The changing role of dental auxiliaries: A literature review

Transcription

1 Autralian Dental Journal 1998;43:(5):354-8 The changing role of dental auxiliarie: A literature review Laura Baltuti* Michael Morgan* Abtract A review of the literature on dental auxiliarie and their utilization in the dental workforce i preented, and their future role i examined in the light of broader iue relating to changing dieae pattern and ervice delivery. Legilative factor, productivity, quality aurance and the potential cope for dental auxiliarie in both the public ector and private practice etting are dicued. A trategy for adopting a team approach in the delivery of dental ervice i uggeted, which would neceitate the dentit taking on the role of team leader and maintaining reponibility for overall treatment planning and quality aurance. Dental auxiliarie could provide baic preventive and retorative dental ervice, allowing dentit to concentrate on providing more complex hightechnology treatment. Implication for the future training of dental auxiliarie are preented. Key word: Dental auxiliarie, ervice delivery, legilation, productivity, quality aurance, team dentitry. (Received for publication September Revied March Accepted March 1998.) Introduction The management of dental carie and periodontal dieae ha been the major focu of dentit and dental auxiliarie in the 20th century. However, changing dieae pattern in the lat few decade have reulted in the need to review ome broader iue in dental ervice delivery, including deciion on the appropriate utilization of dental peronnel in the workforce, and the type of kill mix required by member of the dental team. Epidemiological factor In Autralia, a in mot other indutri a l i z e d countrie, there ha been a dramatic decline in carie in children and adolecent, with high cari e *School of Dental Science, Faculty of Medicine, Dentitry and Health Science, The Univerity of Melbourne. experience now affecting a minority of the younger population. 1 Thi decline in carie activity ha been attributed to increae in preventive meaure uch a the widepread ue of fluoridated toothpate, fluoridation of public water upplie, the ue of fiure ealant, and changing public awarene. Although carie experience ha not declined markedly in middle-aged to older adult, there have been improvement in the management of the dieae experienced in thi population, with fewer teeth extracted, and a greater number of teeth filled. 2 The decreae in tooth lo and edentulim, together with an expanding ageing population, ha reulted in an increaing number of people who are retaining their teeth into later life. Thi ector of the population ha more complex dental need uch a multiurface coronal retoration, retoration for root carie and tooth abraion, a well a an increaing need for dental health education and periodontal care. 3,4 Thee change have led to a need to redefine the role of each member of the dental workforce, o that a p p r o p ri ate dental ervice are provided to the community. Barme, in 1987, tated that change in global dieae pattern have reulted in an overall reduction in need for oral health care and a p o l a rizing of that need toward elf care and minimal imple intervention on the one hand and high technology care on the other. Conidering thi polarization, he uggeted it wa time to re-addre the current dentit to auxiliary ratio in the developed world, with an emphai on increaing the number of auxiliarie. 5 In the long term, a multidiciplinary approach may be needed with dentit providing more complex high-technology ervice together with dental auxiliarie, who may provide mediumlow-technology dental ervice for pecific group in the population. Curr e n t l y, Autralian data have fa i l e d to provide evidence for an early hift in practitioner t r e atment profile. 6 O b v i o u l y, continued monitori n g 354 Autralian Dental Journal 1998;43:5.

