Evaluation of a continuing education intervention "Periodontics in General Practice"

Abstract Evidence exists that some dentists may be failing to perform adequate periodontal diagnostic and preventive care for their patients. Continuing education (CE) is an avenue that is frequently employed as a strategy to alter the style of practice. This paper presents an evaluation of a year-long continuing education intervention “Periodontics in General Practice”, conducted among randomly selected private general dental practices in Adelaide. South Australia. The CE intervention featured a 1-day seminar, bi-monthly newsletters, individualised 3-monthly comparative feedback, and technical assistance. The study employed a longitudinal quasi-experimental design, which allowed for evaluation of the effectiveness of the intervention among practices employing hygienists (n: = 12) and not employing dental hygienists (n: = 12), taking into account the covariates of baseline level of provision of periodontal services, the practice's level of participation in the intervention and attendance at other CE courses in periodontics over the year. A comparison group of practice (n: = 12) did not participate in the intervention over the year. Patient record audits, conducted at baseline and at 12 months, provided data for the evaluation of the effect of the intervention on the recording of periodontal diagnostic, preventive and treatment items. Practices participating in the intervention showed increases in the percentage of records containing at least one periodontal diagnostic notation, and those practices employing hygienists showed an increase in the percentage of records with at least one preventive notation and one treatment item. Using ANCOVA to account for covariation, the main effect of the study group was significant in explaining changes in the provision of preventive periodontal services. The results indicate that an extended continuing education intervention can have significant effect on the provision of periodontal services, and that the magnitude of the effect differs between practices employing and not employing hygienists.     

A comparison of patients attending general dental practices employing or not employing dental hygienists

Previous studies have shown that dental practices employing dental hygienists provide a more periodontally oriented mix of dental services. Little is known about differences in the characteristics of patients who attend these practices, and whether these reflect the orientation of service delivery. In this study, a comparison was made between patients attending private general dental practices employing hygienists and patients attending practices without hygienists in Adelaide, South Australia. A questionnaire was mailed to 2391 patients, and valid responses were received from 632 patients attending 12 practices employing hygienists, and 1052 patients attending 22 practices not employing hygienists. Bivariate analysis of the responses comparing the two groups of patients was conducted using ANOVA for continuous variables and chi-square statistics for categorical variables. A multiple logistic regression model was developed to identify characteristics of patients attending practices with hygienists. Examination of significant (p<0.05) findings revealed that patients attending practices with hygienists had a higher socio-economic status, had a more preventive pattern of use of services, had better knowledge of periodontally related topics and it was more likely that the dental profession was their main source of information on these topics. These findings indicate that patient profiles do reflect the orientation of service delivery within dental practices and raise the question of whether the denial practice alters the patient's knowledge and behaviour or whether certain patients selectively seek care from practices with hygienists.     

Hygienist employment and the presence of periodontal notations in general dental practice patient records

Available data suggest that the provision of periodontal ly related services in general dental practices is low. However, studies indicate that the employment of dental hygienists is associated with increased provision. One method of measuring is by examination of notations in patient treatment records. As part of a project assessing the effectiveness of professional education in changing the provision of periodontal services, 2280 records, comprising 60 randomly selected records of dentate adult patients who had received a dental examination in the previous 6 months were audited in each of 38 practices, 13 of which employed hygienists. Entries of a periodontal nature were classified under 3 categories: diagnostic, preventive and treatment. The presence or absence of each item on each record was recorded. Diagnostic services were notated infrequently overall, but practices employing hygienists had a significantly lower number of records with no diagnostic notations. Preventive items were more frequently notated in practices employing hygienists. Treatment items were most frequently notated in both types of practices. Overall, 13 of the 23 items were recorded significantly more frequently in practices employing hygienists.     

