiene (DH) program devotes considerable time developing students' competency using motivational interviewing (MI). However, the extent to which graduates use MI in clinical practice and their perceptions of MI effectiveness in changing behavior is unknown. METHODS: A cross-section of UMN dental hygiene classes from 2010-2019 were emailed an electronic survey using Qualtricsxm software (n = 208). The survey instrument collected demographic information and queried respondents' current MI use and perceptions of its effectiveness in changing patients' behavior. Survey questions were aligned with the constructs of the Theory of Planned Behavior (TPB): attitudes, subjective norms, and perceived behavioral control. Data analyses included descriptive statistics, cross-tabulations, and one-way ANOVA tests. RESULTS: There were 73 responses for a 35% response rate and 58 surveys (28%) included in data analysis. Respondents (95%) used MI, held positive attitudes toward MI and perceived MI to be an effective behavior counseling method (98%). However, respondents expressed concerns about patients' abilities to change behaviors. The three TPB constructs were found to be predictors of MI use in the clinical environment. A significant association was found between age and the TPB construct: behavioral control (p = 0.02). CONCLUSION: The majority of respondents reported using MI in clinical practice. According to the TPB, respondents exhibited strong behavioral intentions to use MI. Respondents held favorable attitudes toward MI and believed it to be effective in motivating positive behavior change. Respondents were confident in their MI skills and felt supported to use MI in their work environments.

A comparison of dental therapy and dental students' clinical performance.

The aim of the study was to determine if there is a difference between dental therapy students' clinical performance as compared to dental students at the University of Minnesota. An ex post facto research design was used to compare dental therapy students' and dental students' performance on selected clinical procedures. Dental students and dental therapy students from the graduating classes of 2016, 2017, and 2019 at the University of Minnesota comprised the study sample. Fisher's exact test was used to compare pass rates, and Wilcox rank sum test was used to compare performance scores. Dental therapy students' clinical performance on competency examinations and scores on daily clinical procedures showed no statistically significant difference when compared to dental student performance. There was no overall statistical difference in clinical performance between the three student cohorts. Dental therapy students performed equally as well as the dental students.

Caries Management by Risk Assessment vs. Traditional Preventive Strategies: Effect on Oral Health Behaviors and Caries Diagnoses: A Retrospective Case-Control Observational Design.

Results showed patients who had undergone Caries Management by Risk Assessment (CAMBRA) had statistically significant lower plaque scores and improved their oral self-care behaviors. This study supports existing evidence that the use of caries management by risk assessment appears to offer a preventive approach to oral health care delivery.

Human Papillomavirus Content Inclusion in Dental Hygiene Program Curricula in the United States.

Purpose: Human papillomavirus (HPV)-related oropharyngeal cancers (OPC) have significantly increased over the past three decades despite vaccine availability to prevent carcinogenic HPV types. Dental hygienists are well-positioned to provide HPV counsel to patients; however, most do not feel prepared to do so. The purpose of this study was to examine HPV content inclusion in dental hygiene program curricula in the United States (US).Methods: Dental hygiene program directors in the US were invited to participate in an electronic survey (n=309). The 20-item survey assessed the curricular content related to HPV as well as the faculty training in this area. Descriptive statistics were used to analyze the data.Results: Ninety surveys were returned for a response rate of 29%. Most programs spent up to 2 hours on HPV content. Students across all institutional settings received education on OPC risk factors (66.3%); HPV screening, referral, and management (78.7%); HPV vaccine knowledge (79.8%); and communication skills about HPV (77.5%). The majority of HPV-related content was taught by dental hygiene faculty, although dentists, oral pathologists or medical specialists were involved across all institutional settings.Conclusion: Results indicate that dental hygiene programs, regardless of institutional setting, provide two hours or less of HPV didactic content and clinical application. More research is needed to confirm the adequate time and teaching strategies required to assure that dental hygienists are well-prepared to address HPV preventive strategies.