2 of dental ervice provided will be neceary to determine future direction. The World Health Organization Expert Committee Report, 1990, on educational imperative for oral health peronnel upport Barme in hi view by tating: Now and in the immediate future, dentit in the highly indutrialized countrie hould be guided, through expanded opportunitie for retraining and continuou education, into undertaking more complex technological procedure. The impler procedure could then be undertaken more economically but equally well by variou categorie of auxiliary peronnel. 7 In the Autralian context, continued urveillance of treatment modalitie i required a thi polarization into low- and hightechnology care may only become evident after a number of year. Dental auxiliarie in Autralia In Autralia, the principal clinical dental auxiliarie are the dental hygienit and the dental therapit, with dental nure and advanced dental technician providing a narr ower pectrum of ervice. While legilation governing activitie of thee auxiliarie va rie from St ate to St ate, in general, dental therapit provide retorative and preventive treatment for chool-aged children and adolecent within the public ector, wherea hygienit provide a range of ervice, mainly preventive, within both the public and private ector. In mot State, the auxiliarie work under the direction of a dentit. Wetern Autralia i the only State that currently allow dental therapit to work in private practice but future change to the variou dental act in repone to competition law may alter ituation in other State and Territorie. Service delivery factor The potential for expanding the role of auxiliarie ha provided much debate in the literature in Autralia and other countrie. Short 8 allege that diadvantaged group within the community could be more effectively targeted by auxiliarie. Thi viewpoint i upported by the Nuffield Foundation, with particular emphai on the proviion of ervice for patient with pecial need due to illne or diability. 9 In the United Kingdom, for example, a propoition for hygienit to be utilized not only to provide periodontal treatment in the general private practice etting, but alo to provide treatment to elderly or diabled patient through domiciliary viit, wa put forward by member of the General Dental Council. 10 Jut recently, South Autralia ha paed legi l ation to allow dental hy gienit to p r ovide preve n t i ve oral health care ervice to patient in nuring home and place of long-term reidential care. 11 With an increaing demand by the population for more pecialized ervice uch a ort h o d o n t i c treatment, an auxiliary uch a the hygienit could alo be more widely utilized. Procedure uch a taking impreion, removal of archwire or bonded attachment, and proviion of intruction on the maintenance of appliance could be provided by uch auxiliarie. Yap 12 and Wexler, 13 orthodontit with experience in the utilization of hygienit, have o b e rved that uch auxiliarie are valuable in building up a practice, becaue not only do they leave the orthodontit more time for diagnoi, treatment planning, and performing pecialit work, but the hygienit, whoe main focu i on preventive ervice, ha more time to pend with the patient to build a rapport and to maintain good oral hygiene. With the global decline in dental carie there i an increaing number of adolecent and young adult r e q u i ring imple retorat i ve ervice for ingle urface leion. 3 Some author have uggeted that conideration mut be given for a clinical auxiliary (uch a the dental therapit) to work with a dentit, either in a private practice or in the public ervice etting, to provide treatment for thi ector of the population. 14,15 Thi view ha upport in the profeion. A tudy in England and Wale howed that 40 per cent of general dental practitioner would be willing to employ a dental therapit, if legilation allowed it. Furthermore, it appear that younger dentit are more likely to favour delegating work to a dental therapit than their older colleague. 15 The future role of the dental auxiliar A redefinition of the team through which dental care i to be delivered in the future wa the main focu of the Nuffield report (1993) which wa c o n c e rned pecifically with the education and training of auxiliary dental peronnel in the UK. The report recommended that there be two principal type of clinical auxiliarie: (1) a new auxiliary termed the oral health therapit hould replace the hygienit or therapit, and (2) a clinical dental technician hould replace the dental technician, following additional training. The dentit, taking on the role of team leader, would take reponibility for diagnoi, overall treatment planning, and quality aurance. 9 In Autralia, a imilar propoal wa to be piloted by the Autralian Health Miniter Adviory Council (AHMAC), whereby a new clinical dental auxiliary with training beyond the level of current exiting auxiliarie would provide certain retorative and preventive ervice to the adult population in the public ector. Thi propoal ha been met with coniderable oppoition pri n c i p a l l y, but not excluive l y, from dentit in Autralia. Opponent argue that a y Autralian Dental Journal 1998;43:5. 355