Task division between dentists and dental hygienists in Norway

Abstract – Objective: The aim of the study was to investigate the attitudes among dentists and dental hygienists to the policy objective in Norway of delegating more dental work from dentists to dental hygienists. Method: A questionnaire was mailed to a random sample of 1111 dentists and 268 dental hygienists in 2005. The response rates were 45% (504) among the dentists and 42% (112) among the dental hygienists. The survey sought to explore any discrepancies between current and preferred mix of different work tasks, as well as attitudes to the idea of substituting dentists with dental hygienists for certain work tasks. Logistic regression was used to analyse how answers differed by respondent characteristics. Results: Dentists spent only half of their total working hours on complex dental services, i.e. tasks that only dentists are skilled to undertake. Nearly 40% of their time was spent on tasks that dental hygienists are qualified to perform; examinations, screening and basic treatments. Still, the mix of work tasks that dentists preferred would involve slight changes: on average only 2% points more complex treatment and 3–4% points less of those tasks that dental hygienists are permitted to provide. Seemingly contrary, as many as 60% of dentists answered that it was ‘desirable to delegate’ more tasks to dental hygienist. However, only 21% of the dentists agreed that dental hygienists should be the entry point for dental services. Dental hygienists would prefer to do relatively more basic treatments and fewer examinations and screening, and the vast majority among them supported the idea that they could be the entry point for dental services. Conclusion: The results suggest that there will not be major changes in the division of labour between dentists and dental hygienists in Norway, if dentists are to be held responsible for taking such initiatives. Although dentists agree that more of their current work could– in principle – be delegated to dental hygienists, they do not prefer to reduce much of their own current activity of those work tasks that dental hygienists are qualified to perform.     

How Swedish dental hygienists apply their training program in the field

Abstract – The purpose of this study was to evaluate how clinical practice by Swedish dental hygienists was related to type of dental delivery system, period of training, educational institution attended and patient category. Dental hygienists from 14 different dental hygiene schools were represented. Of these schools. 11 are still in operation. A specially designed questionnaire was posted to all dental hygienists in Sweden ( n = 1857). A total of 1399 questionnaire (75.3%) were completed and returned, providing data on 15546 dental appointments. 37.2% of the Swedish dental hygienists are presently working in private practices, 45.8% in the public dental health service and 6.2% in both. Of the patients treated by hygienists, 88.7% were adults: 99.5% in private practice and 78.4% in the public dental health service. 42.0% of all dental hygienists were trained in 1980–84. The mean treatment time per appointment in private practice was 49.7 min and 45 min in the public dental health service. Scaling, root-planing and removal of overhangs took 27 min per visit in private practice and 22 min in the public dental health service. However, there were no significant differences in methods in the two delivery systems with respect to examinations, self-care training, professional mechanical toothcleaning (PMTC), topical fluoride application, or salivary and oral microbiology tests. The adult patient categories were periodontal risk (45.1%), caries risk (9.1%) and hygiene (34.6%). In periodontal risk patients, scaling, root-planing and removal of overhangs took 28 min per appointment and 14 min in caries risk patients.     

Opinions of dentists and directors of nursing concerning dental care provision for Adelaide nursing homes

BACKGROUND: The complex oral health problems of nursing home residents have been well documented. However, the influences on residents' oral health status, including opinions and experiences of dental professionals and nursing home staff, have not yet been adequately investigated. METHODS: The baseline questionnaire component of this longitudinal study was mailed to all registered dentists practising in Adelaide and Adelaide nursing home directors of nursing (DONs). RESULTS: 413 dentists and 97 DONs indicated that Adelaide dentists' interest and training in nursing home dentistry was low. Dental service provision for nursing home residents was very low and dentists preferred to provide treatment at their dental practices. Few dental hygienists were working in nursing homes and dental professionals provided little educational assistance for nursing home staff. Dentists and DONs held several common and many varying perceptions of the problems associated with dental care provision in nursing homes. Both identified a group of nursing home environmental constraints and a lack of portable dental equipment. DONs further identified a group of resident related problems, and dentists a group of dental practice-related problems. CONCLUSIONS: These study results provide important information concerning problems with nursing home dentistry for dental service providers, educators, policy-makers, administrators and nursing home staff.     

Expanded function allied dental personnel and dental practice productivity and efficiency

This study examined the impact of expanded function allied dental personnel on the productivity and efficiency of general dental practices. Detailed practice financial and clinical data were obtained from a convenience sample of 154 general dental practices in Colorado. In this state, expanded function dental assistants can provide a wide range of reversible dental services/procedures, and dental hygienists can give local anesthesia. The survey identified practices that currently use expanded function allied dental personnel and the specific services/procedures delegated. Practice productivity was measured using patient visits, gross billings, and net income. Practice efficiency was assessed using a multivariate linear program, Data Envelopment Analysis. Sixty-four percent of the practices were found to use expanded function allied dental personnel, and on average they delegated 31.4 percent of delegatable services/procedures. Practices that used expanded function allied dental personnel treated more patients and had higher gross billings and net incomes than those practices that did not; the more services they delegated, the higher was the practice's productivity and efficiency. The effective use of expanded function allied dental personnel has the potential to substantially expand the capacity of general dental practices to treat more patients and to generate higher incomes for dental practices.     

