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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.
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The clinical scope of practice for dental hygienists has expanded gradually since hygienists were first introduced into Australia in 1975, following international trends in practice and changes in the educational delivery of dental hygiene programs.1 In Victoria, dental hygienists are currently permitted to manage periodontal disease within the context of an overall treatment plan undertaken by a dentist, with permitted tasks including oral examination, intra- and extra-oral radiographs, scaling and root planing and the administration of local analgesia. Broad-based expansion to the scope of practice for allied dental personnel has been vigorously opposed by professional dental associations in Australia, with common concerns relating to the lack of education and potential compromises to public safety.
Internationally, however, the practice of dental hygiene has been shifting from traditional models of direct and indirect supervision by a dentist towards a more collaborative approach to practice, where the dentist and hygienist work together to decide on the best approach to patient management and the services required.2 In Sweden, Denmark, Norway, Finland, the Netherlands and Colorado (USA), dental hygienists are able to practise independently of dentists.3 Limited forms of independent practice or direct access in restricted practice locations, for example in nursing homes and public health facilities, are permitted in Germany, Latvia, Canada and a number of states in the USA. In most of the provinces in Canada, the profession of dental hygiene is self-regulated, with hygienists and not dentists responsible for registration and licensing.3 Canadian dental hygienists have expressed a strong interest in expanding their scope of practice and their knowledge base to achieve greater professional independence, however there is strong opposition to this from Canadian dentists who believe that hygienists are not adequately trained to practice independently.4
A number of studies investigating dental hygienists working in some form of independent practice have found high levels of patient satisfaction with dental services provided and the ability of independent practices to attract new patients.5,6 There was no evidence of undue risk to public health and safety, and hygiene practices were superior to dental practices in a number of comparable measures including infection control, follow-ups to medical findings, updating the medical history and documentation of periodontal and soft-tissue status.
Workforce planning research in Australia is predicting future critical shortages in the supply of dental services.7 One policy direction to address workforce shortages is targeting the number of dental hygienists currently being trained. In the past five years, there has been an increase both in the number of dental schools training dental hygienists, and the overall number of students being trained. Expanding the clinical scope of practice for hygienists to permit a wider range of duties has also been proposed as a mechanism to improve access to dental services, particularly in underserved populations such as nursing homes.8 Aligning Australian regulations more closely with the international practice of dental hygiene are options that should be explored if improving access to dental hygiene services is to be achieved. Understanding the factors that are important in the employment of dental hygienists in Victoria, as well as the attitudes of various members of the dental team to aspects of dental hygiene practice are important in the debate about the greater utilization of dental hygienists in Victoria.
The aim of this study was to investigate the attitudes of Victorian dentists, dental specialists and dental hygienists to the employment of dental hygienists and their scope of practice.
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There were 179 dental hygienists, 2328 dentists, 37 periodontists and 118 orthodontists registered with the Dental Practice Board of Victoria on 30 June 2005. A list of practice addresses was obtained from the Board. Practitioners with an interstate or overseas address were excluded from the sample. Dentists with a public dental clinic address were excluded from the sample. Dental hygienist practice addresses were cross-matched with dentists and specialists to derive two lists of practitioners whose practice either employed or did not employ a dental hygienist. A random sample of 100 dental hygienists, 100 dentists from practices that employed a hygienist and 100 dentists from practices that did not employ a hygienist were selected for the study. For orthodontists, all 36 who worked in a practice that employed a hygienist and a random sample of 44 who worked in a practice that did not employ a hygienist were selected, and all registered periodontists were included in the study sample. Dentists and specialists who worked in a practice that employed a hygienist were classified as employers, and those who worked in a practice without a hygienist were classified as non-employers.
Three questionnaires were designed and mailed out to subjects, according to their category (dental hygienist, employer or non-employer) with a plain language statement and self-addressed reply paid envelope to return the questionnaire. A second mail-out to non-responders was undertaken approximately six weeks after the initial mail-out.9 All three questionnaires asked for basic socio-demographic data, dental practice demographics, and attitudes towards the employment and scope of practice of hygienists.
The data from the surveys was entered into a spreadsheet, and transferred to SPSS v.14.0 for analysis. The University of Melbourne Human Research Ethics Committee approved the study, and participation was voluntary. The project was supported by the Dental Hygienists’ Association of Australia (Victorian Branch) Inc.
