According to the 2000 U.S. surgeon general s

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1 Allied Restorative Functions Training in Minnesota: A Case Study Brigette R. Cooper, R.D.H., M.S.; Angela L. Monson, R.D.H., M.S. Abstract: In 2003, the Minnesota Dental Practice Act was modified to allow dental hygienists and assistants to place amalgam, composite, glass ionomer, and stainless steel crowns. The concept of utilizing allied professionals to perform expanded functions has been suggested as a way to increase access to care and productivity. A continuing education course was offered to provide required certification for interested dental practitioners (N=12). The objectives of this study were to examine confidence levels and effectiveness of the continuing education program. Pre- and post-course restorative content knowledge, along with confidence levels in knowledge, technical skills, and the ability to implement skills were measured. A matched pairs t-test found a significant increase in participants restorative content knowledge (p<.001). Wilcoxen signed rank tests revealed an increase in confidence in all content knowledge (p<.01) and technical skill (p<.05) categories. Participants did not significantly increase in confidence to implement restorative functions skills into practice (p<.7). Interview data revealed that participants remain unclear about ways to incorporate restorative functions into the schedule. Findings in this case study suggest that content knowledge and confidence levels increase following completion of a restorative functions course. To improve education and training, research is needed to identify why participants confidence in implementation did not increase. Prof. Cooper is Assistant Professor and Prof. Monson is Assistant Professor both in the Department of Dental Hygiene, Minnesota State University, Mankato. Direct correspondence and requests for reprints to Prof. Brigette Cooper, Minnesota State University, Mankato, Department of Dental Hygiene, 3 Morris Hall, Mankato, MN 56001; phone; fax; brigette.cooper@mnsu.edu. Key words: restorative functions, continuing education, expanded functions, dental hygienists, dental assistants Submitted for publication 8/24/06; accepted 10/27/06 According to the 2000 U.S. surgeon general s oral health report, there is a silent epidemic of oral disease affecting poor children, the elderly, and racial/ethnic minorities. 1 Improving access to care specifically for these target populations is required to help reduce oral health disparities. In Minnesota, the overall grade assigned by the 2003 Oral Health America Grading Project for dentist availability was a C. 2 This grade was largely influenced by the lack of pediatric dentists in Minnesota, with only one pediatric dentist available for 2,301 to 2,600 patients. Increasing the legal responsibilities of allied dental professionals may help address oral health disparities and increase access to oral health care. Legal provisions for delegating specific functions to allied professionals vary from state to state. Many state laws have been modified over the years to increase the responsibilities and function of dental hygienists and dental assistants. 3 Specifically, in 2003 the Minnesota Dental Practice Act was modified to allow dental hygienists and dental assistants expanded duties in restorative functions. According to the Minnesota Dental Practice Act of 2006, a licensed dental hygienist or dental assistant may place, contour, and adjust amalgam restorations; place, contour, and adjust glass ionomers; adapt and cement stainless steel crowns; and place, contour, and adjust Class I and Class V supragingival composite restorations where the margins are entirely within the enamel. 4 The impetus for the modification in the Minnesota statutes was the well-documented need to increase the availability of dental care by increasing the efficiency of dentists and delegating selected procedures to dental hygienists and dental assistants. 5,6 As legislated changes occur in state practice acts, so must the curriculum of dental hygiene and dental assisting education. In Minnesota, restorative functions training is offered via continuing education (CE) courses for dental hygienists and dental assistants who are currently licensed, in addition to incorporation of training related to restorative functions into the curriculum of traditional dental hygiene baccalaureate degree programs. The concept of training allied professionals to perform expanded functions as a viable way of increasing productivity and increasing the availability of dental care is not new. Numerous articles have supported the idea that oral health care personnel other than dentists may be trained to provide some of the patient care services traditionally performed by dentists. 7-9 However, the expanded function duties included in previous research primarily involved placing pit and fissure sealants, polishing amalgams, rubber dam application, local anesthesia administration, and other duties of that nature March 2007 Journal of Dental Education 373

