Legal provisions for delegating specific functions. Patient Satisfaction in a Restorative Functions Dental Hygiene Clinic

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1 Milieu in Dental School and Practice Patient Satisfaction in a Restorative Functions Dental Hygiene Clinic Brigette R. Cooper, R.D.H., M.S.; Angela L. Monson, R.D.H., Ph.D. 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. A restorative functions course was added to the curriculum of a dental hygiene program at a state university in Minnesota to teach these skills. Student requirements for the course included clinical experiences on a minimum of twelve patients, as outlined by the Minnesota Board of Dentistry. The objectives of this study were to describe the characteristics and satisfaction levels of patients receiving care in the restorative functions dental hygiene clinic. An online survey was offered to eighty-two adult patients receiving restorative treatment in the clinic, with sixty-four patients agreeing to participate for a response rate of 78 percent. The average patient was thirty-one to forty years old, Caucasian, worked full-time, did not have dental insurance, had a family income of between $20,000 and $40,000, and chose this clinic due to low cost. Ninety-eight percent of responding patients were satisfied or very satisfied with their overall clinic experience, and 98 percent also thought the quality of care at this clinic was the same, better, or much better than previous dental care they had received. Most patients would return to this clinic for future restorative work (97 percent), in addition to recommending this clinic to others seeking restorative work (98 percent). Wilcoxen signed rank tests revealed the patients were significantly more satisfied (p<.001) with the fees of this clinic, as well as the communication, caring, organization, and preparedness of the dental hygiene student as compared to their last restorative visit to a private dentist. Group differences were examined using the non-parametric test, Mann- Whitney, which is similar to the two-sample t-test for parametric data. No significant group differences in the overall satisfaction with this clinic were found according to income level, dental insurance, or ability to pay for an unexpected dental bill. Findings in this study suggest the majority of patients were satisfied with the overall experience of restorations placed by a dental hygienist. Further research is indicated to determine if these results are typical of other dental hygiene restorative functions clinics in the United States. Ms. Cooper is Assistant Professor and Ms. Monson is Associate Professor both in the Department of Dental Hygiene, Minnesota State University, Mankato. Direct correspondence and requests for reprints to Ms. Brigette Cooper, Minnesota State University, Mankato, Department of Dental Hygiene, 3 Morris Hall, Mankato, MN 56001; phone; fax; [email protected]. Key words: dental hygiene students, restorative functions, patient satisfaction Submitted for publication 5/29/08; accepted 9/2/08 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 functions of dental hygienists and dental assistants. 1 Specifically, in 2003 the Minnesota Dental Practice Act was modified to allow dental hygienists and dental assistants to perform expanded duties in restorative functions. According to the Minnesota Dental Practice Act of 2008, a licensed dental hygienist or dental assistant may place, contour, and adjust Class I, II, and V amalgam and glass ionomer restorations; adapt and cement stainless steel crowns; and place, contour, and adjust Class I and Class V supragingival composite restorations in which the margins are entirely within the enamel. 2 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. 3,4 Enactment of the modified Minnesota Dental Practice Act of 2008 was based on the premise that increasing the scope of practice and responsibilities of allied dental professionals may help address oral health disparities and increase access to oral health care. As legislative changes occur in the state practice act, the curriculum of dental hygiene education should also be modified to account for the expanded scope of practice. As the curriculum changes, an internal evaluation protocol of dental hygiene programs should be implemented to ensure the provision of high-quality care. Quality of care can be difficult to define because patient and dental provider criteria may differ. 5 However, patient satisfaction is an essential element in assessing the quality of care. Tra Journal of Dental Education Volume 72, Number 12

