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Experimental Pedodontic Auxiliary Training Program
Experimental pedodontic auxiliary training program
Freeman N. Rosenblum, DDS, MSD, M in n e a p o lis
An experim ental program on th e tra in in g o f a u x ilia ry personnel to perform expanded fu n c tio n s was be gun a t th e U n ive rs ity o f M innesota d ivis io n o f p e d i a tric d e n tis try in 1967. The o b je ctives o f th e study were to d ete rm in e personal and e d u ca tio n a l q u a lifi c a tio n s necessary fo r a u x ilia ry tra in e e s; to d e te r m in e typ e and e xte n t o f tra in in g required fo r d u tie s delegated; to com pare q u a lity and q u a n tity o f p ro cedures perform ed by a u x ilia rie s w ith perform ances o f senior dental students; and to c o rre la te q u a lity o f de n ta l tre a tm e n t rendered w ith tra in e e s ’ a p ti tu d e scores and grades. E xperim ental and co n tro l te a m s were arranged. Over a n ine-m onth period, the experim e ntal team s perform ed on th e average 4 0 % m ore procedures than th e co n tro l team s. In general, th ere was no s ig n ific a n t d iffe re n c e in th e q u a lity and speed o f perform ance between th e senior den ta l stu d e n ts and th e a u x ilia rie s .
Consideration of the expanded use of auxiliary per sonnel is becoming imperative. In 1966, the Coun cil on Dental Education of the American Dental Association made proposals to the profession, ask ing for support of Association programs and poli cies relating to expansion of training opportunities for auxiliary personnel. Specifically, it was pro posed that studies be developed on the possible extension of duties that could be delegated to den tal assistants and hygienists.1 In order to collect information pertinent to the development of programs for training auxiliary per sonnel in expanded functions, an experimental training program was instituted in 1967 at the Uni versity of Minnesota and situated in the division of pediatric dentistry. The program consisted of two 12-month phases, after a 12-month pilot study. The latter began in June 1967, and the experimen tal phases began in June 1968 and June 1969, re spectively. In the following report, unless other wise indicated the first phase of the experimental study only will be described in detail. The second 1082 ■ JADA, Vol. 82, May 1971
experimental phase will form the subject of a sub sequent publication. Specifically, the objectives of the study were fourfold: ■ to determine the personal and educational qualifications necessary for trainees; ■ to determine the type and extent of training re quired for the duties delegated; ■ to compare the quality and quantity of proce dures performed by the auxiliaries with the per formance of senior dental students; and ■ to correlate the quality of dental treatment rendered with the trainees’ aptitude scores and grades.
R e v ie w
o f lite r a tu r e
A comprehensive review of literature by Ham mons2 indicates that the expanded utilization of auxiliary personnel in dentistry is not a recent de velopment. As far back as 1920, the New Zealand government introduced the School Dental Service Plan and began training dental nurses to provide free dental care for all children below the age of 16 years.3 After a two-year training period, dental nurses made examinations and diagnoses, planned treatment, gave prophylaxes, topical fluoride ap plications, and local infiltration anesthesia, pre pared cavities, placed “uncomplicated”restorations, extracted deciduous and permanent teeth un der local anesthesia, and took part in dental health education. In 1960, the General Dental Council in Great Britain initiated a program4 to train high school graduates as dental auxiliaries to place “simple” restorations, extract deciduous teeth, and give pro phylaxes under the supervision of dental officers. In contrast to the New Zealand trainees, these aux iliaries were not trained to diagnose or prepare treatment plans. The first experimental program in North Ameri ca was reported by Ludwick in 1959.5 After a 16week course for training dental technicians, seven men and five women participated in an additional seven-week course and subsequently, as “thera peutic technicians,” provided dental care for
adults in the United States Navy. A double-blind evaluation study showed that the quantity of treat ment performed by an experimental team contain ing such a technician could be doubled without loss of quality. In 1963, Baird6 reported findings on the ex panded utilization of dental hygienists in the Royal Canadian Dental Corps. After a pilot study, an ex perimental program was begun. Three trainees, each with 3Vi years of experience as dental hy gienists, completed a 16-week course. The experi mental team consisted of a dental officer, a thera pist, a chairside dental assistant, a roving assistant, and a clerical assistant. The chairside assistant worked solely with the dental officer. The roving assistant provided assistance as required by the therapist. Three dental cubicles were used by the team, two being equipped for all dental proce dures, and the third containing equipment neces sary for the dental therapist. The dental officer was responsible for supervising the work performed by the therapist. The supervision was extensive in the beginning, but was reduced or eliminated as the therapist gained more experience. From the study, it was concluded that in the treatment of adult pa tients, the productivity of the experimental team was almost 100% greater than that of the conven tional dental officer-assistant team. No attempt was made in this study to assess the quality of den tal care rendered. In contrast to the foregoing study, the program initiated at the University of Alabama in 19632 evaluated the quality of treatment performed by auxiliaries trained in expanded functions, and com pared this factor with the performance of random ly-selected, advanced dental students. On the basis of aptitude tests, interviews, scholastic records, and previous employment, seven high school grad uates were selected to complete a program lasting approximately two years. During this time they learned to apply the rubber dam, adapt matrixes, and insert and finish amalgam, silicate, and tem porary restorations. A double-blind evaluation by independent examiners determined whether the procedures were to be rated as either excellent, ac ceptable, or unacceptable, based on predetermined criteria. The proportion of clinical procedures judged to be excellent was consistently greater for the trained auxiliary than for the dental student. An evaluation of quality of clinical procedures performed by auxiliaries trained in expanded functions was also the primary objective of a pilot study initiated in 1965 by the Division of Indian Health of the United States Public Health Service.7
In addition, the type and extent of training re quired by such an auxiliary was investigated. Dur ing an eight-week training program, eight women, some of whom had had experience in dental assist ing, were taught to adapt matrixes and insert and finish amalgam restorations. The participating den tists were members of the United States Public Health Service with at least one year of clinical ex perience after graduation. The double-blind study indicated that over a period of 40 days there was no significant difference in either the quality or quantity of treatment rendered to Indian and Alas kan schoolchildren by an experimental team (con taining a dentist and two auxiliaries who performed expanded functions) and a control team (contain ing a dentist and two dental assistants). From the foregoing review, it is obvious that the feasibility of expanded utilization of dental auxil iary personnel has been widely considered. Train ees used in experimental programs have had great diversity of background, experience, and dental qualifications. Furthermore, studies vary widely in their reports of the quality and quantity of clin ical procedures rendered by such personnel. Be fore the widespread introduction of training pro grams is possible in the United States, it is appar ent that several aspects of such training need clari fication. These include the qualifications required of trainees, the type and extent of training indicat ed for the duties delegated, and the closeness of clinical supervision required. In addition, there is clearly a need for the establishment of reproduci ble criteria for the evaluation of quality and quan tity of procedures performed. The present study was designed to provide some clarification of these aspects and to make recommendations for the most efficient use of trained auxiliaries.