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The overall response rate was 65.3 per cent, with a higher response rate for hygienists (77.0 per cent), followed by employers (general dentists – 71.1 per cent, periodontists – 61.1 per cent, orthodontists – 76.5 per cent) and non-employers (general dentists – 45.7 per cent, periodontists – 75 per cent, orthodontists – 59 per cent). Hygienists were predominantly female, while dentists and specialists were predominantly male (Table 1). More than half of the dentists and specialists were more than 40 years old, compared with only 31.9 per cent of the hygienists. The employer group had considerable experience working with dental hygienists, with an average of 7.7 years working with a hygienist.
Table 1. Demographic profile of respondents
| ||n||Age group||Gender|
|20–29 yrs (%)||30–39 yrs (%)||40–49 yrs (%)||50+ yrs (%)||Male (%)||Female (%)|
The main reasons for employing a dental hygienist were to provide more time for dentists to undertake more complex work, for the quality of service provided and to reduce waiting times to see a dentist (Table 2). Orthodontists were less likely to cite the quality of service provided and providing more time to provide complex treatment compared with general practitioners, while general practitioners were more likely to cite that patients prefer to be treated by a hygienist.
Table 2. Reasons by employers for employing hygienists
| ||Dentist (%) (n = 63)||Periodontist (%) (n = 10)||Orthodontist (%) (n = 23)||Total (%) (n = 96)|
|Patients prefer to be seen by a hygienist(a)||36.5||10.0||4.3||26.0|
|Quality of service provided(a)||85.7||70.0||56.5||77.1|
|More time for dentists to undertake complex treatment(a)||90.5||90.0||69.6||85.4|
|To reduce waiting time/manage patient workload ||69.8||80.0||82.6||74.0|
|Improve practice profitability||41.3||30.0||52.2||42.7|
There was a range of reasons why dentists and specialists did not employ a hygienist (Table 3). General practitioners and orthodontists did not believe that the quality of service provided by a hygienist was a factor, but one-third of periodontists cited this as a reason for not employing a hygienist. Although 54.3 per cent of the non-employers reported that they would consider employing a hygienist in the future, only 4.4 per cent reported that their practice was currently seeking to employ one.
Table 3. Reasons by non-employers for not employing hygienists
| ||Dentist (%) (n = 40)||Periodontist (%) (n = 9)||Orthodontist (%) (n = 21)||Total (%) (n = 70)|
|No available hygienists||17.5||11.1||0.0||11.4|
|Not cost effective||30.0||11.1||38.1||30.0|
|Patients prefer dentist||37.5||22.2||14.3||28.6|
|Quality of service provided(a)||5.0||33.3||0.0||7.1|
Regarding the impact of employing a hygienist on a range of factors, more than half of the hygienists believed that their employment made dental care more affordable, compared with only 34.9 per cent of employers and 28.0 per cent of non-employers (Table 4). The majority of respondents thought the employment of hygienists improved access to dental services, and made dental practices more efficient. Hygienists were virtually unanimous in agreeing that their employment made dental practices more profitable, with 61.3 per cent of employers agreeing but 14.5 per cent of non-employers believing that hygienists made dental practice less profitable.
Table 4. Impact of the employment of dental hygienists on various aspects of dental practice
| ||Employers (%) (n = 106)||Non-employers (%) (n = 75)||Hygienists (%) (n = 67)|
|Impact on affordability(a)|
| More affordable||34.9||28.0||53.7|
| No change ||61.3||61.3||40.3|
| Less affordable||3.8||10.7||6.0|
|Impact on access(a)|
| Improved access||81.3||67.1||88.1|
| No change ||18.7||31.6||11.9|
| Less access||0.0||1.3||0.0|
|Impact on profitability(a)|
| More profitable||61.3||42.1||95.5|
| No change ||30.2||43.4||4.5|
| Less profitable||8.5||14.5||0.0|
|Impact on efficiency(a)|
| More efficient||86.9||57.3||98.5|
| No change||9.3||33.3||1.5|
| Less efficient||3.7||9.3||0.0|
Subjects were asked to rate their attitudes regarding a number of statements relating to the practice of dental hygiene on a 5-point Likert scale (1-strongly disagree to 5-strongly agree), and mean values are reported in Table 5. There were statistically significant differences in the mean responses for hygienists, employers and non-employers for all statements, with post hoc tests (Tukey’s HSD) showing that these differences were between hygienists and employers, and between hygienists and non-employers, with no differences between employers and non-employers except for the statement ‘Dental hygienists should be able to increase their scope of practice’. Most hygienists believed that they were capable of diagnosing periodontal disease and dental caries and formulating a treatment plan, but employers and non-employers varied in their opinions.