2 ditionally, dental patient satisfaction was measured by a clinician s technical skill with limited regard for patient opinion. Many patients may have difficulty evaluating the technical quality of the dental service they received. 6 For a variety of reasons, an increased emphasis is now placed on measuring patient satisfaction. 7 This may be due to the association among patient satisfaction, patient compliance with recommended treatment, and the resulting quality of health care. 8 Patient satisfaction affects patient decisions on whether or not to return for more dental treatment. 8 Thus, knowing patient perceptions of the dental care provided is an important factor when pairing patient expectations with treatment received. Additionally, patient satisfaction data could aid in identifying areas of care that require improvement. Literature Review Measures of patient satisfaction with medical care have been widely reported. 9 Some studies have shown that the quality of interpersonal communication between the health care provider and the patient plays a large role in determining patient satisfaction Similar research has been done in the dental field. Ross and Duff found patients return to the dentist for continued care due to satisfaction with the interpersonal communication component rather than perceived technical quality of care. 12 Gurdal et al. investigated satisfaction with dental care among 1,001 patients at a dental faculty outpatient clinic at a major university in Turkey. 8 They found that despite the significant variations among the cultural and ethnic structures of different societies, personal interactions take priority in establishing satisfying dental treatment. Alvesalo and Uusi-Heikkila analyzed the use of services, behavioral features, and their intercorrelations among a random sample of ninety-four patients visiting a dental clinic at a university in Connecticut. 13 They found the greatest percentage of respondents relied on the advice of friends, relatives, or neighbors when choosing a dental provider. They also reported a positive and significant correlation between degree of utilization of dental care and satisfaction with care provided. Chu et al. studied patient satisfaction with dental treatment by surveying 311 students and staff at a university in Hong Kong under a recently introduced item-based fee-paying system and reasons for non-attendance at the clinic. 14 They found the university s recent attempts to shorten patient waiting time and the change to a fee-paying system, from the previous time-based system, improved patient satisfaction with the clinic. Mascarenhas investigated patient satisfaction at a university in Ohio, measuring overall satisfaction and subscales of access, pain management, and quality of two dental delivery systems. 15 She concluded there was no significant difference in patient satisfaction levels between the two systems. Limited studies have been reported regarding patient satisfaction with dental hygiene providers. Chaffin et al. assessed patient satisfaction and attempted to identify predictors of patient satisfaction with hygiene providers in military dental treatment facilities. 16 Their study demonstrated that beliefs about care are the most important factors associated with patient satisfaction with the dental hygiene provider. They found that interpersonal experience had a strong association with patient assessment of care, suggesting that training providers about the relationship between satisfaction and interpersonal relations may enhance patients overall satisfaction with the care they receive. It would be beneficial to both the patient and the dental provider to regularly assess care delivered. One way to do this is to conduct surveys on patient satisfaction with dental treatment. Results from these surveys could potentially aid in identifying patient satisfaction and perceptions of treatment at a particular point in time. Our review of the literature indicates that no information has been published in dental journals regarding patient satisfaction after receiving restorative treatment by a dental hygienist. To expand our limited knowledge base in this area, we conducted a study to examine patient characteristics and satisfaction levels in a dental hygiene restorative functions clinic. Methods A survey was used to determine patient characteristics and satisfaction levels upon completion of treatment in a dental hygiene restorative clinic. Human subject approval was obtained from the Institutional Review Board, Minnesota State University, Mankato. Informed consent was obtained from all participants. Twenty-three senior dental hygiene students were enrolled in the restorative functions course at this state university in Minnesota. It was a fourcredit, sixteen-week course in the spring of The restorative functions coursework included a December 2008 Journal of Dental Education 1511

3 didactic component in addition to laboratory and clinical requirements. Laboratory requirements included placing sixty surfaces of amalgam, thirty surfaces of composite, twenty surfaces of glass ionomer, and seven stainless steel crowns on prepared typodont teeth. Upon completion of all laboratory requirements, the students would then place restorations on patients in a clinical setting. Each student was required, by the Minnesota Board of Dentistry, to place restorations on at least twelve different patients, in addition to placing on patients a minimum of ten surfaces of amalgam, five surfaces of composite and glass ionomer, and four stainless steel crowns. We developed a standardized protocol for all patients receiving restorative treatment in the dental hygiene clinic. The dental hygiene student seated the patient, reviewed the patient s medical history with the patient and dental hygiene instructor, and delivered an anesthetic. The dentist prepared the tooth needing treatment, and the dental hygiene student placed the restoration, assisted by a classmate. The dentist returned to evaluate and grade the restoration prior to dismissing the patient. The dentists involved in the restorative clinic were three part-time adjunct faculty members at the university and four area dentists. A restorative functions patient satisfaction survey was offered to all eighty-two adult patients receiving treatment by dental hygiene students from February to May Sixty-four patients elected to complete the survey (78 percent). We developed the survey after examining patient satisfaction surveys used in previous research. 