M a t e r ia ls a n d
m e th o d s
■ Selection of trainees: In both the pilot and experimental studies, most trainees selected were recent graduates of an 11 -month dental assisting program at the University of Minnesota. For the pi lot study, four trainees were selected, based on their high school records, dental assisting records, and the results of the space relations test and chalk carving examination prepared by the American Dental Association. One of these trainees had had two years’ experience in dentistry (one year as a dental assistant in a private dental office and a further year supervising in a dental assisting pro gram). In the first phase of the experimental study Rosenblum: PEDODONTIC AUXILIARY PROGRAM ■ 1083
one of the four trainees had recently completed her training at another school in the same state. In ad dition to the means already listed, selection was based on college grade point average, results of college aptitude and of two subjective tests, the Minnesota Counseling Inventory, and the Strong Vocational Interest Test. To investigate the rela tive importance of the trainee’s inherent qualities in the performance of expanded duties, we select ed applicants with widely varying abilities. A rank ing was applied to each objective test (rank num ber 1 being highest and rank number 4 lowest) to aid in the comparison of trainees. ■ Course in expanded duties: After a threemonth laboratory and didactic program that em phasized pediatric dentistry, the auxiliaires spent approximately nine months performing expanded duties in the pediatric dental clinic. Faculty mem bers presented four one-hour lectures and one quiz per week for each week of the first three months. At the beginning of the experimental study, the most experienced graduate from the pilot study was appointed as dental auxiliary supervisor, to provide closer supervision of laboratory exercises and liaison between faculty and auxiliaries. Labo ratory exercises were graded at each stage; at the end of the first three months, a final written and laboratory examination was given and trainees were not permitted to proceed to clinical work un til they reached a cumulative grade average of 75 %. A summarized outline of the material covered in the lectures and laboratory exercises is shown in Table 1. ■ Team concept: Experimental and control teams were arranged. The former comprised a den tal student, an auxiliary performing expanded functions, and an auxiliary acting as a dental as sistant for both the student and auxiliary. Control teams contained a dental student and a dental as sistant. The 30 participating dental students were above-average seniors, selected on the basis of their grade achievements in adult operative dentist ry and the theory of pediatric dentistry. Three open-design operatories were available to each team, but the style of equipment prevented the implementation of four-handed, sit-down den tistry. Dental students provided their own equip ment. ■ Time period: Each student was allotted to the clinic for half a day per week for approximately 30 weeks. Suitable rotation ensured that 20 weeks 1084 ■ JADA, Vol. 82, May 1971
T a b le 1 ■ S u m m a riz e d o u tlin e o f p ro g ram o f lectures and la b o ra to ry exercises fo r a u x ilia rie s (e x p e rim e n ta l s tu d y ). W eek L e c tu re subject 1-2 3
4 5
6
A n a t o m y of de cid uou s d e n titio n D ental caries, c a vity p re p a ra tio n , and restorative m aterials P lacem ent o f m atrixes and w edges; am algam R u b b e r d a m ; c rite ria fo r eva luating q u a lity of resto rations
7
L in ers and bases; p o lish in g o f am algam S y n th e tic restorative m aterials
8
Stainless steel c ro w n s
9
Im p re ssio n m aterials and techniques C h ild d e v e lo p m e n t, m an agé m e nt. A p p lic a tio n o f topical anesthetics. Space m aintaine rs, s o ld ering and w e ld in g
10
11
12
R e vie w , clinical o rie n ta tio n
L a b o r a to r y exercises W a x c a rvin g of de cid u o u s d e n titio n W a x resto rations in prepared cavities (iv o rin e teeth) A s w eek 3 A p p lic a t io n o f ru b b e r da m , am algam restorations in p re pared cavities (iv o rin e te e th ) P o lis h in g o f inserted resto rations In s e rtio n of liners and s y n th e tic restorative m aterials A d a p ta tio n , c e m e n ta tio n of stainless steel c ro w n s Im p re ssio ns and stu d y m odels A s w ee k 9
F a b ric a tio n of som e fixe d a nd rem ovab le space m aintaine rs F in a l w ritte n and practical e x a m in a tio n
were spent with an experimental team and 10 with the control team. ■ Duties delegated to auxiliary: In the laborato ry and clinic, the auxiliaries were trained in the fol lowing duties: placement of rubber dam; adapta tion and placement of matrixes and wedges; inser tion and finishing of restorations; selection, adap tation, and cementation of stainless steel crowns; fabrication of space maintainers; taking alginate im pressions for and preparing study models; prophy laxis and application of topical fluoride. ■ Duties delegated to student: Whereas the stu dent in the control team performed all phases of dental treatment, the duties of the student in the experimental team were limited to diagnosis, treatment-planning, advice on nutrition, administra tion of local anesthetics, cavity preparation, and extractions. In addition, he was responsible for the design of space maintainers (subsequently fab ricated by the auxiliary), endodontic treatment, and for management of patient behavior. ■ Patient selection: The patients treated by all teams were selected at random from those coming for routine care at the pediatric dental clinic. ■ Quality evaluation: In the pilot study, five different instructors, assigned on a daily basis, evaluated the quality of procedures performed. However, since the instructors did not undergo a
standardizing trial there was considerable varia tion in the assessment of quality and in the subse quent experimental study all evaluations were performed by one instructor. In the experimental study it was administratively impossible to incor porate a blind method of evaluation since the eval uator was also the clinical instructor. Quality was evaluated for 16 different procedures and record ed on prepared forms that permitted ready tabula tion and collation of data. The student could ob serve the work of the auxiliary but could not alter or suggest changes. Only the evaluator could rec ommend improvements, and these were accom plished after the evaluations were made. Procedures performed were evaluated on the basis of predetermined criteria as either clinically acceptable, functionally acceptable, or unaccepta ble. “Clinically acceptable” performances were those rated as acceptable according to all possible criteria. “Functionally acceptable” performances T a b le 2 ■ C rite ria used in th e e v a lu a tio n o f a Class II am algam re s to ra tio n . A sp e ct C o n t o u r o f occlusal surface C o n t o u r o f m arginal ricjge C o n t o u r o f p ro x im a l surface G in g iv a l m argins O cclusal m argins
P ro x im a l m argins
O c c lu s io n S u rfa ce finish
D e sc rip tio n of q u a lity A c c e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d A c c e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d A cc e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d A c c e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d ; ove rh a n g; v oids A c c e p ta b le ; bu cca l, lingual, mesial, or distal m argins are eith e r excessive or ins u fficie n t in restorative m aterial A c c e p ta b le , buccal or lingual m argins are e ith er excessive or ins u fficie n t in restorative m aterial A c c e p ta b le ; p re m a tu re c o n ta c t; inadequate c o n ta ct A c c e p ta b le , voids or pits in the surface; n o t a high lu ster finish
R ela tive ran k A u x ilia r y
A
B
C
D
P ercentile ran k, high school College a p titu d e test Co lle ge grade p o in t average Spa ce relations a p titu d e test C h a lk carvin g a p titu d e test P reclinical la b o ra to ry grades P reclinical le cture grades Class I am algam p la c e m e n t q u a lity Class II am algam pla ce m e n t q u a lity Class V am algam p la c e m e n t q u a lity Class I am algam p o lish q u a lity Class II am algam polish q u a lity Class V am algam po lish q u a lity Class I am algam po lish tim e Class il am algam po lish tim e Class V am algam polish tim e
4 2 2 3 1 1
2 3 4 It 2 4 3 2t 4 1 4 4 2 1 1 1
3 4 3 4 4 2 2 It 2t 2 2 2 1 2 2 4
1 1 1 It 2 3 1 2t 2t 3 3 3 4 3 4 3
* R a n k ac h ie ve m e n t: t E q u iv a le n t ranks.
1 —
1 1 3 4 3 2
■ Quantity of work done: The number of proce dures performed over a nine-month period by ex perimental and control teams was tabulated. ■ Mean time estimations: A wall clock adjacent to the units was used to determine the time re quired to complete certain tasks. This information was obtained by the dental assistant assigned to that area and marked on specially prepared forms. The times required to insert, carve, and polish amalgam restorations and to adapt stainless steel crowns were recorded.
R e s u lt s
T a b le 3 ■ R e la tiv e ra n k achieved b y a u x ilia rie s in selection tests, la b o ra to ry exercises a n d c lin ic a l p ro c e d u re s .*
It 1
were those rated as unacceptable but that could be remedied. “Unacceptable” performances were those rated as requiring the procedure to be re done. During the course of the pilot study it was found that in some instances the criteria were inad equate, and for the experimental study the criteria were made more stringent. For each procedure del egated to the auxiliary or the student in the con trol team, the number of criteria to be evaluated ranged from eight to 12. As an example, the crite ria for evaluating the placement of a Class II ama1gam restoration are shown in Table 2.
In the ranking method used, as shown in Table 3, the chalk carving aptitude test provided the best in dication of laboratory and clinical performance. However, since the sample of trainees was small and the correlation not absolute, no definite con clusion can be drawn regarding the use of this test. One other factor, high school rank, suggested a possible correlation to preclinical lecture grades. The other criteria used for selection provided no useful aid in the prediction of clinical performance. The subjective tests used showed that all train ees were well-adjusted, emotionally stable, social ly outgoing, highly motivated toward involvement in health professions, and interested in creative pursuits. T a b le 4 ■ T im e lo s t* due to fa ilu re s and c a n c e lla tio n s o f a p p o in tm e n ts . M ean p e rc e n t a p p o in tm e n ts lost Fall
W in te r
S p rin g
C o n tro l E x p e rim e n ta l
6 .5 ± 5 .3 6 .4 ± 5 .7 7.6 ± 6 .6 7 .9 ± 4 .4 12 .6 ± 7 .2 6 .2 ± 4 .6
T o ta l
7 .5 ± 4 .7 10 .6 ± 6 .7 6 .7 ± 5 .2
T o ta l 6 .8 ± 5 .9 8 .9 ± 5.5
h igh est; 4 — lo w e s t* Ta rd in e s s is n o t re corde d as tim e lost.
