the role of mid - level dental care providers is increasing in importance due to the need for oral health promotion and disease prevention . these workforce members can address the problem of access to care by means of complementary relationships with dentists , especially in underserved areas . one model of a mid - level provider , called the dental therapist , is a registered professional who can provide certain facets of dental treatment , including preventive and restorative procedures . the education of dental therapists and dental hygienists is combined in a 3-year undergraduate university curriculum leading to the bachelor degree . the dual - qualification curriculum is usually called the oral health curriculum . in particular , in australia , a dual - qualified dental therapists / hygienist is categorized as an oral health therapist under one registration . figure 1 summarizes the historical transition of the qualifications for dental therapists and dental hygienists in australia and new zealand . these dual - qualified dental therapists / hygienists have accomplishments in a wide range of dental services involving diagnosing and recognizing oral conditions , planning and delivering preventive and restorative treatment , and collaborating with other dental and general health practitioners . historical transition of the qualification for dental therapists and dental hygienist in australia and new zealand the hiroshima university - dental behavioral inventory ( hu - dbi ) is a questionnaire that consists of twenty items in a dichotomous format ( agree / disagree ) to observe oral health - related attitudes and behaviors regarding toothbrushing . the hu - dbi has been previously used to examine the oral health attitudes and behaviors of dental students and dental hygiene students . before this study , the hu - dbi had not previously been applied to oral health students . while completing the undergraduate curriculum , the aim of this study was to determine the oral health attitudes and behaviors of 1- and 3-year oral health students from charles sturt university , australia and the university of otago , new zealand . this study was approved by the institutional review board of charles sturt university ( approval # 414/2013/04 ) and by the university of otago human ethics committee . oral health students ' oral health - related behaviors and attitudes were measured by means of the hu - dbi questionnaire in the 1 year of the curriculum ( year 1 ) and the final year of the curriculum ( year 3 ) at charles sturt university , in australia and the university of otago , in new zealand . year 1 and year 3 oral health students at the two universities were participated in this survey and responded to english version of the hu - dbi questionnaire . a total of 52 students in year 1 and 45 students in year 3 answered in 2013 . we analyzed the responses for each university by comparing the data from the year 1 students with the data from the year 3 students , using the fisher 's exact tests . we applied exact logistic regression models to each hu - dbi question separately to examine whether year 1 students have oral health behaviors similar to those of year 3 dental students while accounting for discrepancies between universities . these exact methods are statistically conservative to prevent erroneous conclusions and are appropriate for this study size . the data were analyzed with sas 9.3 ( sas institute , inc . , cary , nc , usa ) . table 1 shows the frequencies and percentages of students and their mean age in year 1 and year 3 . at charles sturt university , the average ages ( standard deviation [ sd ] ) of year 1 and year 3 respondents were 24.2 ( 8.1 ) and 25.5 ( 6.9 ) years old , respectively . at the university of otago , the average ages ( sd ) of year 1 and year 3 respondents were 24.9 ( 8.0 ) and 23.7 ( 4.2 ) years old , respectively . overview of the respondents ' background characteristics table 2 shows the items on the hu - dbi questionnaire and the percentages of  agree  responses of the oral health students in year 1 and year 3 by university . the responses of the students in the two groups differed significantly only for question # 3 at charles sturt university . the responses of the students in the two groups differed significantly to questions # 8 , # 15 , and # 18 at the university of otago . items on the hiroshima university dental behavioral inventory and percentages of  agree  responses of dental students in year 1 and year 3 table 3 shows that the estimated odds ratios and 95% confidence intervals from the exact logistic regression models were significant for only four questions . it was more likely that , after adjustment for university , year 1 students would agree on questions # 3 , # 8 , # 15 , and # 18 . for question # 3 , year 1 students had 2.4 times the odds of worrying about the color of their teeth than did those in year 3 ( p = 0.03 ) . for question # 15 , year 1 students had 3.4 times the odds of putting off going to the dentist until experiencing pain than did year 3 students ( p = 0.03 ) . for question # 8 , year 1 students had more than 11 times the odds of perceiving tooth decline despite brushing compared with year 3 students ( p = 0.02 ) . year 1 students had more than 13 times the odds of feeling the need to brush with strong strokes than did year 3 students ( p < 0.01 ) . significant hiroshima university - dental behavioral inventory questions and odds ratios of agreement for year 1 versus year 3 students the oral health curriculum in australia and new zealand consists of a 3-year curriculum that covers basic science , as well as education for dental therapy , dental hygiene , and oral health