8,9,13,14 When we examined reliability, the Cronbach s alpha for the study on the cluster of satisfaction questions within the context of the university clinic was.94. Further demonstration of reliability was demonstrated with a Cronbach s alpha of.91 for the cluster of satisfaction questions within the context of the previous dental visit. The survey was a voluntary, twenty-four-item, online questionnaire completed on the computer available at each station. The dental hygiene student offered the survey to each patient immediately upon completion of treatment performed during the appointment. The student was instructed to tell each patient completing the survey that it was optional and confidential and would not affect future appointments at the restorative clinic. The time required to complete the survey was approximately ten minutes. Oral instructions were provided by the student in addition to the written directions on the survey. To assess patients satisfaction with their oral health, patients were asked to respond to the first three questions in Table 1. The patient s dental history was assessed with six questions. The remaining four questions assessed the patients willingness to return to the university for dental care, their willingness to recommend this clinic to others seeking dental care, their overall satisfaction with their previous dental experiences, and their comparison of the care they had received that day with dental care they had received elsewhere. The eleven items listed in Table 2 assessed patients satisfaction levels on a variety of factors regarding the restorative treatment provided Table 1. General survey questions in three content areas Satisfaction with oral health How satisfied are you with the overall health of your teeth and gums? How satisfied are you with your ability to chew overall? How satisfied are you with the appearance of your teeth and/or dentures? Dental history Do you visit a dental office more than once a year for the purpose of maintaining a healthy oral condition (whether or not you have dental problems)? When was the last time you visited a private dentist (other than MSU) for restorative dental treatment (fillings)? How many fillings do you have in your mouth? (ask hygienist if you are unsure) To what degree does the cost of dental treatment impact your desire to receive dental care? To what degree does dental anxiety or fear impact your desire to receive dental care? Please select the main reason you chose to seek dental care at the university clinic. Patient satisfaction Would you be willing to return to the university clinic if future restorative work is needed? Would you recommend the university clinic to others seeking restorative dental treatment? Please describe your overall satisfaction with previous dental experiences. Compare the quality of care received today to dental care received elsewhere Journal of Dental Education Volume 72, Number 12

4 Table 2. Mean comparisons of treatment factors between university clinic and previous dental office Treatment Factor University Clinic Previous Dental Office P Treatment time Appointment availability Cost *** Infection control * Overall facilities * Technical competence of provider * Communication with provider *** Caring nature of provider *** Organization of provider *** Professionalism of provider ** Overall satisfaction ** Note: P value from Wilcoxen sign rank test: *p<.05 level; **p<.01; ***p<.001 level. Overall satisfaction level based on fourpoint Likert scale: very dissatisfied (1), dissatisfied (2), satisfied (3), very satisfied (4). at the university as compared to their previous private dental visit. The remaining questions on the survey addressed demographics (gender, age, work status, college attendance) and financial status (dental insurance, annual family income, and ability to pay for an unexpected $500 dental bill). Survey answers were recorded using a Likert-item response with four categories (very dissatisfied=1, dissatisfied=2, satisfied=3, very satisfied=4), multiple-choice answers to categorize responses, and yes/no answers. No validity or reliability testing of the survey was conducted prior to conducting this study. The questions were based on surveys administered for similar research purposes in previous patient satisfaction studies. 