Rosenblum: PEDODONTIC AUXILIARY PROGRAM ■ 1085
■ Course in expanded duties and duties delegated to auxiliary: It was necessary to reexamine one trainee before permitting her to proceed to clinical work. In all instances, the auxiliaries adapted read ily and rapidly to working with children in a clini cal situation. During the first month of the clinical phase, the auxiliaries were found to have had in adequate experience in restoring first permanent molars and additional laboratory exercises were given. In addition, it was deemed necessary to give further lectures on the occlusion of the deciduous and mixed dentitions. ■ Time period: In all quarters all teams lost some time because of failure of patients to appear or late cancellation of appointments. The mean percent of time lost, calculated from the actual number of patient-appointments missed, is shown in Table 4. In this table, tardiness is not recorded as time lost. During the winter quarter, the experi mental teams lost a significantly greater amount of time (p<0.05) than the control teams. ■ Patient selection: Over the 30-week period the control teams treated 118 patients and the experi mental team 363 patients. The age of patients in control teams ranged from 4.1 to 13.0 years (mean 8.6 ±2.0 SD) and those seen by the experimental teams from 4.2 to 13.0 years (mean 8.7 ± 2.0 SD). Tables 5 and 6 show that, in general, patients were evenly distributed between teams with respect to sex and age. However, in the winter quarter the experimental teams treated proportionally more young patients. ■ Quantity o f procedures performed: Tables 7 and 8 show, respectively, the total number of pro cedures performed by the ten experimental and ten control teams and the mean number of proce dures performed per half day. In all three quarters the experimental teams performed a significantly greater number of procedures than the control teams (p<0.05). Over the 30-week period, the productivity of the experimental teams exceeds that of the control
T a b le 5 ■ D is trib u tio n o f p a tie n ts b y sex.
Sex C o n tro l E x p e rim e n ta l T o ta l
Fall F M 16 62 78
13 62 75
N u m b e r o f pa tien ts S p rin g W in te r M F M F 18 61 79
1086 ■ JADA, Vol. 82, May 1971
21 58 79
30 56 86
20 64 84
T o ta l 118 363 481
teams by approximately 40%. An analysis of vari ances of these means shows that the productivity of the experimental teams is significantly greater than that of the control teams (F—ratio 4.84, at a T a b le
6■
D is trib u tio n o f p a tie n ts by age. Fall
A g e range (y rs )
N u m b e r o f patients W in te r S p rin g 4 -8 9 -1 3 4 -8 9 -1 3
T o ta l
4 -8
9 -1 3
C o n tro l E x p e rim e n ta l
13 56
16 61
14 53
24 68
22 52
29 73
118 363
T o ta l
69
77
67
92
74
102
481
T a b le 7 ■ Q u a n tity o f pro ced u res p e rfo rm e d in 3 0 w eeks b y te n e x p e rim e n ta l and c o n tro l team s. P roced ure
C o n tr o l
E x p e rim e n ta l
S tu d y m ode l im pressions P ro p h yla x is and topical flu o rid e P lacem ent Class 1 am algam restorations Placem ent Class II am algam restorations Placem ent Class III resto rations Placem ent Class V am algam restorations Placem ent of stainless steel c ro w n s
9 99 147
10 182 183
99
116
19 53
18 76
15
32
T o ta l
441
61 7 *
♦M ean n u m b e r o f p ro ce d u re s fo r each o f the t w o e x pe ri m ental groups of ten team s.
T a b le 8 ■ M ean n u m b e r o f p rocedu res p e rfo rm e d per h a lf d ay b y team s d u rin g 3 0 w eeks. M ean p ro ce dures per half day Fall
W in te r
S p rin g
C o n tro l E x p e rim e n ta l
3 .1 3 ± 1 .0 0 2 .7 7 ± 0 .7 1 4 .2 2 ± 0 .7 0 4 .6 0 ± 1 .0 7
1 .9 8 ± 0 .5 4 3 .9 8 ± 1 .2 3
T o ta l
3 .8 6 ± 0 .8 1
3 .3 2 + 1 .0 6
3 .9 9 ± 0 .9 8
T o ta l 2 .6 3 ± 0 .7 7 4 .2 7 ± 1 .0 3
T a b le 9 ■ C o m p a ris o n b e tw e e n th e d e n ta l a u x ilia ry and d en tal s tu d e n t in tim e re q u ire d to c o m p le te th e pro ced u re. Procedure Place Class 1 restorations Place Class II restorations Place Class III restorations Place Class V restorations Polish Class 1 restorations Polish Class II restorations Polish Class 111 restorations Polish Class V restorations A d a p t stainless steel c ro w n
Chi square
Degrees of free dom
Critic a l value 5 %
6 .3 8 1
5
1 1 .0 7 0
S ignificance fa vo rin g N e ith er
9 0 .7 5 0
5
1 1 .0 7 0
S tu d e n t
1 .9 9 4
5
1 1 .0 7 0
N e ith e r
7 .6 9 3
4
9 .4 8 8
N e ith e r
9 .4 3 4
5
1 1 .0 7 0
N e ith e r
6 .4 6 3
5
1 1 .0 7 0
N e ith e r
1 .4 5 3
3
7 .8 1 5
N e ith e r
3 3 .8 0 1
2
5 .9 9 1
S tu d e n t
0 .7 8 3
2
5 .9 9 1
N e ith e r
T a b le 10 ■ Q u a lity c o m p a ris o n b e tw e e n th e d e n ta l a u x ilia r y a n d d e n ta l s tu d e n t. Proced ure A lg in a te im pressions and p re p a ra tio n of s tu d y m odels A p p lic a t io n o f ru b b e r d a m c la m p A p p lic a tio n o f ru b b e r dam In s e rtio n o f m a trix In s e rtio n o f w edge R em oval o f m a trix Place Class 1 resto rations Place Class II resto ra tion s Place Class III resto rations Place Class V restorations Polish Class 1 restorations Polish Class II restorations Polish Class III resto rations Polish Class V resto rations A d a p ta tio n o f stainless steel c ro w n s (P u m ic e ) p ro p h y la x is
Chi square
Degrees of fre e d o m
0 .4 5 6
1
3 .8 4 1
N e ith e r
5 3 .4 7 1
1
3 .8 4 1
A u x ilia r y
5 3 .6 7 9 7 .0 8 5 3 .7 4 0 0 .3 6 0 9 .7 1 9 9 .8 6 3 0 .8 8 0 0 .5 0 6 1 5 .7 1 4 1 5 .2 9 5 1 .2 6 2 0 .5 7 7 5 .0 7 6
2 2 2 1 5 5 2 2 4 5 2 2 3
5 .9 9 1 5 .9 9 1 5 .9 9 1 3 .8 4 1 1 1 .0 7 0 1 1 .0 7 0 5 .9 9 1 5 .9 9 1 9 .4 8 8 1 1 .0 7 0 5 .9 9 1 5 .9 9 1 7 .8 1 5
A u x ilia r y A u x ilia r y N e ith e r N e ith e r N e ith e r N e ith e r N e ith e r N e ith e r S tu d e n t A u x ilia r y N e ith e r N e ith e r N e ith e r
0 .0 1 5
1
3 .8 4 1
probability level of 0.05 with 1.58 degrees of free dom).