Table 5. Mean agreement of dentists and hygienists towards aspects of dental hygiene practice (1 – strongly disagree to 5 – strongly agree)
| ||Employer (n = 107)||Non-employer (n = 76)||Hygienist (n = 67)|
|Dental hygienists should be able to increase the scope of practice(a)||3.3||2.5||4.2|
|Dental hygienists are capable of diagnosing periodontal disease(a)||3.8||3.6||4.6|
|Dental hygienists are capable of diagnosing caries(a)||3.3||3.3||4.1|
|Dental hygienists are capable of treatment planning(a)||2.7||2.5||4.2|
|Dental hygienists are capable of treating patients without prescription(a)||2.2||2.0||3.6|
|Dental hygienists are capable of practising independently(a)||2.2||1.9||3.6|
|Dental hygienists should be allowed to practice independently(a)||1.8||1.6||3.5|
|Dental hygienists require a degree of supervision(a)||3.7||3.9||2.7|
|Dental hygienists can make a meaningful contribution to dental team(a)||4.5||4.0||4.8|
|Training more dental hygienists can help with workforce shortage(a)||3.6||2.9||3.9|
There was not unanimous support for independent practice from hygienists, with only 58.3 per cent believing that they were capable of practising independently and 52.3 per cent believing that hygienists should be allowed to practice independently. Few employers and non-employers agreed that hygienists were capable of independent practice and even less were in favour of allowing independent practice for dental hygienists.
Hygienists thought they should be able to increase their scope of practice, with 82.0 per cent in favour, while only 26.9 per cent of employers and 52.6 per cent of non-employers disagreed/strongly disagreed. When asked specifically about changes to the Dental Practice Board of Victoria’s Code of Practice for dental hygienists, 56.5 per cent of hygienists and 40.8 per cent of employers were in favour of changes to the clinical scope of practice for dental hygienists, while 82.9 per cent of non-employers were in favour of the status quo (Chi-squared, p < 0.001). Employers were interested in an expanded scope of practice that allowed hygienists to undertake activities such as in-surgery tooth whitening (11.2 per cent) and further orthodontic procedures (5.6 per cent), while hygienists wanted changes that allowed them to work more independently, including the provision of care directly to residents of nursing homes (25.4 per cent), permitted in-surgery tooth whitening (13.4 per cent) and the placement of temporary restorations (9.0 per cent). The vast majority of all subjects thought that hygienists made a meaningful contribution to the dental team, with 86.6 per cent of all respondents agreeing or strongly agreeing. Employers and hygienists believed that training more hygienists could help with the oral health workforce shortage, but this was not supported by non-employers.
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An acceptable overall response rate of 65.3 per cent was obtained, particularly from hygienists and employers, hence the data presented in this study would closely represent the opinions of these two groups. Fifty-six per cent of employers have worked with hygienists for more than five years, and this substantial amount of experience validates their opinions regarding the capabilities of hygienists. However, the response rate from the non-employer group was much lower, particularly the general practitioners. This might be due to a lack of interest, time to complete the questionnaire or experience with dental hygienists. Therefore, data obtained from this group may not be representative of the non-employer population.
Female dentists and specialists are underrepresented in this study, with only 15.2 per cent of the sample being female, compared to 31.6 per cent of Victorian dentists and specialists.10 The proportion of dental practitioners aged above 45 years in this sample was slightly higher than that of the Victoria population (57.1 per cent and 49.0 per cent, respectively). The majority of these older respondents had graduated before dental hygienists commenced training in Victoria in 1996. Consequently, they may have limited knowledge of, and exposure to, dental hygienists, resulting in a potential bias against hygienists.
Employers and hygienists acknowledged the positive impact of employing a dental hygienist, with strong beliefs that a hygienist improved access to dental care and increased practice profitability and efficiency. However, fewer than half of the non-employers believed that a hygienist would have a positive impact on practice profitability, and nearly two-thirds of employers and non-employers believed that there would be no changes to the affordability of services. The issue of affordability of dental services and practice profitability is complex, and is dependent on a number of factors such as practice workload, fees, materials and consumables, and employment costs associated with the hygienist and any additional support staff. The employment of a hygienist provides more time for the dentist to undertake more complex and profitable treatment. While the employment costs of a hygienist to undertake preventive and periodontal treatment may generally be less than that of a dentist, this is likely to be offset by longer appointment times for hygienists to provide treatment compared with a dentist. A number of respondents indicated that fees for treatment provided by a hygienist were the same as those provided by a dentist. This supports the contention from the respondents that the employment of a hygienist would not impact on the affordability of services.