Efficacy of a Prototype Solution to Facilitate the Removal of Supragingival Dental Calculus: A proof of concept study.

Purpose: The purpose of this study was to determine whether the adjunctive use of an experimental calculus disruption solution (EXP-955), combined with the exclusive use of hand instruments, decreases the amount of time required to remove supragingival dental calculus deposits.Methods: A single-site, randomized, split-mouth clinical trial was conducted to compare the time needed to remove supragingival dental calculus on deposits pretreated with an experimental calculus disruption solution vs. calculus deposits that were not pretreated. Quadrants were randomized to either the treatment or control group and the principal investigator (PI) was timed while using hand instruments to remove the calculus. At the end of each session, both the subjects and the PI completed a questionnaire assessing their perceptions regarding the various aspects of the appointment and the solution. Descriptive statistics were used to analyze the data. Recurring themes from the questionnaire were examined.Results: Twenty-five healthy subjects, each having two quadrants matched for number of teeth and level of calculus deposits, completed the study (n=25). A statistically significant difference was found in in the supragingival calculus removal times between the control, (M=12.5 minutes; SD=6.0), and the treatment, (M=9.7; SD=4.6), quadrants; Mean difference (95% CI) = 2.8 (1.8-3.7), p<0.0001. Thematic analysis of the questionnaire responses showed that the perceptions of the principal investigator and subjects were positive towards the use of the solution with less pain being a common participant comment. The experimental calculus disruption solution was well tolerated by all subjects.Conclusions: Results from this proof of concept study provide preliminary evidence that use of an experimental calculus disruption solution (EXP-955) reduced the time needed to remove supragingival calculus while using hand instrumentation.

Using motivational interviewing to reduce parental risk related behaviors for early childhood caries: a pilot study.

BACKGROUND: Decades of epidemiological studies have documented high rates of early childhood caries (ECC) among American Indian and Alaska Native (AIAN) children. The aim of this pilot study was to investigate if a motivational interviewing (MI) intervention improved oral self-care behaviors of AIAN caregivers of infants, and determine if the MI intervention promoted positive changes in caregivers' ECC risk-related behaviors. METHODS: Caregivers of infants presenting for well- child visits in a medical clinic were randomized to treatment and control groups. At the first visit, a caries risk test (CRT) for cariogenic bacteria was completed for both groups. The Parental Care of Child's Teeth (PCCT) was administered at the second visit and used to assess ECC risk-related behaviors. Over the course of four well-child visits, caregivers in the treatment group participated in a MI discussion focusing on behavior changes and desired outcomes for their personal oral health and their child's. The duration of the intervention was 1 year. The control group was given oral health information traditionally provided at well-child visits. At the fourth well-child visit, the CRT and PCCT questionnaire were administered again. RESULTS: The mean bacterial load for mutans streptococcus (MS) was similar at both visits. A slight reduction in the mean bacterial levels of lactobacilli was observed in both the test and control groups after the last visit, although not at a level of statistical significance. The treatment group showed minimal improvement in child feeding practices and nighttime bottle habits. CONCLUSIONS: Motivational Interviewing had little effect on oral self-care behaviors as measured by bacterial load, nor did MI reduce parental risk related behavior for early childhood caries. TRIAL REGISTRATION: Clinicaltrials.gov# NCT04286256. Retrospectively registered, February 26, 2020.

Reflective Learning Outcomes of Community-Based Experiences: A Qualitative Study.

The aim of this study was to explore the meaning of community-based experiences for senior dental and dental hygiene students through the use of critical incident essays. A total of 108 senior dental students and 22 senior dental hygiene students were invited to participate in the study. Each student was required to write about one critical incident that occurred at one of four community clinic rotation sites during the 2012-13 school year. The participation rate was 78% of the students. Professional responsibility, a willingness to volunteer, and an understanding of the importance of oral health education were the main themes that emerged from analysis of the essays. These results suggest that community-based learning, with reflection, challenged how these students perceived oral health disparities and expanded the meaning of professional responsibility for them.