C ritic a l value 5 %
S ig nificance favo ring
N e ith e r
steel crown restorations placed by the experimen tal teams were classified as unacceptable and re quired immediate replacement. Eighteen of these failures were related to faulty technique at the time of placement and 12 were fractured after placement. Table 10 illustrates 16 of the procedures evalu ated'and the chi square values for the differences in quality of performance between the auxiliaries and dental students. For five of these procedures, there is no significant difference in the quality of performance by these individuals. However, the auxiliary is superior in the application of the rub ber dam clamp and rubber dam, and insertion of the matrix band. In the placement of the four dif ferent types of amalgam restorations shown here, there is no significant difference in quality between the auxiliary and dental student. However, the stu dent is significantly better in the polishing of Class I amalgam restorations and the auxiliary is superi or for polishing Class II amalgam restorations. The data shown in Table 3 indicate that there is
■ Mean time estimations: A comparison of the times taken by auxiliaries and students using a chi square test shows that, for most procedures, the differences are not statistically significant (Table 9). However, dental students are significantly more rapid in the placement of Class II and the polish ing of Class V amalgam restorations. When individual auxiliaries are compared for the parameters shown in Table 3, it is seen that one auxiliary (B) is consistently, and significantly, more rapid than the other three auxiliaries in the polishing of restorations. However, such speed is not consistent with superior quality (Table 3). ■ Quality evaluation: At the time of placement, six of the 333 amalgam and stainless steel crown restorations placed by the control teams were clas sified as unacceptable because of faulty technique and required immediate replacement. At the time of placement, 30 of the 851 amalgam and stainless
T a b le 11 ■ Q u a lity c o m p a ris o n b e tw e e n th e fo u r d e n ta l a u x ilia rie s . P ro ced ure A lg in a te im pressions and p re p a ra tio n o f s tu d y m odels A p p lic a tio n o f ru b b e r dam c la m p A p p lic a tio n o f ru b b e r dam In sertio n o f m a trix In sertio n o f w edge R em oval o f m a trix Place Class 1 resto ra tion s Place Class II resto ra tion s Place Class III restorations Place Class V resto rations Polish Class 1 resto ra tion s Polish Class II resto rations Polish Class V restorations A d a p ta tio n o f stainless steel c ro w n s (P u m ic e ) p ro p h y la x is
Chi square 3 .0 1 4
3
7 .8 15
Significance fa vo rin g N e ith e r
3 .0 5 9
3
7 .8 1 5
N e ith e r
6 .0 7 2 2 .3 0 4 4 .7 1 6 1 .5 5 9 9 .8 1 6 3 2 .3 6 9 3 .9 8 1 9 .4 9 6 1 6 5 .5 0 9 2 3 .4 4 3 3 .7 4 5 4 .9 2 0
6 3 3 3 9 12 3 3 9 3 3
1 2 .5 9 2 7 .8 1 5 7 .8 1 5 7 .8 1 5 1 6 .9 1 9 2 1 .0 2 6 7 .8 1 5 7 .8 1 5 1 6 .9 1 9 2 1 .0 2 6 7 .8 1 5 7 .8 1 5
N e ith e r N e ith e r N e ith e r N e ith e r N e ith e r A u x ilia r y N e ith e r A u x ilia r y A u x ilia r y A u x ilia r y N e ith e r N e ith e r
3
7 .8 1 5
N e ith e r
1 .5 67
Degrees of free dom
12
C ritic a l value 5 %
A B A A
Rosenblum: PEDODONTIC AUXILIARY PROGRAM ■ 1087
considerable variation between auxiliaries in the quality of procedures performed. However, of the 15 procedures evaluated, the differences were sta tistically significant in only four instances (Table 11). In the placement and polishing of Class II amalgam restorations and the polishing of Class I amalgam restorations, auxiliary A was significantly superior whereas auxiliary B was significantly su perior in the placement of Class V amalgam resto rations. It is of interest that the former auxiliary was the best in the chalk carving aptitude test and in grades achieved in preclinical laboratory exer cises. When intra-auxiliary comparisons are made of quality of procedures performed (Table 3), each auxiliary shows some consistency in the quality of placement and polishing of amalgam restorations. Each auxiliary also shows some consistency in the speed of polishing restorations. It is of interest that the fastest auxiliary (B) rarely achieved the best quality. Despite poor performance in the objective tests used in selection, auxiliary C performed work of consistently high quality in preclinical and clin ical procedures. These trends are also seen in the quality of preparation of impressions and study models; the placement of rubber dams, matrixes, and wedges; and in the adaptation and placement of stainless steel crowns.
D is c u s s io n
As there were only four trainees in the present ex perimental study, extrapolations on the relative significance of selection tests cannot be made. It can only be suggested that chalk carving aptitude is a selection test that may provide some indication of the auxiliaries’ ability to perform clinical proce dures. Records gained from high school appear to provide some indication of the trainees’ compre hension of lecture material. The results of evalua tion of personality, although not applicable for statistical evaluation, were of extreme importance. Because of the demand for meticulous work and the close contact with patients who may be appre hensive, it is important to select friendly, mature, and emotionally stable individuals. The present research on the training of auxiliaries indicates that there is a range of opinions on the usefulness of their selection. From the basis of tests assessing certain types of abilities, Hammons’ study2 and the present investigation made use of selection tests. In those studies where individuals were selectted after previously having spent considerable time 1088 ■ JADA, Vol. 82, May 1971
as dental assistants, technicians, or hygienists, no attempt was made to test the individual’s ability.5-7 However, these trainees may have been previously selected on the basis of selected tests. Until other methods are developed for predicting a person’s ability to perform expanded functions, these selec tion tests may provide helpful information. In agreement with the observations of Baird,6 the present study suggests that auxiliaries who have had previous experience as dental ancillaries require considerably less time for training in ex panded functions than do those without such back ground experience. Such a conclusion is substanti ated by the work of Hammons2 who took approxi mately two years to train high school graduates to perform expanded functions. Productivity is related to the skill of the opera tor and factors such as the availability of auxiliary personnel, facilities, and utilization of clinical time. Abramowitz7 has reported that productivity was not increased significantly by the addition of an auxiliary performing expanded functions. How ever, he did note that the dental officer was fre quently idle while waiting for the auxiliary to com plete a procedure. In contrast, Baird6 and Ludwick5 reported that the addition of an auxiliary sig nificantly increased productivity, and this observa tion is supported by the present study. It was ob served in this study that the usefulness of an auxil iary is closely dependent on efficient patient sche duling in order to ensure uninterrupted work for both operators. Even though the experimental teams lost proportionately more time than did the control teams, they were able to be more produc tive. Since the dental student and auxiliary re quired similar times to complete most procedures, the greater production of the experimental team must be attributed to the additional auxiliary. The decline in productivity in the spring quar ter may be related to a number of factors. Pend ing state legislation regarding the role of such aux iliaries introduced an atmosphere of uncertainty and despair among the trainees. In addition, the dental students became less highly motivated as their time for graduation approached. The duties assigned to the auxiliaries in this present study were similar in nature to those re ported by other investigators.2-5-7 They included procedures that could be redone or altered with out harming the health of the patient. These studies differed in the age of the patients treated. In the present study and in that reported by Abramowitz,7 treatment was confined to children. In contrast, Ludwick5 and Baird6 cared for adults.
Therefore, the auxiliary can be of value in the treatment of patients of all ages. This would be an important factor if she is to play an integral part in the general practice of dentistry. The placement and polishing of amalgam resto rations provided the bulk of treatment performed in this and other studies.2’5-7 Comparison may be made on these bases. For the 949 amalgam resto rations evaluated in the present study, only three of the 11 parameters evaluated for quality showed any significant differences. This suggests that the dental auxiliary trained in this study is capable of performing restorative procedures of a standard comparable with that achieved by a senior dental student. Such an observation is in agreement with that reported by Hammons.2 Ludwick,5 Baird,6 and Abramowitz7 also concluded that the quality of dental care rendered by the auxiliaries and den tists was comparable. The usefulness of the auxiliary as a member of the dental team has been demonstrated in this pa per as well as by other investigators. The dental profession must now consider whether it is willing to accept such an addition. It then becomes the re sponsibility of dental educators and governmental representatives to work together toward the im plementation of training programs. The design of these programs should be made flexible enough to allow for changes in the lecture and laboratory cur riculum in order to prepare people in the shortest amount of time with the best possible background.
S u m m a ry
The performance of 20 experimental and 10 con trol teams in a pediatric dental clinic was compared for quality and quantity. Each experimental team consisted of a dental assistant, senior dental stu dent, and an auxiliary trained to perform expand ed functions. Each control team consisted of a sen ior dental student and an assistant. In addition, criteria for selection auxiliaries, the training time required, and the type of curriculum necessary were questioned. Procedures delegated to the auxiliary were the application of rubber dam; taking of alginate im pressions and preparation of study models; matrix adaptation; insertion, carving, and finishing of restorations; adaptation and cementation of stain less steel crowns; fabrication of space maintainers; performance of pumice prophylaxis, and fluoride application.
Over a nine-month period the experimental teams performed on the average 40% more proce dures than the control teams. In general, there was no significant difference in the quality and speed of performance between the senior dental student and auxiliary. The dental student was able to carve Class II and polish Class V amalgam restorations faster than the auxiliary. The auxiliary was superior in the application of rubber dam, insertion of matrix band, and polish ing Class II amalgam restorations. The dental stu dent was superior in polishing Class I amalgam restorations. In the placement of four different types of amalgam restorations there was no signifi cant difference in quality between the two teams. Of the criteria used in selection of auxiliary trainees, only the score achieved in the chalk carv ing test provided an indication of the auxiliary’s ability to perform clinical procedures. Records gained from high school appear to provide some indication of the trainee’s comprehension of lec ture material. The results of this present study suggest that a three-month course is adequate to educate previ ously trained dental assistants in the performance of expanded functions in pediatric dentistry.