8,9,13,14 Data were collected and analyzed by SPSS Version Given the nature of the data, both parametric and nonparametric tests were run. Completed surveys and examinations were analyzed and tabulated using Wilcoxen signed rank tests and Mann- Whitney tests. Much of the material was descriptive in nature. The statistical significance for both tests was set at p<0.05. Results The average patient was male, thirty-one to forty years old, and Caucasian, worked full-time, did not have dental insurance, had a family income of between $20,000 and $40,000, and chose this clinic due to its low cost. The majority of patients (58 percent) completing the survey reported that they visit a dentist at least once a year for the purpose of maintaining a healthy oral condition. The average participant had visited a private dentist, other than the university clinic, more than three years ago for restorative dental treatment. The typical patient had six to ten restorations. The majority of patients reported they were satisfied or very satisfied with the overall health of their teeth and gums (96 percent), satisfied with their ability to chew (93 percent), and satisfied with the appearance of their teeth (89 percent). Almost half of the patients (48 percent) reported that the cost of dental treatment greatly impacts their desire to receive care. The majority of patients (69 percent) reported that dental anxiety has little impact on their desire to receive dental care. Ninety-eight percent of the patients were satisfied or very satisfied with their overall clinic experience, and 98 percent also thought the quality of care at this clinic was the same, better, or much better than the previous dental care they had received. Most patients said they would return to this clinic for future restorative work (97 percent), in addition to recommending this clinic to others seeking restorative work (98 percent). Wilcoxen signed rank tests revealed the patients were significantly more satisfied (p<.001) with the fees of this clinic, along with the communication, caring, organization, and preparedness of the dental hygiene student as compared to their last restorative visit with a private dentist. The patients were also significantly more satisfied (p<.01) with the professionalism of the student and overall quality of care compared to their last private dentist restorative visit. Additionally, patients were significantly more satisfied (p<.05) with infection control, the overall facility, and the technical competence of December 2008 Journal of Dental Education 1513

5 the dental hygiene student as compared to their last private dentist restorative visit. The Mann-Whitney tests revealed no significant group differences when comparing overall satisfaction with this clinic according to income level, dental insurance, or ability to pay for an unexpected dental bill (Table 3). Additionally, there was no significant difference when comparing overall satisfaction with this clinic between those who chose this clinic due to low cost compared to all others (Table 3). Discussion Assessment and evaluation of patient satisfaction in this restorative functions clinic was critical due to the recent curricular changes made to the dental hygiene education program. The results of this study indicate that the patients were overwhelmingly satisfied with the care they received at the dental hygiene restorative functions clinic. When we compared data regarding care patients received in the restorative functions clinic to that of care received in the traditional dental hygiene clinic at this university, the two clinics had similar findings with an overall positive response. We implemented the online patient satisfaction survey during the second year of course implementation, which provided a one-year window of opportunity to assess and refine patient selection and scheduling, treatment planning, appointment length, and the student-to-dentist ratio in clinic. For example, during the initial year of clinic operations, many patients with extensive restorative needs were scheduled, resulting in frustration for the student, dentist, and patient. Only patients with small to moderately sized Class I and II restorative needs were assigned to the clinic in During the second year of the clinic, patients were scheduled for an entire three-hour clinic in the evening to allow enough time to complete several restorations and to accommodate the patients and dentists schedules. After the first year, the investigators realized the optimal supervision was one dentist for every four students, which allowed sufficient time for the dentist to prepare the teeth needing to be restored, in addition to being available for student instruction and questions. Two patients (3 percent) stated they were dissatisfied with the overall quality of care and would not return to this clinic for another appointment, giving the reason as the amount of time needed to complete treatment. It is assumed that the majority of patients were not acquainted with the student completing work on them, as only 9 percent reported they came to this clinic primarily because they were recruited by a dental hygiene student. Some patients may have been satisfied with this clinic because they believe work done in a university setting is more reliable due to the presence of academic supervision and evaluation. As anticipated, the majority of patients (56 percent) chose this university clinic due to the low cost of its services. The majority of patients (55 percent) seen at the clinic had no insurance, and 14 percent had government insurance. One might anticipate that patients with private dental insurance might choose a regular dental office in the community. However, 31 percent of participants in this study chose the university clinic despite the fact they had private dental insurance. One might also theorize that patients with no dental insurance or government insurance find it more difficult to find care. Because the university clinic serves all patients regardless of insurance type, one might speculate that these patients would Table 3. Mean satisfaction comparisons for specific patient subgroups Patient Subgroup Mean Satisfaction Score P Comfortable/slightly difficult to pay a $500 bill Moderately difficult/unable to pay a $500 bill 3.37 $39,000 income and below $40,000 income and above 3.30 Governmental or no insurance Private insurance 3.35 Chose university clinic due to cost Chose university clinic for other reasons 3.56 Note: P value from Mann-Whitney test. Overall satisfaction level based on four-point Likert scale: very dissatisfied (1), dissatisfied (2), satisfied (3), very satisfied (4) Journal of Dental Education Volume 72, Number 12