2 Little information has been published in the dental literature regarding allied restorative functions training and implementation specifically, educating dental hygienists and dental assistants to place amalgam, glass ionomer, composite, or stainless steel crowns. Sixty-four graduates of the Indiana University-Purdue University Fort Wayne Dental Hygiene program, classes of , were surveyed to assess utilization and perception of preparation to place amalgam restorations. 12 Only two graduates (3.1 percent) reported performance of amalgam placement, and 57.4 percent felt inadequately prepared to perform this task. However, the respondents to this survey revealed that the classes of 1991 and 1992 at this school were not taught this technique as part of their laboratory instruction, which may account for the low ratings. 12 In Washington state, 113 dental practices were examined to determine implementation of expanded functions by auxiliaries. Hygienists performed 11.6 percent of composite placement and 20.2 percent of amalgam placement and carving, with the dentist performing the remaining percentage of these duties. Sixty-eight percent of temporary crowns or fillings were delegated to auxiliaries, with the majority completed by dental assistants. 13 To expand our limited knowledge base related to training dental auxiliaries to perform restorative procedures, this study was conducted to examine participants perceptions of the effectiveness of training, knowledge levels, and confidence following completion of a restorative functions continuing education program. Methods A questionnaire to examine confidence levels in knowledge and technical skill and a written examination to measure restorative content knowledge were used as the outcome measures to assess CE program participants perceptions of training and readiness. Human subject approval was obtained from the Institutional Review Board, Minnesota State University, Mankato. Informed consent was obtained from all participants. The restorative functions continuing education course was a sixty-four credit, eight-day course over the span of three weeks in the summer of The first five days involved didactic and laboratory experience, and the remaining three days involved clinical experience during which course participants directly treated patients. Participants in the course were three licensed dental hygienists and nine licensed and registered dental assistants. Four dentists, two with academic backgrounds, provided the instruction and evaluated the participants during the eight-day course. The two dentists with academic backgrounds were individually approached by the investigators to consider involvement in this CE course. They, in turn, contacted two wellrespected dentists in the area, one a pediatric dentist and one a general dentist, to lend their expertise. They agreed to involvement in this CE course as they felt positively toward the concept of expanded restorative care for dental auxiliaries. The didactic course content was evenly distributed among the four dentists. One dentist in academia provided didactic information on dental anatomy, occlusion, cavity classification, and armamentarium. Another dentist with prior teaching experience introduced bonding agents and composites. The pediatric dentist lecture material included glass ionomer, cement, bases, liners, and stainless steel crowns, and the general dentist s course content included amalgam, occlusal adjustment, polishing, and finishing. Additionally, the investigators and course instructors contacted ten area practicing dentists to volunteer their services to prepare identified teeth during the clinical component of the course. Each of the ten dentists volunteered between four and eight hours during the three clinical days of patient treatment. Their role was restricted to tooth preparation and did not include evaluation of the restorative work, which was completed by the four course instructors. A restorative functions confidence questionnaire and knowledge pre-test were administered to all participants on day one of the course, prior to communication of any didactic information. An identical questionnaire and knowledge post-test were administered upon completion of the class (day eight). One hundred percent of the participants responded to both questionnaires and the knowledge pre- and post-tests (n=12). The confidence questionnaire was developed by the investigators, and the knowledge pre-test and post-test were developed by the four dentists teaching the course. The questionnaire was a voluntary, eighteenitem, paper and pencil survey divided into three components as described below. It was distributed and collected in the same class session. The time required to complete the survey was approximately five minutes. Oral instructions were provided in addition to written instructions. To assess perceived level of confidence in restorative knowledge, course par- 374 Journal of Dental Education Volume 71, Number 3

3 ticipants were asked to respond to the first six questions listed in Table 1. To assess the participants perceived level of confidence in restorative technical skills, course participants were asked to respond to the next nine questions listed in Table 1. The final three questions in Table 1 were used to determine the perceived ability of the participant to learn these techniques and implement them into practice upon completion of the course. Survey answers were recorded using a Likert-item response with five categories (strongly disagree=1, disagree=2, neutral or unsure=3, agree=4, strongly agree=5). An unconfident attitude was defined as a response of strongly disagree or disagree. A confident attitude was defined as a response of strongly agree or agree. A response of not sure was equated with uncertainty. No validity or reliability testing of the questionnaire was conducted. The knowledge pre-test and posttest consisted of a 100-item, multiple choice, paper and pencil examination. It was administered as a knowledge evaluation tool, and the content of the questions was designed to parallel course curriculum. The preand post-tests were timed (two hour) examinations that were required for successful completion of the course. Three weeks elapsed between the pre-test and the post-test. No validity or reliability testing on the examination was conducted. Additionally, upon completion of the post-test, participants completed an evaluation of the course using a short-answer