This study was supported by US Public Health Service Grant No. 108-67-165. The author is indebted to Dr. Louise Brearly who devoted a great deal of tim e and effort in the evaluations and prepara tion of this paper. In addition, the author wishes to thank Mr. John Proshek, Gerri Reid, Norma Rust, Candy M iller, Annie Straka, and all the auxiliaries, assistants, and dental students involved in this research project. Doctor Rosenblum is clinical associate, division of pediat ric dentistry, University of Minnesota School of Dentistry, Minneapolis, 55455. 1. Miller, B.F. The constituent society's role in increasing the utilization and functions of dental hygienists and dental assistants. Presented before State Secretaries Management Conference. June 1967. 2. Hammons, P.E., and Jamison, H.C. Expanded functions for dental auxiliaries. JADA 75:658 Sept 1967. 3. Grayland, E. The role of the New Zealand dental nurse. CAL 30:6 Dec 1967. 4. Information and announcements. School for dental aux iliaries. Brit Dent J 109:323 Oct 18, 1960. 5. Ludwick, W.E.; Schnoebelen, E.O.; and Kroedler, D.J. Greater utilization of dental technicians. Report of clinical tests. Great Lakes, III, US Naval Training Center, 1964. 6. Baird, K.M.; Purdy, E.C.; and Protheroe, D.H. Pilot study on advanced training and employment of auxiliary den tal personnel in the Royal Canadian Dental Corps. Final report. J Canad Dent Assn 2 9:778 Dec 1963. 7. Abram owitz,J.Expandedfunctionsfordentalassistants: A prelim inary study. JADA 7 2 :386 Feb 1966. Rosenblum: PEDODONTIC AUXILIARY PROGRAM a 1089
Freeman N. Rosenblum, DDS, MSD, M in n e a p o lis
An experim ental program on th e tra in in g o f a u x ilia ry personnel to perform expanded fu n c tio n s was be gun a t th e U n ive rs ity o f M innesota d ivis io n o f p e d i a tric d e n tis try in 1967. The o b je ctives o f th e study were to d ete rm in e personal and e d u ca tio n a l q u a lifi c a tio n s necessary fo r a u x ilia ry tra in e e s; to d e te r m in e typ e and e xte n t o f tra in in g required fo r d u tie s delegated; to com pare q u a lity and q u a n tity o f p ro cedures perform ed by a u x ilia rie s w ith perform ances o f senior dental students; and to c o rre la te q u a lity o f de n ta l tre a tm e n t rendered w ith tra in e e s ’ a p ti tu d e scores and grades. E xperim ental and co n tro l te a m s were arranged. Over a n ine-m onth period, the experim e ntal team s perform ed on th e average 4 0 % m ore procedures than th e co n tro l team s. In general, th ere was no s ig n ific a n t d iffe re n c e in th e q u a lity and speed o f perform ance between th e senior den ta l stu d e n ts and th e a u x ilia rie s .
Consideration of the expanded use of auxiliary per sonnel is becoming imperative. In 1966, the Coun cil on Dental Education of the American Dental Association made proposals to the profession, ask ing for support of Association programs and poli cies relating to expansion of training opportunities for auxiliary personnel. Specifically, it was pro posed that studies be developed on the possible extension of duties that could be delegated to den tal assistants and hygienists.1 In order to collect information pertinent to the development of programs for training auxiliary per sonnel in expanded functions, an experimental training program was instituted in 1967 at the Uni versity of Minnesota and situated in the division of pediatric dentistry. The program consisted of two 12-month phases, after a 12-month pilot study. The latter began in June 1967, and the experimen tal phases began in June 1968 and June 1969, re spectively. In the following report, unless other wise indicated the first phase of the experimental study only will be described in detail. The second 1082 ■ JADA, Vol. 82, May 1971
experimental phase will form the subject of a sub sequent publication. Specifically, the objectives of the study were fourfold: ■ to determine the personal and educational qualifications necessary for trainees; ■ to determine the type and extent of training re quired for the duties delegated; ■ to compare the quality and quantity of proce dures performed by the auxiliaries with the per formance of senior dental students; and ■ to correlate the quality of dental treatment rendered with the trainees’ aptitude scores and grades.
R e v ie w
o f lite r a tu r e
A comprehensive review of literature by Ham mons2 indicates that the expanded utilization of auxiliary personnel in dentistry is not a recent de velopment. As far back as 1920, the New Zealand government introduced the School Dental Service Plan and began training dental nurses to provide free dental care for all children below the age of 16 years.3 After a two-year training period, dental nurses made examinations and diagnoses, planned treatment, gave prophylaxes, topical fluoride ap plications, and local infiltration anesthesia, pre pared cavities, placed “uncomplicated”restorations, extracted deciduous and permanent teeth un der local anesthesia, and took part in dental health education. In 1960, the General Dental Council in Great Britain initiated a program4 to train high school graduates as dental auxiliaries to place “simple” restorations, extract deciduous teeth, and give pro phylaxes under the supervision of dental officers. In contrast to the New Zealand trainees, these aux iliaries were not trained to diagnose or prepare treatment plans. The first experimental program in North Ameri ca was reported by Ludwick in 1959.5 After a 16week course for training dental technicians, seven men and five women participated in an additional seven-week course and subsequently, as “thera peutic technicians,” provided dental care for
adults in the United States Navy. A double-blind evaluation study showed that the quantity of treat ment performed by an experimental team contain ing such a technician could be doubled without loss of quality. In 1963, Baird6 reported findings on the ex panded utilization of dental hygienists in the Royal Canadian Dental Corps. After a pilot study, an ex perimental program was begun. Three trainees, each with 3Vi years of experience as dental hy gienists, completed a 16-week course. The experi mental team consisted of a dental officer, a thera pist, a chairside dental assistant, a roving assistant, and a clerical assistant. The chairside assistant worked solely with the dental officer. The roving assistant provided assistance as required by the therapist. Three dental cubicles were used by the team, two being equipped for all dental proce dures, and the third containing equipment neces sary for the dental therapist. The dental officer was responsible for supervising the work performed by the therapist. The supervision was extensive in the beginning, but was reduced or eliminated as the therapist gained more experience. From the study, it was concluded that in the treatment of adult pa tients, the productivity of the experimental team was almost 100% greater than that of the conven tional dental officer-assistant team. No attempt was made in this study to assess the quality of den tal care rendered. In contrast to the foregoing study, the program initiated at the University of Alabama in 19632 evaluated the quality of treatment performed by auxiliaries trained in expanded functions, and com pared this factor with the performance of random ly-selected, advanced dental students. On the basis of aptitude tests, interviews, scholastic records, and previous employment, seven high school grad uates were selected to complete a program lasting approximately two years. During this time they learned to apply the rubber dam, adapt matrixes, and insert and finish amalgam, silicate, and tem porary restorations. A double-blind evaluation by independent examiners determined whether the procedures were to be rated as either excellent, ac ceptable, or unacceptable, based on predetermined criteria. The proportion of clinical procedures judged to be excellent was consistently greater for the trained auxiliary than for the dental student. An evaluation of quality of clinical procedures performed by auxiliaries trained in expanded functions was also the primary objective of a pilot study initiated in 1965 by the Division of Indian Health of the United States Public Health Service.7
In addition, the type and extent of training re quired by such an auxiliary was investigated. Dur ing an eight-week training program, eight women, some of whom had had experience in dental assist ing, were taught to adapt matrixes and insert and finish amalgam restorations. The participating den tists were members of the United States Public Health Service with at least one year of clinical ex perience after graduation. The double-blind study indicated that over a period of 40 days there was no significant difference in either the quality or quantity of treatment rendered to Indian and Alas kan schoolchildren by an experimental team (con taining a dentist and two auxiliaries who performed expanded functions) and a control team (contain ing a dentist and two dental assistants). From the foregoing review, it is obvious that the feasibility of expanded utilization of dental auxil iary personnel has been widely considered. Train ees used in experimental programs have had great diversity of background, experience, and dental qualifications. Furthermore, studies vary widely in their reports of the quality and quantity of clin ical procedures rendered by such personnel. Be fore the widespread introduction of training pro grams is possible in the United States, it is appar ent that several aspects of such training need clari fication. These include the qualifications required of trainees, the type and extent of training indicat ed for the duties delegated, and the closeness of clinical supervision required. In addition, there is clearly a need for the establishment of reproduci ble criteria for the evaluation of quality and quan tity of procedures performed. The present study was designed to provide some clarification of these aspects and to make recommendations for the most efficient use of trained auxiliaries.