3 two-tier ytem of dental ervice would be created within the community, with diadvantaged group being offered an inferior quality of ervice. 16 Thi repone ha er ved only to further alienate exiting peronnel within the dental profeion at a time when dentitry hould be more focued on a team effort, a i the cae with other primary health care provider within the medical profeion. The dentit a a team leader could, for example, delegate tak to a dental auxiliary who i pecifically trained to perform thoe tak. Dental procedure uch a the application of fiure ealant or prophylaxi could be performed by a dental hygienit or a dental therapit, thu allowing the dentit to focu on more complex procedure uch a crown and bridge work or endodontic. Thi approach would inevitably impact upon the current role of dentit in Autralia and they may be redirected, either through training or market force, to work in area not within the pan of dental auxiliarie. Thee role would focu on high-technology procedure uch a placement of implant or crown and bridge work. Within the medical profeion there i a trong emphai on health care delivery a a team. In p ri m a ry health care, kill mix i increaingly becoming the norm with doctor working cloely alongide qualified clinical nure and other a u x i l i a rie uch a radiologit, phy i o t h e r a p i t, a u d i o l o git and peech pat h o l o gi t. Mobile intenive care ambulance officer, who are highly killed in providing emergency life-upport and work largely independently of doctor, are well recognized by the medical profeion a auxiliarie who provide an eential primary health care ervice. Although the medical profeion ha encouraged the development of their auxiliarie, the dental profeion appear in many repect to be following a different path. Dentit uch a Renon, 17 Maon, 18 Pike, 19 and Linz, 20 ugget that dental ervice need to be more fully integrated in the primary health care concept by etablihing cloer link between the dentit, dental auxiliarie and other health care worker. Pike tate that in the pat there had been a tendency for dentitry to become marginalized from the ret of medicine, in part due to a lack of appreciation of the contribution that the dental profeion provide to primary health care, and alo due to a lack of integration between the member of the dental team. 19 Productivity and quality aurance Both hopital-baed and field reearch how that dental auxiliarie can provide many ervice at lower cot and with no lo of quality A ten year tudy review by Dougla and Cole howed no variation in the quality of procedure performed by an auxiliary and thoe performed by a dentit, with three tudie howing higher quality in low-technology ervice, uch a application of fiure ealant, when delive r e d by auxiliarie. 29 Other tudie have indicated that many traightforward tak can be performed more efficiently and more cot effectively by adding an auxiliary to an already exiting team of a dental and chairide aitant, with increae in productivity ranging from 30 to 80 per cent. 28,30 For example, a urvey of dental practice in the US howed that there wa a linear increae in productivity aociated with the utilization of dental auxiliarie. A the number of auxiliarie increae from none to five or more, both the median and mean gro and net income rie, almot in direct proportion. Several other workforce tudie ugget that together with increae in productivity and a decreae in operating cot, quality of care wa maintained and patient acceptance of a u x i l i a rie wa high. 28 The decreaed operat i n g cot, due in part to lower wage rate of dental auxiliarie, ha the potential to reduce overall out-ofpocket cot to the conumer. Caution hould be taken when auming that the aving made by individual through reduced provider cot tranlate to ocietal cot. Although expanion of the role of auxiliarie i likely to decreae the cot of dental care per unit of care provided, the money pent on dental care may actually increae, following gr e at e r availability and acce of ervice with the increaed utilization of auxiliarie. With more emphai in the future being placed on preventive care, the Nuffield Foundation reported that it i more cot effective to utilize an auxiliary for procedure uch a fiure ealant placement, fluoride application, caling and polihing, for the dual reaon that it take le time to train an auxiliary, and that there i le cot in maintaining an auxiliary alary. 9 Utilization of auxiliarie in thi manner would provide upport to the dentit and would provide more time for the dentit to concentrate on providing high-technology treatment whilt till retaining reponibility for overall treatment planning and co-ordination of the team. Thi view i upported by the World Health Organization with the recommendation that a new type of dentit i required, who will be a broadly trained oral phyician reponible for the continuing care of the orofacial region. Thee oral phyician of the future will be the leader of oral health team concerned with health education, dieae prevention and treatment, and maintenance of patient health, and will be upported by auxiliarie. 31 Additional benefit to the oral health workforce can be achieved through the expanded ue of a u x i l i a rie becaue horter training time for auxiliarie allow for the workforce to be adjuted more readily to changing need within the community. However, it i important to enure that 356 Autralian Dental Journal 1998;43:5.