Using Situated Learning Theory to Build an Interactive Learning Environment to Foster Dental Students' Professionalism: An Ignite Project.

Recognition that professionalism is at the heart of dentistry's contract with society has led to an emphasis on educational strategies designed to improve cultivation of professional behaviors. The aim of this study was to investigate the effectiveness of a project based on situated learning theory and using an Ignite format to support dental students' learning and promote professionalism. Learning activities were evaluated in terms of new thinking, changing perspectives, and professional relationships. Professional relationship development and professional self-identity were explored. First-year dental students (n=108) enrolled in a two-semester professional development course at one U.S. dental school in fall 2017 comprised the study sample; all participated in the study. The mixed-methods study design used simultaneous triangulation with the qualitative component adding insight to the evaluation results. A 25-question evaluation form was used to collect quantitative data, and student self-assessment essays provided qualitative information. On the survey, the students' responses were generally agree/strongly agree and ranged from 60% (creating the presentation, changed perspective on academic integrity) to 98% (interaction and discussion with facilitators, appreciate professional relationships beyond dental school). Four themes emerged from content analysis of the essays: Behavior and Consequences: Academic Integrity and Professionalism, Patient Trust: Conflicts of Interest, Professional Interactions, and Professional Standards and Reputation. Overall, this Ignite project was found to advance the desired learning goals with respect to initial professional development. The social interactions with peers and outside practitioners facilitated introspection and learning. Students saw themselves as part of a profession, they started to appreciate and develop professional relationships, and many left the event with a deeper understanding of issues related to academic integrity, professional behavior, and conflicts of interests in dental practice.

Introducing and Evaluating Intraprofessional Team-Based Care Delivery in a Dental School Clinic: A Pilot Study.

There is growing interest in developing more efficient, patient-centered, and cost-effective models of dental care delivery using teams of professionals. The aims of this small pilot study were to assess the number of patient visits, type and number of procedures performed, and clinic revenues generated by an intraprofessional team of dental, dental hygiene, and dental therapy students and to determine the students' and patients' perceptions of this model of care. Sixteen senior students from three student cohorts (dental, dental hygiene, and dental therapy) at the University of Minnesota piloted a team-based dental delivery model from January to April 2015. The group was named the Team Care Clinic (TCC), and the team for each clinical session consisted of one dental student, three dental hygiene students, and one dental therapy student. Data were collected from the school's database to determine the number of patient visits, type and number of procedures performed, and clinic revenue generated by the TCC. Focus groups were used to assess student perceptions of the experience, and patient satisfaction surveys were administered to assess the patients' experience. The TCC students were given twice as many patients as non-TCC students, and they managed them effectively. Working as a team, the TCC student providers completed twice as many procedures per patient encounter as non-TCC students. Patients and students said their experiences in the TCC were positive, and students expressed a preference for team-based care delivery. The results of the study suggest the team-based dental care delivery model is promising. Team-based care delivery may allow providers to accomplish more during a patient appointment and increase provider satisfaction.

Dental School Faculty Attitudes Toward Dental Therapy: A Four-Year Follow-Up.

This study is a follow-up to a 2010 study at one U.S. dental school that found faculty attitudes toward the dental therapy model were mixed and there was a clear divide in attitudes between faculty members who were full-time educators and part-timers who also practiced outside the educational institution. The aim of this study was to determine faculty attitudes toward and perceptions of the dental therapy model at the same school four years after implementation of the dental therapy program. The identical questionnaire used in 2010 was used in this survey conducted from November 2013 to January 2014. All 254 full-time and part-time faculty members were invited to participate; responses were received from 75 faculty members, for a 30% response rate. Four years after the initial survey, the respondents showed greater acceptance of dental therapists and of dental therapy as a mechanism for addressing access to care problems. A majority of the respondents reported feeling a personal responsibility to ensuring the dental therapy model succeeded (52%); indicated being comfortable having a dental therapist provide care for their patients (60%); and agreed that the ability to delegate work to a dental therapist would make a dentist's job more satisfying (54%). Faculty members who also worked in a private practice viewed the role of dental therapists in private practice more favorably in 2014 than in 2010. This study provides insight into how attitudes of educators toward a new profession evolve over time. The faculty appeared to be undergoing a reorientation on the topic of dental therapy. This transition in point of view may have been facilitated by factors such as continued exposure to the new professionals, information sharing, and time.