M a t e r ia ls a n d
m e th o d s
■ Selection of trainees: In both the pilot and experimental studies, most trainees selected were recent graduates of an 11 -month dental assisting program at the University of Minnesota. For the pi lot study, four trainees were selected, based on their high school records, dental assisting records, and the results of the space relations test and chalk carving examination prepared by the American Dental Association. One of these trainees had had two years’ experience in dentistry (one year as a dental assistant in a private dental office and a further year supervising in a dental assisting pro gram). In the first phase of the experimental study Rosenblum: PEDODONTIC AUXILIARY PROGRAM ■ 1083
one of the four trainees had recently completed her training at another school in the same state. In ad dition to the means already listed, selection was based on college grade point average, results of college aptitude and of two subjective tests, the Minnesota Counseling Inventory, and the Strong Vocational Interest Test. To investigate the rela tive importance of the trainee’s inherent qualities in the performance of expanded duties, we select ed applicants with widely varying abilities. A rank ing was applied to each objective test (rank num ber 1 being highest and rank number 4 lowest) to aid in the comparison of trainees. ■ Course in expanded duties: After a threemonth laboratory and didactic program that em phasized pediatric dentistry, the auxiliaires spent approximately nine months performing expanded duties in the pediatric dental clinic. Faculty mem bers presented four one-hour lectures and one quiz per week for each week of the first three months. At the beginning of the experimental study, the most experienced graduate from the pilot study was appointed as dental auxiliary supervisor, to provide closer supervision of laboratory exercises and liaison between faculty and auxiliaries. Labo ratory exercises were graded at each stage; at the end of the first three months, a final written and laboratory examination was given and trainees were not permitted to proceed to clinical work un til they reached a cumulative grade average of 75 %. A summarized outline of the material covered in the lectures and laboratory exercises is shown in Table 1. ■ Team concept: Experimental and control teams were arranged. The former comprised a den tal student, an auxiliary performing expanded functions, and an auxiliary acting as a dental as sistant for both the student and auxiliary. Control teams contained a dental student and a dental as sistant. The 30 participating dental students were above-average seniors, selected on the basis of their grade achievements in adult operative dentist ry and the theory of pediatric dentistry. Three open-design operatories were available to each team, but the style of equipment prevented the implementation of four-handed, sit-down den tistry. Dental students provided their own equip ment. ■ Time period: Each student was allotted to the clinic for half a day per week for approximately 30 weeks. Suitable rotation ensured that 20 weeks 1084 ■ JADA, Vol. 82, May 1971
T a b le 1 ■ S u m m a riz e d o u tlin e o f p ro g ram o f lectures and la b o ra to ry exercises fo r a u x ilia rie s (e x p e rim e n ta l s tu d y ). W eek L e c tu re subject 1-2 3
4 5
6
A n a t o m y of de cid uou s d e n titio n D ental caries, c a vity p re p a ra tio n , and restorative m aterials P lacem ent o f m atrixes and w edges; am algam R u b b e r d a m ; c rite ria fo r eva luating q u a lity of resto rations
7
L in ers and bases; p o lish in g o f am algam S y n th e tic restorative m aterials
8
Stainless steel c ro w n s
9
Im p re ssio n m aterials and techniques C h ild d e v e lo p m e n t, m an agé m e nt. A p p lic a tio n o f topical anesthetics. Space m aintaine rs, s o ld ering and w e ld in g
10
11
12
R e vie w , clinical o rie n ta tio n
L a b o r a to r y exercises W a x c a rvin g of de cid u o u s d e n titio n W a x resto rations in prepared cavities (iv o rin e teeth) A s w eek 3 A p p lic a t io n o f ru b b e r da m , am algam restorations in p re pared cavities (iv o rin e te e th ) P o lis h in g o f inserted resto rations In s e rtio n of liners and s y n th e tic restorative m aterials A d a p ta tio n , c e m e n ta tio n of stainless steel c ro w n s Im p re ssio ns and stu d y m odels A s w ee k 9
F a b ric a tio n of som e fixe d a nd rem ovab le space m aintaine rs F in a l w ritte n and practical e x a m in a tio n
were spent with an experimental team and 10 with the control team. ■ Duties delegated to auxiliary: In the laborato ry and clinic, the auxiliaries were trained in the fol lowing duties: placement of rubber dam; adapta tion and placement of matrixes and wedges; inser tion and finishing of restorations; selection, adap tation, and cementation of stainless steel crowns; fabrication of space maintainers; taking alginate im pressions for and preparing study models; prophy laxis and application of topical fluoride. ■ Duties delegated to student: Whereas the stu dent in the control team performed all phases of dental treatment, the duties of the student in the experimental team were limited to diagnosis, treatment-planning, advice on nutrition, administra tion of local anesthetics, cavity preparation, and extractions. In addition, he was responsible for the design of space maintainers (subsequently fab ricated by the auxiliary), endodontic treatment, and for management of patient behavior. ■ Patient selection: The patients treated by all teams were selected at random from those coming for routine care at the pediatric dental clinic. ■ Quality evaluation: In the pilot study, five different instructors, assigned on a daily basis, evaluated the quality of procedures performed. However, since the instructors did not undergo a
standardizing trial there was considerable varia tion in the assessment of quality and in the subse quent experimental study all evaluations were performed by one instructor. In the experimental study it was administratively impossible to incor porate a blind method of evaluation since the eval uator was also the clinical instructor. Quality was evaluated for 16 different procedures and record ed on prepared forms that permitted ready tabula tion and collation of data. The student could ob serve the work of the auxiliary but could not alter or suggest changes. Only the evaluator could rec ommend improvements, and these were accom plished after the evaluations were made. Procedures performed were evaluated on the basis of predetermined criteria as either clinically acceptable, functionally acceptable, or unaccepta ble. “Clinically acceptable” performances were those rated as acceptable according to all possible criteria. “Functionally acceptable” performances T a b le 2 ■ C rite ria used in th e e v a lu a tio n o f a Class II am algam re s to ra tio n . A sp e ct C o n t o u r o f occlusal surface C o n t o u r o f m arginal ricjge C o n t o u r o f p ro x im a l surface G in g iv a l m argins O cclusal m argins
P ro x im a l m argins
O c c lu s io n S u rfa ce finish
D e sc rip tio n of q u a lity A c c e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d A c c e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d A cc e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d A c c e p ta b le ; u n d e rc o n to u re d ; o v e rc o n to u re d ; ove rh a n g; v oids A c c e p ta b le ; bu cca l, lingual, mesial, or distal m argins are eith e r excessive or ins u fficie n t in restorative m aterial A c c e p ta b le , buccal or lingual m argins are e ith er excessive or ins u fficie n t in restorative m aterial A c c e p ta b le ; p re m a tu re c o n ta c t; inadequate c o n ta ct A c c e p ta b le , voids or pits in the surface; n o t a high lu ster finish
R ela tive ran k A u x ilia r y
A
B
C
D
P ercentile ran k, high school College a p titu d e test Co lle ge grade p o in t average Spa ce relations a p titu d e test C h a lk carvin g a p titu d e test P reclinical la b o ra to ry grades P reclinical le cture grades Class I am algam p la c e m e n t q u a lity Class II am algam pla ce m e n t q u a lity Class V am algam p la c e m e n t q u a lity Class I am algam p o lish q u a lity Class II am algam polish q u a lity Class V am algam po lish q u a lity Class I am algam po lish tim e Class il am algam po lish tim e Class V am algam polish tim e
4 2 2 3 1 1
2 3 4 It 2 4 3 2t 4 1 4 4 2 1 1 1
3 4 3 4 4 2 2 It 2t 2 2 2 1 2 2 4
1 1 1 It 2 3 1 2t 2t 3 3 3 4 3 4 3
* R a n k ac h ie ve m e n t: t E q u iv a le n t ranks.
1 —
1 1 3 4 3 2
■ Quantity of work done: The number of proce dures performed over a nine-month period by ex perimental and control teams was tabulated. ■ Mean time estimations: A wall clock adjacent to the units was used to determine the time re quired to complete certain tasks. This information was obtained by the dental assistant assigned to that area and marked on specially prepared forms. The times required to insert, carve, and polish amalgam restorations and to adapt stainless steel crowns were recorded.