4 all auxiliary peronnel are trained to a profeionally agreed tandard, and regitered with an approved a u t h o rity which i accorded mutual recognition between State. It i critical appropriate alarie and career pathway are etablihed o that killed team member are recruited and remain in the workforce. With the aim of fotering a team approach and a better undertanding and appreciation of each health care profeional role, Grace 32 and Maon, 18 maintain that dentit and auxiliarie hould be trained together, wherever poible, within the ame dental chool or hopital environment. According to Grace, the u and them approach that till perit in ome area of dentitry i a hangover from the pat, and mut be removed for the ake of dental patient and the future of dentitry. 33 Legilative factor One concern raied by dentit i that the dental auxiliary may work illegally without the uperviion of a licened dentit and that thi, in turn, would affect the quality of the auxiliary work and create competition between dentit and auxiliarie. 34,35 A an example, when the poibility that hygienit be allowed to make domiciliary viit to the elderly wa dicued in the UK, there wa an expreion of concern that they would tart their own practice independent of the uperviing dentit. 10 Another common perception i that expanding role will follow a change of function. If an auxiliary i taught one apect of treatment, uch a taking impreion, it i poible that they will extend thi concept further, believing that they are capable of providing all apect of that treatment regime, uch a contruction of denture. 10 The concern amongt dentit that auxiliarie will overtep the boundarie put in place by legilation, may conveniently ignore the likelihood that uch intance may be related a much to inappropriate d e l e g ation by the uperviing dentit, a to a u x i l i a rie working outide their legal limit. 36 Another conideration i that duty tatement for auxiliarie vary coniderably from State to State, and ome auxiliarie may find themelve in breach of the State Act when they perform a procedure for which they are trained. 37 The etablihment of conitent nationwide legi l ation for auxiliari e would eliminate thee difficultie and would alo allow greater flexibility for auxiliarie who wih to tranfer to other State or Territorie. Further, definition of what exactly contitute upervied treatment i not clear. Superviion could range from a dentit needing to be preent in the operatory, to generalized guidance from a dentit who i remote from the ite. A urvey of dentit in England, 15 and a imilar urvey of New Zealand d e n t i t, 38 h owed that the perceived level of u p e rviion required by the dentit wa a coniderable caue for concern and a limiting factor in the employment of auxiliarie in private practice. Many dentit felt that auxiliarie would require a high level of uperviion and thi would be diruptive to their own clinical activitie. Of greater concern for ome practitioner wa that patient may feel their dental care wa le peronalized if auxiliarie were u e d. 39 H owe ver, a Dougla and Lipcombe r e p o rted in their review on the ue of dental auxiliarie, patient acceptance ha been linked to dentit acceptance. If the dentit i upportive of the auxiliary role, patient acceptance i rarely noted a a problem. They found that conumer were willing to accept more routine procedure from an auxiliary than dentit were actually willing to delegate. 28 Concluion Depite the perceived barrier by ome dentit to the increaed utilization of auxiliarie, urve y indicate a trend of increaing number of dentit willing to employ them in the pri vate practice etting. Many view auxiliarie, uch a hygienit, a practice builder who not only increae patient motivation but who alo provide a valuable ervice in the area of dietary counelling, moking ceation, and oral hy giene intru c t i o n. 15, 40 Thi i not withtanding the coniderable potential for their employment in the public ector, particularly in the proviion of ervice for patient with high oral health need. 9 Although at thi tage there i cant evidence for acceptance of auxiliarie, and ome care mut be taken in making reference baed upon i n t e rn ational experience, there i no reaon to upect the ituation would be any different in Autralia. If dental auxiliarie are to be appropri ately utilized, dentit mut be prepared to adopt a more poitive team approach and embrace the role of team leader, with delegation of le complex tak to an auxiliary who i appropriately trained to carry out that tak. Thi, in turn, will require ome change in the type of work that a dentit perform with an increaing emphai on more pecialized treatment. Furthermore, ome careful planning i required for the legilation and career pathway of dental auxiliarie to bring them into line with their medical counterp a rt. Significant change have already been achieved by the dental profeion in the prevention and treatment of oral dieae, with uch meaure a the ue of fluoride, and new technology for the retoration of teeth. The next challenge i to develop a more poitive collaboration between member of the dental team o that the wide range of kill available within the dental ector are effectively utilized. A wa tated by Nah, Today we mut Autralian Dental Journal 1998;43:5. 357

5 acknowledge that each profeional member of the dental team ha a unique role to play, and that each peron can play that role better than any other member of the team. 41 The dental profeion mut trive to become a leader, rather than a follower, in the proviion of primary health care. When thi happen, dentitry will be able to move confidently, in partnerhip with the other phere of medicine, into the 21t century. Reference 1. Spencer AJ, Davie M, Slade G, Brennan D. Carie prevalence in Autralaia. Int Dent J 1994;44: Barnard PD. National Oral Health Survey Autralia Canberra: Autralian Government Publihing Service, Spencer AJ, Brennan DS, Szuter FS. Changing proviion of retorative ervice in Autralia. J Dent 1994;22: Johnon PM. Dental hygiene practice: international profile and future direction. Int Dent J 1992;42: Barme DE, Tala H. Health manpower out of balance: conflict and propect for oral health. In: Bankowli Z, Meja A, ed. Health manpower out of balance conflict and propect. 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The future of allied dental education: creating a profeional team. J Dent Educ 1993;57: Addre for correpondence/reprint: Dr Laura Baltuti, School of Dental Science, The Univerity of Melbourne, 711 Elizabeth Street, Melbourne, Vic Autralian Dental Journal 1998;43:5.