The attitude of dentists and dental hygienists varied considerably regarding the scope of practice of dental hygienists. Most dental hygienists and employers supported expanding the scope of practice for hygienists, whereas the majority of non-employers opposed any expansion. Procedures such as in-office tooth whitening and bonding of orthodontic brackets were suggested by many employers and hygienists as procedures that could be undertaken by a dental hygienist. Many hygienists also expressed an interest in being able to work in nursing homes without the presence of a supervising dentist. This model of practice may improve access to that section of the community who currently have difficulty obtaining preventive dental services, and is a model that has been adopted in a number of jurisdictions internationally.
Since the majority of employers reported that employing a hygienist increased the profitability and efficiency of their practice, support for an expansion of the scope of practice for hygienists may be interpreted as an avenue to further increase their profitability and efficiency. This links in with a broader argument regarding projected increases in the demand for dental services and oral health workforce shortages in Australia, and the expansion of the role of allied dental personnel as one mechanism to manage this disparity in supply and demand. Spencer et al.7 argue that increasing dental productivity as a means of addressing increasing demand can be achieved by the reconfiguration of the traditional dental team through the substitution of services normally provided by a dentist being provided by allied dental personnel such as a dental hygienist.7 They also argue that the utilization of a hygienist within a dental practice can create a complementary effect, with more complex procedures able to be undertaken by the dentist, although this may result in the creation of additional demand for services and may not necessarily reduce projected workforce shortages. This increase in demand may be created by the practice because the opportunity exists to service new demand, or because of increased patient awareness and expectations. Nonetheless, substitution of dental service provision may provide incremental improvements in productivity and access to dental care. At the practice level, expanding the role of the dental hygienist may lead to an overall increase in profitability due to its complementary effect, while at a population level, substitution may address the increasing demand for dental services.
Previous studies have shown a relatively uniform and strong opposition from dentists to the expansion of roles and scope of practice for dental hygienists, and particularly to the concept of independent practice.4,11 However, this is not necessarily matched by the general public, who may be more supportive of independent dental hygiene practices.12 The present study found that although there was opposition from dentists and specialists towards expanding scope of practice, reducing supervision and allowing independent practice, employers were generally less opposed than non-employers. The greater level of support from the employers is likely to be a reflection of their more intimate understanding of the capabilities of a hygienist than their non-employing colleagues, who may not have the same level of knowledge or experience, and may be basing their opinions on outdated notions of hygienist education and training.
Another reason why many dentists may have been opposed to any expansion in the scope of practice for dental hygienists is that they may have identified it as an avenue which would lead to independent practice for dental hygienists. Most dentists disagreed with dental hygienists being able to engage in independent practice, which may be attributed to a fear of losing control over patient management, potential loss of income or concerns for the quality of dental care provided by hygienists. Comments from dentists and specialists regarding increasing scope of practice and independent practice reflected the view that dentists believed that hygienists did not possess adequate training and education in examination, diagnosis and treatment planning to practice independently, particularly with regard to the diagnosis of oral pathology. Many dentists and specialists also argued that dental hygiene services would not be more affordable to patients in an independent practice setting, since practice overheads would be the same for a hygienist regardless of whether they were employed or operating in an independent practice.
Hygienists have become an integral part of dental practice overseas, with 73 per cent of practitioners in the United Kingdom believing that hygienists have an important role to play in preventive dentistry.13 Similar support was expressed by Victorian dentists for the positive role hygienists have to play in dental practice, with the majority of all subjects believing that dental hygienists made a meaningful contribution to the dental team in terms of efficiency, profitability and access to dental care.
Despite half of the non-employers stating they would consider employing a hygienist, less than 5 per cent were actively looking to employ one. The main reasons provided for not employing a hygienist were limited chairs and the lack of available hygienists, reasons often cited in the literature.13–15 In the USA, Canada and Japan, the ratio of dentists to hygienists is 1:1, indicating that there is strong demand from both dentists and patients to utilize the services of dental hygienists.16 In Victoria, the ratio of hygienists to dentists is approximately 1:13, and until recently, there were fewer than 20 dental hygienists graduating annually.10 Increases in the number of new training places for dental hygienists across Australia in the past three years will help to relieve the demand for dental hygiene services.
Another significant barrier to the employment of dental hygienists was the attitudes of non-employers regarding the role of dental hygienists in practice. There was clearly a perception that the employment of a hygienist would be detrimental to a dental practice because patients preferred to be treated by a dentist, the quality of dental hygienist services would not be of the same standard as that provided by dentists and that services provided by a dental hygienist were not cost-effective, and would therefore impact on practice viability. Interestingly, these issues appeared to be less of a concern for dentists currently employing a hygienist. Indeed, only 8.5 per cent of employers thought that hygienists made their practice less profitable and 77.1 per cent employed a hygienist because of the quality of dental care provided.