R e s u lt s
T a b le 3 ■ R e la tiv e ra n k achieved b y a u x ilia rie s in selection tests, la b o ra to ry exercises a n d c lin ic a l p ro c e d u re s .*
It 1
were those rated as unacceptable but that could be remedied. “Unacceptable” performances were those rated as requiring the procedure to be re done. During the course of the pilot study it was found that in some instances the criteria were inad equate, and for the experimental study the criteria were made more stringent. For each procedure del egated to the auxiliary or the student in the con trol team, the number of criteria to be evaluated ranged from eight to 12. As an example, the crite ria for evaluating the placement of a Class II ama1gam restoration are shown in Table 2.
In the ranking method used, as shown in Table 3, the chalk carving aptitude test provided the best in dication of laboratory and clinical performance. However, since the sample of trainees was small and the correlation not absolute, no definite con clusion can be drawn regarding the use of this test. One other factor, high school rank, suggested a possible correlation to preclinical lecture grades. The other criteria used for selection provided no useful aid in the prediction of clinical performance. The subjective tests used showed that all train ees were well-adjusted, emotionally stable, social ly outgoing, highly motivated toward involvement in health professions, and interested in creative pursuits. T a b le 4 ■ T im e lo s t* due to fa ilu re s and c a n c e lla tio n s o f a p p o in tm e n ts . M ean p e rc e n t a p p o in tm e n ts lost Fall
W in te r
S p rin g
C o n tro l E x p e rim e n ta l
6 .5 ± 5 .3 6 .4 ± 5 .7 7.6 ± 6 .6 7 .9 ± 4 .4 12 .6 ± 7 .2 6 .2 ± 4 .6
T o ta l
7 .5 ± 4 .7 10 .6 ± 6 .7 6 .7 ± 5 .2
T o ta l 6 .8 ± 5 .9 8 .9 ± 5.5
h igh est; 4 — lo w e s t* Ta rd in e s s is n o t re corde d as tim e lost.
Rosenblum: PEDODONTIC AUXILIARY PROGRAM ■ 1085
■ Course in expanded duties and duties delegated to auxiliary: It was necessary to reexamine one trainee before permitting her to proceed to clinical work. In all instances, the auxiliaries adapted read ily and rapidly to working with children in a clini cal situation. During the first month of the clinical phase, the auxiliaries were found to have had in adequate experience in restoring first permanent molars and additional laboratory exercises were given. In addition, it was deemed necessary to give further lectures on the occlusion of the deciduous and mixed dentitions. ■ Time period: In all quarters all teams lost some time because of failure of patients to appear or late cancellation of appointments. The mean percent of time lost, calculated from the actual number of patient-appointments missed, is shown in Table 4. In this table, tardiness is not recorded as time lost. During the winter quarter, the experi mental teams lost a significantly greater amount of time (p<0.05) than the control teams. ■ Patient selection: Over the 30-week period the control teams treated 118 patients and the experi mental team 363 patients. The age of patients in control teams ranged from 4.1 to 13.0 years (mean 8.6 ±2.0 SD) and those seen by the experimental teams from 4.2 to 13.0 years (mean 8.7 ± 2.0 SD). Tables 5 and 6 show that, in general, patients were evenly distributed between teams with respect to sex and age. However, in the winter quarter the experimental teams treated proportionally more young patients. ■ Quantity o f procedures performed: Tables 7 and 8 show, respectively, the total number of pro cedures performed by the ten experimental and ten control teams and the mean number of proce dures performed per half day. In all three quarters the experimental teams performed a significantly greater number of procedures than the control teams (p<0.05). Over the 30-week period, the productivity of the experimental teams exceeds that of the control
T a b le 5 ■ D is trib u tio n o f p a tie n ts b y sex.
Sex C o n tro l E x p e rim e n ta l T o ta l
Fall F M 16 62 78
13 62 75
N u m b e r o f pa tien ts S p rin g W in te r M F M F 18 61 79
1086 ■ JADA, Vol. 82, May 1971
21 58 79
30 56 86
20 64 84
T o ta l 118 363 481
teams by approximately 40%. An analysis of vari ances of these means shows that the productivity of the experimental teams is significantly greater than that of the control teams (F—ratio 4.84, at a T a b le
6■
D is trib u tio n o f p a tie n ts by age. Fall
A g e range (y rs )
N u m b e r o f patients W in te r S p rin g 4 -8 9 -1 3 4 -8 9 -1 3
T o ta l
4 -8
9 -1 3
C o n tro l E x p e rim e n ta l
13 56
16 61
14 53
24 68
22 52
29 73
118 363
T o ta l
69
77
67
92
74
102
481
T a b le 7 ■ Q u a n tity o f pro ced u res p e rfo rm e d in 3 0 w eeks b y te n e x p e rim e n ta l and c o n tro l team s. P roced ure
C o n tr o l
E x p e rim e n ta l
S tu d y m ode l im pressions P ro p h yla x is and topical flu o rid e P lacem ent Class 1 am algam restorations Placem ent Class II am algam restorations Placem ent Class III resto rations Placem ent Class V am algam restorations Placem ent of stainless steel c ro w n s
9 99 147
10 182 183
99
116
19 53
18 76
15
32
T o ta l
441
61 7 *
♦M ean n u m b e r o f p ro ce d u re s fo r each o f the t w o e x pe ri m ental groups of ten team s.
T a b le 8 ■ M ean n u m b e r o f p rocedu res p e rfo rm e d per h a lf d ay b y team s d u rin g 3 0 w eeks. M ean p ro ce dures per half day Fall
W in te r
S p rin g
C o n tro l E x p e rim e n ta l
3 .1 3 ± 1 .0 0 2 .7 7 ± 0 .7 1 4 .2 2 ± 0 .7 0 4 .6 0 ± 1 .0 7
1 .9 8 ± 0 .5 4 3 .9 8 ± 1 .2 3
T o ta l
3 .8 6 ± 0 .8 1
3 .3 2 + 1 .0 6
3 .9 9 ± 0 .9 8
T o ta l 2 .6 3 ± 0 .7 7 4 .2 7 ± 1 .0 3
T a b le 9 ■ C o m p a ris o n b e tw e e n th e d e n ta l a u x ilia ry and d en tal s tu d e n t in tim e re q u ire d to c o m p le te th e pro ced u re. Procedure Place Class 1 restorations Place Class II restorations Place Class III restorations Place Class V restorations Polish Class 1 restorations Polish Class II restorations Polish Class 111 restorations Polish Class V restorations A d a p t stainless steel c ro w n
Chi square
Degrees of free dom
Critic a l value 5 %
6 .3 8 1
5
1 1 .0 7 0
S ignificance fa vo rin g N e ith er
9 0 .7 5 0
5
1 1 .0 7 0
S tu d e n t
1 .9 9 4
5
1 1 .0 7 0
N e ith e r
7 .6 9 3
4
9 .4 8 8
N e ith e r
9 .4 3 4
5
1 1 .0 7 0
N e ith e r
6 .4 6 3
5
1 1 .0 7 0
N e ith e r
1 .4 5 3
3
7 .8 1 5
N e ith e r
3 3 .8 0 1
2
5 .9 9 1
S tu d e n t
0 .7 8 3
2
5 .9 9 1
N e ith e r
T a b le 10 ■ Q u a lity c o m p a ris o n b e tw e e n th e d e n ta l a u x ilia r y a n d d e n ta l s tu d e n t. Proced ure A lg in a te im pressions and p re p a ra tio n of s tu d y m odels A p p lic a t io n o f ru b b e r d a m c la m p A p p lic a tio n o f ru b b e r dam In s e rtio n o f m a trix In s e rtio n o f w edge R em oval o f m a trix Place Class 1 resto rations Place Class II resto ra tion s Place Class III resto rations Place Class V restorations Polish Class 1 restorations Polish Class II restorations Polish Class III resto rations Polish Class V resto rations A d a p ta tio n o f stainless steel c ro w n s (P u m ic e ) p ro p h y la x is
Chi square
Degrees of fre e d o m
0 .4 5 6
1
3 .8 4 1
N e ith e r
5 3 .4 7 1
1
3 .8 4 1
A u x ilia r y
5 3 .6 7 9 7 .0 8 5 3 .7 4 0 0 .3 6 0 9 .7 1 9 9 .8 6 3 0 .8 8 0 0 .5 0 6 1 5 .7 1 4 1 5 .2 9 5 1 .2 6 2 0 .5 7 7 5 .0 7 6
2 2 2 1 5 5 2 2 4 5 2 2 3
5 .9 9 1 5 .9 9 1 5 .9 9 1 3 .8 4 1 1 1 .0 7 0 1 1 .0 7 0 5 .9 9 1 5 .9 9 1 9 .4 8 8 1 1 .0 7 0 5 .9 9 1 5 .9 9 1 7 .8 1 5
A u x ilia r y A u x ilia r y N e ith e r N e ith e r N e ith e r N e ith e r N e ith e r N e ith e r S tu d e n t A u x ilia r y N e ith e r N e ith e r N e ith e r
0 .0 1 5
1
3 .8 4 1
probability level of 0.05 with 1.58 degrees of free dom).