Did Intraprofessional Training with Dental Therapists Affect Dental Students' Attitudes Toward Caring for the Underserved?

Dental therapy was recently introduced as a new oral health care workforce model to increase care for vulnerable populations in Minnesota. Nine dental therapy and 98 dental students began intraprofessional training at the University of Minnesota in 2009. The aim of this longitudinal study was to determine whether intraprofessional education with the dental therapy students would affect the dental students' attitudes toward caring for underserved populations. One class of dental students was surveyed annually between 2009 and 2013 using the Attitudes Toward Health Care survey to measure attitudinal changes about treating vulnerable patients across their four years of dental school. Participation ranged from 68% to 99% in each year. The results showed that the dental students had positive attitudes toward treating vulnerable patients on entering dental school, but their attitudes became less positive over the four years. While the composite survey results were similar to other studies using the same instrument, variations were seen by domain. These students' attitudes about societal expectations and personal efficacy remained stable, while their dentist/student responsibility and access to care attitudes showed statistically significant declines. Their positive attitudes toward treating the underserved declined over four years regardless of intraprofessional training with dental therapy students. As attitudes toward caring for vulnerable patients are shaped by both personal attitudes and societal norms, additional research is needed to determine whether the addition of an intentional curricular thread may alter results over time compared to intraprofessional training alone.

Dental therapy practice patterns in Minnesota: a baseline study.

OBJECTIVES: A chronic shortage of dentists, the importance of oral health, and the lack of access to care led to the introduction of a new oral health practitioner in Minnesota, the dental therapist. Dental therapy graduates from the University of Minnesota have been in practice since 2012. To date, there has been no formal study of how they have been incorporated into dental practice. The purpose of this study was to obtain baseline knowledge of dental therapists' practice patterns in Minnesota and determine if dentists' patterns of work changed after a dental therapist was employed. METHODS: Four dental practices were sampled purposefully to obtain various practice types and geographic locations within Minnesota. Secondary data were collected from practice management software databases in each practice between January-March, 2015. Data were used to describe the work undertaken by dental therapists, the types of patients seen and payer mix. Additionally, data from 6 months before and after employment of the dental therapist were collected to determine whether dentists' practice patterns changed after a dental therapist was employed. RESULTS: Dental therapists were employed full-time, seeing an average of 6.8 patients per day. No distinct pattern emerged with regard to ages of patients seen by dental therapists. Dental therapists saw up to 90% of uninsured patients or patients on public assistance. Restorative services across practices comprised an average of 68% of work undertaken by dental therapists. Dentists delegated a full range of procedures within the dental therapy scope of practice indicating trust and acceptance of dental therapists. Dentists in two practices began to take on more complex dental procedures after a dental therapist joined the practice. CONCLUSION: Dental therapists are treating a high number of uninsured and underinsured patients, suggesting that they are expanding access to dental care in rural and metropolitan areas of Minnesota. Dentists appear to have an adequate workload for dental therapists and are delegating a full range of procedures within their scope of practice. Dentists performed fewer restorative and preventive procedures after a DT was hired.

Examining the influence of professional identity formation on the attitudes of students towards interprofessional collaboration.