Use of dental hygienists and returns to scale in child dental care in Norway

Abstract The purpose of this study was to investigate, in the provision of dental care for children, technically and economically efficient combinations of dentists and dental hygienists and to study returns to scale by analyzing production functions. Data from 137 dental health clinics were analyzed. Output was registered as the number of 3–18-yr-old children to whom the clinic delivered complete dental care. Resource input was registered as hours spent by dentists, denial hygienists and dental assistants to deliver care to the children. The average clinic that employed dental hygienists used one hygienist hour per three dentist hours for child dental care. It would save dentist time, but not costs, to extend the use of hygienists. Increased use of dental hygienists might be economically efficient if the work distribution between the personnel groups were changed, for example, by delegating more examinations and preventive care to hygienists. There were technical opportunities for further substitution of dental hygienists for dentists both by introducing dental hygienists in the clinics that only used dentists in child dental care and by extending use of hygienists in clinics that already employed hygienists. This study found no productivity gain from centralizing treatment of children in large dental clinics.     

Attitudes of two groups of dentists towards dental hygienists

The purpose of the study was to assess whether cooperation with a dental hygienist was based on pursuit of financial gain or on aspirations to improve patient care. To this end a questionnaire was sent to 972 dentists. 412 dentists replied, of whom 178 had patients treated by a dental hygienist. Questions were asked regarding practice profile, preventive orientation and dentists' opinion about the material and immaterial value of cooperation with a dental hygienist. Discriminant analysis showed that the main distinguishing factor between dentists who did and dentists who did not cooperate with dental hygienists was their opinion about the quality of the dental hygienists' work in relation to the non-financial costs for patients, insurance companies, and dentists. The difference in the dentists' opinions about the direct profitability of dental hygienists was not significant. The conclusion can be drawn that the orientation of Dutch dentists towards care for their patients plays a more important role in a dentist's decision to cooperate with a dental hygienist than is usually presumed.     

Patterns of oral care in dental school and general dental practice

This study compared patterns of oral care provided by predoctoral dental students for patients seeking treatment at the University of Washington (UW) with patterns reported for general dental offices by the Washington Dental Service (WDS). Dental care included about 5 million services provided to 880,317 patients by 2,803 WDS general dentists and about 45,600 dental services provided to 9,488 patients by 155 UW dental students during 1999. There was high fidelity between databases and randomly surveyed patient records for treatment provided in both UW (95 percent) and WDS (97 percent) populations. While patient age patterns were generally similar, UW students completed more procedures for young children and for adults older than seventy-four years but completed fewer procedures for age groups of from thirteen to eighteen and from forty-five to fifty-four than general dental offices. The relative mix of all services completed by UW and WDS providers was similar (ANOVA, P=0.82). Within categories of service, the percentage of total services completed by students compared to those submitted by community dentists to WDS was about the same for examinations, radiographs, fluoride and sealants, amalgams, composites, single crowns, and endodontics. The percentage of total procedures completed showed a greater emphasis by UW students on inlays/onlays, dentures, extractions, and periodontal maintenance, and lesser experience with implants, orthodontics, sedation, and emergency procedures than general dental offices. We conclude that the relative distribution of clinical services provided by UW dental students is comparable to those procedures reported to WDS by dental offices in the adjacent community.     

Answers from dentists, dental hygienists and dental assistants to questions asked by patients concerning preventive dental matters

142 dentists, 21 dental hygienists and 35 dental assistants were asked lo fill in a questionnaire which consisted of 40 questions about preventive dental matters regularly asked by Dutch dental patients. The 40 questions were submitted to experts in the field of preventive dentistry. The experts were in agreement on 26 questions. It was decided to use these questions for analysis. The average percentage of correctly answered questions was: for the dentists 53%, for the dental hygienists 58% and for the dental assistants 37%. The group of 142 dentists was further analyzed. It appears that the knowledge about preventive dental matters increases subsequently with each year of gradual ion. Analysis of the dentists who graduated from Dutch dental schools in their capacity as private practitioner, as faculty member or in the school dental service, revealed that there was no difference in knowledge between these groups. With some reservations the conclusion can be stated that an obvious necessity exists for post-academic courses in preventive dentistry in the groups concerned. Greater uniformity is needed between the views of the experts and the dental professionals who treat patients daily.     