format and participated in an informal exit interview with the investigators of this study. The exit interviews were designed to evaluate effectiveness of the CE course and address obstacles they envisioned encountering upon returning to practice. Data were collected and analyzed by SPSS Version Given the nature of the data, both parametric and nonparametric tests were run. Completed questionnaires and examinations were analyzed and tabulated using paired t-test and Wilcoxen signed rank tests. Much of the material was descriptive in nature. Statistical significance for both tests was set at p<0.05. However, much of the assessment material that was collected by written responses was descriptive in nature. Table 1. Comparing confidence levels before and after the restorative functions course Content Knowledge I feel confident in my knowledge of premolar occlusal anatomy. I feel confident in my knowledge of molar occlusal anatomy. I feel confident in my knowledge of amalgam composition. I feel confident in my knowledge of composite material. I feel confident in my knowledge of cement composition. I feel confident in my knowledge of glass ionomer composition. Technical Skill I feel confident in placement of rubber dams. I feel confident in placement of Tofflemire retainers. I feel confident in triturating and packing amalgam. I feel confident in carving amalgam. I feel confident in adjusting the occlusion of amalgam restorations. I feel confident in placement of composite restorations. I feel confident in adjusting the occlusion of composite restorations. I feel confident in placement of stainless steel crowns. I feel confident in placement of glass ionomer restorations. Practical Application I feel confident in my ability to learn restorative function techniques. I feel confident in my ability to provide patient treatment to restorative function. I feel confident in my ability to incorporate restorative functions into private practice. Results The mean age of participants was 40.3 years, with a range of twenty-one to fifty-five years. One hundred percent were female. The mean years of dental experience was 18.5, with a range of three to twenty-five years. Participants responses for the confidence questionnaire are shown in Table 2. Wilcoxen signed rank tests were used to test for significant differences in participants confidence levels on the pre- and postcourse administrations of the questionnaire. Data analysis revealed an increase in confidence in all content knowledge categories (p<.01) and all technical skill categories (p<.05). Content knowledge categories were composition of amalgam, glass ionomer, and composite, cement, and stainless steel crowns. Technical skill categories were placement and carving of amalgam, placement of Tofflemire retainers, placement of glass ionomer and composite, adjusting the occlusion of restorations, mixing cement, and placing stainless steel crowns. Participant attitude categories were learning restorative functions skills March 2007 Journal of Dental Education 375

4 Table 2. Differences in participants confidence levels before and after the restorative functions course Specific Area Z P Knowledge of premolar occlusal anatomy **.003 Knowledge of molar occlusal anatomy **.003 Knowledge of amalgam composition **.008 Knowledge of composite material **.002 Knowledge of cement composition **.004 Knowledge of glass ionomer composition **.002 Placement of rubber dam *.015 Placement of Tofflemire retainer *.028 Triturating and packing amalgam *.011 Carving amalgam **.003 Adjusting occlusion of amalgam restoration **.004 Placement of composite restoration *.010 Adjusting occlusion of composite restoration **.002 Placement of stainless steel crown **.003 Placement of glass ionomer restoration **.004 Ability to learn restorative function techniques *.011 Ability to provide patient treatment to restorative function **.008 Ability to incorporate restorative functions into private practice Note: Z score from Wilcoxen Signed Rank Test. *p<.05 level; **p<.01 level. Confidence levels based on five-point Likert scale: very confident, somewhat confident, unsure or neutral, somewhat unconfident, very unconfident. and implementing them into practice. Participants did not significantly increase in confidence regarding the ability to implement restorative functions skills into practice (p<.70). The results of the participants performance on the pre- and post-course administrations of the knowledge test are summarized in Table 3. A matched pair t-test was used to test for significant differences between the participants pre- and post-test scores. The mean score of the twelve participants who completed the pre-test was 76.3, with a range of 72 to 82. The mean score on the post-test for participants was 83.9, with a range of 75 to 88. Statistical analysis found a significant increase in participants restorative content knowledge (p<.001). When grouped according to profession, both dental hygienists (p=.035) and dental assistants (p=.003) reported a significant gain from pre- to post-test scores. The pre-test mean scores for dental hygienists and dental assistants were 77.0 and 76.0, respectively, while the post-test mean scores for dental hygienists and dental assistants were 86.7 and 83.0, respectively. Additionally, on the participants course assessment feedback and one-on-one interviews, they unanimously self-reported an increase in restorative content knowledge. Discussion The results indicate that providing restorative functions education for dental hygienists and dental assistants enhanced the confidence of participants concerning restorative content, technical skills, and their ability to acquire this information, and the course also augmented their knowledge of restorative technique. When