An expectation of introductory interprofessional education (IPE) is improvement in attitudes towards other professions. However, the theory surrounding professional identity formation suggests this expectation may be premature. The objective of this study was to quantify first-year health professional students' attitudes towards their own and other professions and to investigate the relationship between strength of professional identity and attitudes towards other professions and interprofessional learning. Using a pre/post-test design, researchers administered the Readiness for Interprofessional Learning Scale (RIPLS) and the Interdisciplinary Education Perception Scale (IEPS) to 864 first-year healthcare students in the Academic Health Center (AHC) at the University of Minnesota. The findings showed a decline in student attitudes towards their own and other professions. Additionally, a positive correlation between a weakened professional identity and readiness for interprofessional learning was demonstrated. This study found that an introductory IPE course did not positively affect student attitudes towards other professions, or strengthen professional identity or readiness for interprofessional learning. Analysis of the findings support the successive stages of professional identity formation.

Minnesota dentists׳ attitudes toward the dental therapist workforce model.

The purpose of this study was to evaluate dentists' attitudes and perceptions toward dental therapists, a new licensed dental provider in Minnesota. This study employed mixed modes to administer a survey using a stratified random sample of 1000 dentists in Minnesota. The response rate was 55% (AAPOR RR1: n=551/999). Results showed a majority of dentists were opposed to dental therapists performing irreversible procedures. In addition, results identified perceived barriers to hiring a dental therapist and found dentists do not believe dental therapists will alleviate oral health disparity in the State.

Endoscopic vs. tactile evaluation of subgingival calculus.

PURPOSE: Endoscopic technology has been developed to facilitate imagery for use during diagnostic and therapeutic phases of periodontal care. The purpose of this study was to compare the level of subgingival calculus detection using a periodontal endoscope with that of conventional tactile explorer in periodontitis subjects. METHODS: A convenience sample of 26 subjects with moderate periodontitis in at least 2 quadrants was recruited from the University of Minnesota School of Dentistry to undergo quadrant scaling and root planing. One quadrant from each subject was randomized for tactile calculus detection alone and the other quadrant for tactile detection plus the Perioscope ™ (Perioscopy Inc., Oakland, Cali). A calculus index on a 0 to 3 score was performed at baseline and at 2 post-scaling and root planing visits. Sites where calculus was detected at visit 1 were retreated. T-tests were used to determine within-subject differences between Perioscope™ and tactile measures, and changes in measures between visits. RESULTS: Significantly more calculus was detected using the Perioscope™ vs. tactile explorer for all 3 subject visits (p<0.005). Mean changes (reduction) in calculus detection from baseline to visit 1 were statistically significant for both the Perioscope™ and tactile quadrants (p<0.0001). However, further reductions in calculus detection from visit 1 to visit 2 was only significant for the Perioscope™ quadrant (p<0.025), indicating that this methodology was able to more precisely detect calculus at this visit. CONCLUSION: It was concluded that the addition of a visual component to calculus detection via the Perioscope™ was most helpful in the re-evaluation phase of periodontal therapy.

Cultivating professional responsibility in a dental hygiene curriculum.

To prepare dental hygienists for future roles in the health care system, dental hygiene education must prepare graduates with skills, ethics, and values that align with professional responsibility. The objective of this study was to determine the effectiveness of curricular changes designed to develop professional identity and responsibility over the entire span of the dental hygiene curriculum. Twenty-four dental hygiene students at the University of Minnesota were surveyed about their attitudes toward access to dental care, society's and health professionals' responsibility to care for the underserved, and their personal efficacy to provide care for the underserved. Surveys were conducted at three time points in the curriculum. The Attitudes Toward Health Care instrument adapted by Holtzman for dental use was used to survey the students. The findings indicate that this institution's curricular changes were effective in cultivating professional responsibility among these students. Their attitude scores increased across the six-semester curriculum, and students in their last semester of the program believed that all individuals have a right to dental care and that society has an obligation to provide dental care. These students' sense of obligation to care for the needy became stronger and their perceptions of their own ability to impact the community and act as an agent of change also increased.