Attitudes among dentists and dental hygienists towards extended scope and independent practice of dental hygienists

Aims: Attitudes of dentists and dental hygienists towards extended scope and independent dental hygiene practice are described in several studies, but the results are heterogenous. The purpose of this systematic review was to compare the attitudes of dentists and dental hygienists towards extended scope and independent dental hygiene practice. Methods: PubMed, AMED and CINAHL were screened by two independent assessors to identify relevant studies. Only quantitative studies that reported the percentages of dentists'' and dental hygienists'' attitude towards extended scope and independent dental hygiene practice were included. The random-effects model was used to synthesise possible heterogenous influences. Results: Meta proportions with regard to a positive attitude towards extended scope of practice are 0.54 for dentists and 0.81 for dental hygienists. Meta proportions of a positive attitude towards independent practice are 0.14 for dentists and 0.59 for dental hygienists. A meta analysis with regard to negative attitudes could only be performed on extended scope of practice and did not reveal a difference between the two professions. We obtained homogeneous outcomes of the studies included regarding negative attitudes of dentists . A minority of dentists hold negative attitudes towards extended scope of dental hygiene practice. Study outcomes regarding negative attitudes of dental hygienists were heterogeneous. Conclusions: Positive attitudes are present among a majority of dentists and dental hygienists with regard to extended scope of dental hygiene practice, while for independent dental hygiene practice this holds for a minority of dentists and a majority of dental hygienists.Key words: Dental practice, general dental practice, hygienist, oral health policy, primary oral health care     

Variations in self-reported provision of services by general dentists in private practice

BackgroundVariations in dentists&;apos; provision of services have been documented, but information about contributing factors is limited.MethodsThe authors used responses to a 2003 survey of general dentists in private practice in California (46 percent response rate; 3,098 dentists included in the final sample) to assess variations in service provision and its correlates. They used logistic regressions to assess the correlation of various characteristics with the self-reported percentage of time spent providing services.ResultsThe results show variations in services provided by general dentists in private practice. Multiple factors, including the dentist&;apos;s sex, region of practice, employment of hygienists, patients&;apos; race and population income in the area of practice were significantly and independently associated with provision of services.ConclusionsThe survey results reflect practice variations that existed before the latest economic downturn, which resulted in a loss of jobs and medical and dental insurance. The data serve as the baseline for future studies of changes in dental practice and for assessing the impact of the 2010 health care reform legislation on dental practice.Practice ImplicationsImprovements in oral health care, the recent economic decline and health care reform may lead to changes in dental practice and in the dental workforce.     

Vacant posts reported in dental practice: implications for human resource planning

OBJECTIVES: To describe the proportion of dental practitioners who report vacancies within their dental practice for the following: dental surgeons, dental hygienists, dental nurses and dental receptionists. To determine the proportion of dental practitioners working in general dental practice who would consider employing a dental therapist. METHOD: Analysis of data from the British Dental Association Omnibus Survey 2000. The sample comprised 992 qualified dentists in all fields of practice. FINDINGS: The most commonly reported vacancies were for dental surgeons (18% of practitioners reported vacancies), dental nurses (17%) and dental hygienists (12%). Approximately 46% of general dental practitioners reported that they would employ a dental therapist if legislation permitted. The main reason for not employing a dental therapist was insufficient space in the dental practice. CONCLUSIONS: A large number of vacancies exist for dental surgeons, dental nurses and dental hygienists in the United Kingdom. Around half of dental practices express an interest in employing dental therapists should legislation permit.     

Attitudes of the Victorian oral health workforce to the employment and scope of practice of dental hygienists

BACKGROUND: Increasing the number of dental hygienists and expanding their scope of practice are two policy directions that are currently being explored to increase the supply of dental services in the context of projected oral health workforce shortages in Australia. Understanding factors relating to the employment of hygienists and the attitudes of the oral health workforce to dental hygiene practice are important in this policy debate. METHODS: A postal survey of a random sample of Victorian dentists, periodontists, orthodontists and hygienists was undertaken in 2006. Dentists and specialists were grouped into those whose practice employed or did not employ a hygienist. Data on the attitudes of dentists, specialists and hygienists towards various aspects of dental hygiene practice were explored. RESULTS: A response rate of 65.3 per cent was achieved. Hygienists believed that their employment made dental care more affordable (53.7 per cent) and improved access to dental care (88.1 per cent), while few dentists believed hygienists made care more affordable. Most hygienists believed they were capable of diagnosing periodontal disease and dental caries and formulating a treatment plan, but there was less support from employers and non-employers. Dentists were strongly opposed to independent practice for dental hygienists, although there was qualified support from employers for increasing the scope of practice for hygienists. CONCLUSIONS: Dentists who worked with hygienists acknowledged their contribution to increasing practice profitability, efficiency and accessibility of dental services to patients. Hygienists and employers supported increasing the scope of dental hygiene practice, however the majority of non-employers opposed any expansion.     