promotion . as they progress to year 3 , students have opportunities to participate in clinical practice at university , community , and rural clinics under the supervision of registered clinicians . this curriculum promotes positive oral health - related attitudes and behaviors to students and enables oral health students to act as valuable role models for their patients and to promote oral health for individuals and the community . the results of this study suggest that education for oral health students has a significant effect . year 3 students were less likely to  agree  with responses to questions such as  i worry about the color of my teeth ( # 3 ) ;  i think my teeth are getting worse despite my daily brushing  ( # 8) ;  i put off going to the dentist until i have toothache  ( # 15 ) ; and  i do n't feel i 've brushed well unless i brush with strong strokes  ( # 18 ) . the exact logistic regression model revealed the biggest odds for question # 18 where year 1 students had odds more than 13 times those of year 3 students . these results are consistent with studies focusing on dental students or oral hygiene students in other countries . the results for # 8 are consistent with those in reports on dental students from greece and peru . another report , which compared dental hygiene and nursing students in japan showed a significant decrease in agree  responses to question # 18 from dental hygiene students as their courses progressed , whereas there was no difference between first- and final - year nursing students . regarding the percentages of  agree  responses to # 15 , there was a notably low percentage except for the year 1 students at the university of otago . based on the responses , oral health students at the two universities studied seem to attend dental offices more frequently when compared with dental hygiene students in japan , korea , jordan , and saudi arabia . the percentage of  agree  responses to # 9 in all four responding groups was higher than 80% . these attitudes may be attributed to cultural differences , socioeconomic backgrounds , personal experiences , and dental health knowledge . the practical implication of this study is that it may serve as a reference for academic institutions considering the implementation of curricula to prepare mid - level providers into becoming a significant workforce . although 54 countries , both developed and developing , have adopted this workforce in their societies , controversy still exists over whether mid - level providers are adequately educated and competent to provide the appropriate level of care or not . however , one review has clearly stated that mid - level providers have abilities to harmlessly and competently perform a limited set of irreversible dental procedures at least as well as dentists or dental students . moreover , results obtained in this study recognized that despite the limited 3-year curriculum , some aspects of modification of oral health attitudes and behaviors for oral health students are consistent with those for dental students in other countries . dental disease is a silent epidemic among disadvantaged children , large portions of whom live in poverty or low - income households , as mentioned in the us surgeon general 's report , oral health in america . that report also mentioned tooth decay as the most common chronic disease in these children . the prevalence of dental disease is due to a lack of access to dental services and an insufficient public health infrastructure . hence , it will become increasing important to provide productive preventive treatment in collaboration with solving the access issue . mid - level providers who are well - trained through an appropriate educational curriculum will have a significant potential to improve these issues by taking a significant role on the dental team . results from this study in australia and new zealand revealed that oral health students who had been educated with a 3-year curriculum had more positive oral health attitudes and behaviors than students who were at the beginning of their course . well - educated mid - level providers on a dental team can play a key role in alleviating dental care access issues , thus benefiting both individuals and the community .
objective : the aim of this study was to evaluate the oral health attitudes and behavior of students in the oral health curriculum in australia and new zealand.materials and methods : the hiroshima university - dental behavioral inventory was administered to students in the first ( year 1 ) and final years ( year 3 ) of the oral health curriculum at charles sturt university in australia and the university of otago in new zealand . 
 a total of fifty - two year 1 students and forty - five year 3 students completed english version of the questionnaire in 2013 . 
 the responses were statistically analyzed by fisher 's exact tests and exact logistic regression models.results:the responses of students in years 1 and 3 differed significantly for  i worry about the color of my teeth  at charles sturt university and at the university otago , for  i think my teeth are getting worse despite my daily brushing ,   i put off going to the dentist until i have a toothache ,  and  i do n't feel i 've brushed well unless i brush with strong strokes . 
 the estimated odds ratios from the exact logistic regression models showed that year 1 students were more likely to agree with above - mentioned four questions.conclusions:oral health students who had been educated in a 3-year oral health curriculum in australia and new zealand had more positive attitudes and behaviors related oral health than did students at the beginning of their curriculum .