examining the difference in test scores between dental hygienists and dental assistants, the results show a statistically significant gain from pre- to post-test scores. The difference in mean pre- and post-test knowledge scores was 7.7. While this is statistically significant, it suggests both dental hygienists and dental assistants already knew much of the didactic information communicated in the course. However, the participants did not show an increase in confidence in implementing restorative functions into practice. This lack of confidence in implementation capacity was also identified in course assessment feedback and exit interviews. Specifically, participants reported little confidence in their ability to efficiently schedule patients to provide restorative treatment. The dental hygienists Table 3. Dental auxiliaries scores on restorative functions knowledge pre- and post-tests Mean N Standard Deviation Standard Error Mean Significance Pre-exam Post-exam Journal of Dental Education Volume 71, Number 3

5 reported they were accustomed to a schedule of patients needing preventive care and were unsure of how to work in tandem with a dentist. This is a surprising, yet practical, concern that needs to be addressed with further investigation. If dental hygienists and dental assistants go through the rigors of restorative functions training, it is of no value if they are unable to practically apply the acquired skills. Follow-up evaluation is needed to determine if participants were able to effectively implement restorative functions into their practice schedule. It would also be of interest to examine ways dentists utilize allied professionals in states where delegation of restorative functions is possible. This study has several limitations that preclude generalization to other populations. The assessment instruments utilized to measure knowledge gained from course completion and pre- and post-confidence levels were not validated. The participant number (n=12) represents a small sample size, and all the participants were from the same geographic area. Further study is needed to confirm these findings with other restorative functions participants in other states. However, this case study contributes to the dental literature by documenting the impact of restorative functions training on one group of allied professionals participating in a continuing education course at a U.S. dental hygiene school. Conclusions Much evaluation is yet to be done within dental education regarding restorative functions training for dental hygienists and dental assistants. Clearly, this study represents a preliminary and limited investigation of the degree to which a restorative functions CE course can modify the knowledge and confidence levels of participants. However, based on the relative success of this initial effort, subsequent efforts can now be more ambitious. A review of the literature indicates that this study represents the first evaluation of the confidence levels and knowledge regarding restorative functions within a group of dental hygienists and dental assistants receiving restorative training. Given that restorative functions may be legally delegated to allied dental professionals in a number of states, restorative functions training should be available for interested professionals via continuing education courses or possibly through integration into the curricula of dental hygiene and dental assistant students, where feasible. Our findings indicate training in restorative functions provides allied dental professionals the confidence and knowledge necessary to perform restorative function procedures, leading to delegation of these procedures by the dentist, which in turn could lead to an increase in the availability of dental care for the public. Further research is needed to identify reasons contributing to the lack of confidence in the capacity to implement restorative functions in practice. The most obvious future research need is to evaluate the quality of care and patient satisfaction when dental auxiliaries provide restorative care. REFERENCES 1. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, Oral Health America. Keep America smiling: the oral health America national grading project At: www. oralhealthamerica.org/oralhealthparity.html. Accessed: September 1, Cooper MD. A survey of expanded duties usage in Indiana: a pilot study. J Dent Hygiene 1993;67(5): Minnesota Dental Practice Act At: Accessed: July 23, Waller RR. Expanded duties of auxiliaries: a survey of opinions of Georgia dentists. J Am Dent Assoc 1973;86(5): Milgrom P, Bergner M, Chapko M, et al. The Washington state dental auxiliary project: delegating expanded functions in general practice. J Am Dent Assoc 1983;107(5): Burt BA, Eklund SA, Lewis DW. Dentistry, dental practice, and the community. 4 th ed. Philadelphia: W.B. Saunders Co., 1992: Boyer EM. A second look at expanded functions research: unintended outcomes for the public s safety. J Dent Hygiene 1996;70(1): Sisty NL, Henderson WG, Paule CL, Martin JF. Evaluation of student performance in the four-year study of expanded functions for dental hygienists at the University of Iowa. J Am Dent Assoc 1978;97(10): Rich SK, Smorang J. Survey of 1980 California dental hygiene graduates to determine expanded-function utilization. J Public Health Dent 1984;44(1): Deuben CJ. Survey of expanded functions included within dental hygiene curricula. Educational Directions 1981;(9): Brian J, Cooper MD. Utilization of advanced hygienist skills in the private practice. Indiana Dent Assoc J 1997;76(3): Chapko MK, Milgrom P, Bergner M, Conrad D, Skalabrin N. Delegation of expanded functions to dental assistants and hygienists. Am J Public Health 1985;75(1):61-5. March 2007 Journal of Dental Education 377