6 be more satisfied with treatment received simply because they were able to find dental care. Results of this study show there were no significant group differences when comparing overall satisfaction with this clinic according to income level, dental insurance, or ability to pay for an unexpected $500 dental bill. Additionally, there was no significant difference when comparing overall satisfaction with this clinic between those who chose this clinic due to low cost compared to all others. Follow-up evaluation is needed to determine patient satisfaction with dental work completed at the dental hygiene restorative functions clinic at a six-month or one-year interval, while further investigating the validity and reliability of the survey. At that time, it would be of interest for dental faculty members to perform a clinical and radiographic evaluation to assess long-term integrity of the restorations placed in this clinic. This study has several limitations that preclude generalization to other populations. The assessment instrument used to measure patient satisfaction levels was not validated. The participant number (N=64) represents a small sample size, and the participants were from the same geographic area. Additionally, the patients were most likely aware of the uniqueness of this approach to care that is typically performed by dental students and dentists, leading to a positive patient disposition about the experience. Further study is needed to confirm these findings with other patients receiving restorative care from dental hygiene students in other areas. However, this study contributes to the dental literature by documenting satisfaction levels of patients receiving restorative care from students in a U.S. dental hygiene program. Conclusions Much evaluation is yet to be done within dental education regarding patient satisfaction in a dental hygiene restorative clinic. Clearly, this study represents a preliminary investigation of patients satisfaction with restorative treatment by dental hygiene students. However, based on the relative success of this initial effort, we have concluded that subsequent efforts at our institution can now be more ambitious. Our review of the literature indicates that this study represents the first evaluation of patient satisfaction with care provided by dental hygiene students in a restorative dentistry clinic. In conclusion, our findings indicate that the majority of patients were satisfied with the overall experience of restorations placed by a dental hygienist. Further research is indicated to determine if these results are typical of other dental hygiene restorative function clinics. REFERENCES 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: leg.state.mn.us/statutes/?id=150a.10. Accessed: April 6, 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, Conrad D, Skalabrin N. The Washington state dental auxiliary project: delegating expanded functions in general practice. J Am Dent Assoc 1983;107(5): Burke L, Croucher R. Criteria of good dental practice generated by general dental practictioners and patients. Int Dent J 1996;46: Kress GC, Shulman JD. Consumer satisfaction with dental care: where have we been, where are we going? J Am Coll Dent 1997;64(1): Newsome PRH, Wright GH. A review of patient satisfaction. 2. Dental patient satisfaction: an appraisal of recent literature. Br Dent J 1999;186: Gurdal P, Cankaya H, Onem E, Dincer S, Yilmaz T. Factors of patient satisfaction/dissatisfaction in a dental faculty outpatient clinic in Turkey. Community Dent Oral Epidemiol 2000;28: Hashim R. Patient satisfaction with dental services at Ajman University, United Arab Emirates. East Mediterr Health J 2005;11(5): Ben-Sira Z. Affective and instrumental components in the physician-patient relationship. J Health Soc Behav 1980;21: Ross CE, Wheaton B, Duff RS. Client satisfaction and the organization of medical practice: why time counts. J Health Soc Behav 1981;22: Ross CE, Duff RS. Returning to the doctor: the effect of client characteristics, type of practice, and experiences with care. J Health Soc Behav 1982;23: Alvesalo I, Uusi-Heikkila Y. Use of services, care-seeking behavior, and satisfaction among university dental clinic patients in Finland. Community Dent Oral Epidemiol 1984;12: Chu CH, Yeung CY, LoEC. Monitoring patient satisfaction with university dental services under two fee-paying systems. Community Dent Oral Epidemiol 2001;29: Mascarenhas AK. Patient satisfaction with the comprehensive care model of dental care delivery. J Dent Educ 2001;65(11): Chaffin J, Chaffin S, Mangelsdorff D, Finstuen K. Patient satisfaction with dental hygiene providers in US military clinics. J Dent Hygiene 2007;81(1):1 9. December 2008 Journal of Dental Education 1515