Differences in Characteristics of California Dentists Who Employ Dental Hygienists and Those Who Do Not

BackgroundDental hygienists can increase dentists’ productivity, yet nationwide, one-third of dentists do not employ a hygienist. The profession needs more information on the characteristics of these dentists and their reasons for not employing hygienists.MethodsThe author used a 2003 survey of California dentists and a logistic regression analysis to assess factors independently associated with dentists’ employment of hygienists. These factors included dentists’ personal, practice, population, productivity and patient care characteristics. She also assessed characteristics of dentists who did not employ hygienists and their reasons for not doing so.ResultsDentists who worked full time, employed more administrative personnel, had more operatories, had longer appointments, had more income from private payers and had more elderly patients were more likely to employ hygienists than were dentists with alternative characteristics. Graduates of dental schools outside the United States and those with fewer white patients were less likely to employ hygienists. Reasons for not employing hygienists included personal choice, high costs and not having a sufficient volume of work.ConclusionsThe author's findings suggested that in employing hygienists, dentists consider preferences, practice income and patient demand, among other factors. Further examination of reasons for employing hygienists is warranted.Practice ImplicationsHiring a hygienist increases a dental practice's patient capacity, yet not all dentists can or choose to do so. Policies aimed at increasing dental workforce capacity must take into account dentists’ characteristics and preferences.     

Concordance of chart and billing data with direct observation in dental practice

Abstract – Objectives: The commonly used methods of chart review, billing data summaries and practitioner self‐reporting have not been examined for their ability to validly and reliably represent time use and service delivery in routine dental practice. A more thorough investigation of these data sources would provide insight into the appropriateness of each approach for measuring various clinical behaviors. The aim of this study was to assess the validity of commonly used methods such as dental chart review, billing data, or practitioner self‐report compared with a ‘gold standard’ of information derived from direct observation of routine dental visits. Methods: A team of trained dental hygienists directly observed 3751 patient visits in 120 dental practices and recorded the behaviors and procedures performed by dentists and hygienists during patient contact time. Following each visit, charts and billing records were reviewed for the performed and billed procedures. Dental providers characterized their frequency of preventive service delivery through self‐administered surveys. We standardized the observation and abstraction methods to obtain optimal measures from each of the multiple data sources. Multi‐rater kappa coefficients were computed to monitor standardization, while sensitivity, specificity, and kappa coefficients were calculated to compare the various data sources with direct observation. Results: Chart audits were more sensitive than billing data for all observed procedures and demonstrated higher agreement with directly observed data. Chart and billing records were not sensitive for several prevention‐related tasks (oral cancer screening and oral hygiene instruction). Provider self‐reports of preventive behaviors were always over‐estimated compared with direct observation. Inter‐method reliability kappa coefficients for 13 procedures ranged from 0.197 to 0.952. Conclusions: These concordance findings suggest that strengths and weaknesses of data collection sources should be considered when investigating delivery of dental services especially when using practitioner survey data. Future investigations can more fully rely on charted information rather than billing data and provider self‐report for most dental procedures, but nonbillable procedures and most counseling interactions will not be captured with routine charting and billing practices.     

Accuracy of dental hygienists in diagnosing dental decay

Abstract During recent decades, the duties and care rendered by Swedish dental hygienists have continuously expanded, and since 1991 they are licensed to practice dental hygiene independently. The aim of the present study was to investigate the accuracy of dental hygienists in examining and recording dental caries in comparison with dentists performing identical examinations. The study included two parts: A) Registration of carious lesions from radiographs of 100 extracted teeth, where the correct diagnosis could be verified, and B) clinical examination and registration of carious lesions in 213 patients. No statistically significant differences could be found between the dental hygienists” and their control dentists' accuracy to diagnose and record dental decay, with the exception of the number of initial lesions (white spot lesions) registered clinically, where the dental hygienists recorded more buccal and lingual lesions. Irrespective of the group of examiners (dental hygienists or dentists), however, the inter-examiner variation was wide. The variation decreased with the size of the lesion and increased with the age of the patient. This study suggests that no patient with a restorative treatment need would have been neglected if the dental hygienists had performed the examination, and, possibly, a more accurate non-restorative treatment need would have been addressed.