C ritic a l value 5 %
S ig nificance favo ring
N e ith e r
steel crown restorations placed by the experimen tal teams were classified as unacceptable and re quired immediate replacement. Eighteen of these failures were related to faulty technique at the time of placement and 12 were fractured after placement. Table 10 illustrates 16 of the procedures evalu ated'and the chi square values for the differences in quality of performance between the auxiliaries and dental students. For five of these procedures, there is no significant difference in the quality of performance by these individuals. However, the auxiliary is superior in the application of the rub ber dam clamp and rubber dam, and insertion of the matrix band. In the placement of the four dif ferent types of amalgam restorations shown here, there is no significant difference in quality between the auxiliary and dental student. However, the stu dent is significantly better in the polishing of Class I amalgam restorations and the auxiliary is superi or for polishing Class II amalgam restorations. The data shown in Table 3 indicate that there is
■ Mean time estimations: A comparison of the times taken by auxiliaries and students using a chi square test shows that, for most procedures, the differences are not statistically significant (Table 9). However, dental students are significantly more rapid in the placement of Class II and the polish ing of Class V amalgam restorations. When individual auxiliaries are compared for the parameters shown in Table 3, it is seen that one auxiliary (B) is consistently, and significantly, more rapid than the other three auxiliaries in the polishing of restorations. However, such speed is not consistent with superior quality (Table 3). ■ Quality evaluation: At the time of placement, six of the 333 amalgam and stainless steel crown restorations placed by the control teams were clas sified as unacceptable because of faulty technique and required immediate replacement. At the time of placement, 30 of the 851 amalgam and stainless
T a b le 11 ■ Q u a lity c o m p a ris o n b e tw e e n th e fo u r d e n ta l a u x ilia rie s . P ro ced ure A lg in a te im pressions and p re p a ra tio n o f s tu d y m odels A p p lic a tio n o f ru b b e r dam c la m p A p p lic a tio n o f ru b b e r dam In sertio n o f m a trix In sertio n o f w edge R em oval o f m a trix Place Class 1 resto ra tion s Place Class II resto ra tion s Place Class III restorations Place Class V resto rations Polish Class 1 resto ra tion s Polish Class II resto rations Polish Class V restorations A d a p ta tio n o f stainless steel c ro w n s (P u m ic e ) p ro p h y la x is
Chi square 3 .0 1 4
3
7 .8 15
Significance fa vo rin g N e ith e r
3 .0 5 9
3
7 .8 1 5
N e ith e r
6 .0 7 2 2 .3 0 4 4 .7 1 6 1 .5 5 9 9 .8 1 6 3 2 .3 6 9 3 .9 8 1 9 .4 9 6 1 6 5 .5 0 9 2 3 .4 4 3 3 .7 4 5 4 .9 2 0
6 3 3 3 9 12 3 3 9 3 3
1 2 .5 9 2 7 .8 1 5 7 .8 1 5 7 .8 1 5 1 6 .9 1 9 2 1 .0 2 6 7 .8 1 5 7 .8 1 5 1 6 .9 1 9 2 1 .0 2 6 7 .8 1 5 7 .8 1 5
N e ith e r N e ith e r N e ith e r N e ith e r N e ith e r A u x ilia r y N e ith e r A u x ilia r y A u x ilia r y A u x ilia r y N e ith e r N e ith e r
3
7 .8 1 5
N e ith e r
1 .5 67
Degrees of free dom
12
C ritic a l value 5 %
A B A A
Rosenblum: PEDODONTIC AUXILIARY PROGRAM ■ 1087
considerable variation between auxiliaries in the quality of procedures performed. However, of the 15 procedures evaluated, the differences were sta tistically significant in only four instances (Table 11). In the placement and polishing of Class II amalgam restorations and the polishing of Class I amalgam restorations, auxiliary A was significantly superior whereas auxiliary B was significantly su perior in the placement of Class V amalgam resto rations. It is of interest that the former auxiliary was the best in the chalk carving aptitude test and in grades achieved in preclinical laboratory exer cises. When intra-auxiliary comparisons are made of quality of procedures performed (Table 3), each auxiliary shows some consistency in the quality of placement and polishing of amalgam restorations. Each auxiliary also shows some consistency in the speed of polishing restorations. It is of interest that the fastest auxiliary (B) rarely achieved the best quality. Despite poor performance in the objective tests used in selection, auxiliary C performed work of consistently high quality in preclinical and clin ical procedures. These trends are also seen in the quality of preparation of impressions and study models; the placement of rubber dams, matrixes, and wedges; and in the adaptation and placement of stainless steel crowns.
D is c u s s io n
As there were only four trainees in the present ex perimental study, extrapolations on the relative significance of selection tests cannot be made. It can only be suggested that chalk carving aptitude is a selection test that may provide some indication of the auxiliaries’ ability to perform clinical proce dures. Records gained from high school appear to provide some indication of the trainees’ compre hension of lecture material. The results of evalua tion of personality, although not applicable for statistical evaluation, were of extreme importance. Because of the demand for meticulous work and the close contact with patients who may be appre hensive, it is important to select friendly, mature, and emotionally stable individuals. The present research on the training of auxiliaries indicates that there is a range of opinions on the usefulness of their selection. From the basis of tests assessing certain types of abilities, Hammons’ study2 and the present investigation made use of selection tests. In those studies where individuals were selectted after previously having spent considerable time 1088 ■ JADA, Vol. 82, May 1971
as dental assistants, technicians, or hygienists, no attempt was made to test the individual’s ability.5-7 However, these trainees may have been previously selected on the basis of selected tests. Until other methods are developed for predicting a person’s ability to perform expanded functions, these selec tion tests may provide helpful information. In agreement with the observations of Baird,6 the present study suggests that auxiliaries who have had previous experience as dental ancillaries require considerably less time for training in ex panded functions than do those without such back ground experience. Such a conclusion is substanti ated by the work of Hammons2 who took approxi mately two years to train high school graduates to perform expanded functions. Productivity is related to the skill of the opera tor and factors such as the availability of auxiliary personnel, facilities, and utilization of clinical time. Abramowitz7 has reported that productivity was not increased significantly by the addition of an auxiliary performing expanded functions. How ever, he did note that the dental officer was fre quently idle while waiting for the auxiliary to com plete a procedure. In contrast, Baird6 and Ludwick5 reported that the addition of an auxiliary sig nificantly increased productivity, and this observa tion is supported by the present study. It was ob served in this study that the usefulness of an auxil iary is closely dependent on efficient patient sche duling in order to ensure uninterrupted work for both operators. Even though the experimental teams lost proportionately more time than did the control teams, they were able to be more produc tive. Since the dental student and auxiliary re quired similar times to complete most procedures, the greater production of the experimental team must be attributed to the additional auxiliary. The decline in productivity in the spring quar ter may be related to a number of factors. Pend ing state legislation regarding the role of such aux iliaries introduced an atmosphere of uncertainty and despair among the trainees. In addition, the dental students became less highly motivated as their time for graduation approached. The duties assigned to the auxiliaries in this present study were similar in nature to those re ported by other investigators.2-5-7 They included procedures that could be redone or altered with out harming the health of the patient. These studies differed in the age of the patients treated. In the present study and in that reported by Abramowitz,7 treatment was confined to children. In contrast, Ludwick5 and Baird6 cared for adults.
Therefore, the auxiliary can be of value in the treatment of patients of all ages. This would be an important factor if she is to play an integral part in the general practice of dentistry. The placement and polishing of amalgam resto rations provided the bulk of treatment performed in this and other studies.2’5-7 Comparison may be made on these bases. For the 949 amalgam resto rations evaluated in the present study, only three of the 11 parameters evaluated for quality showed any significant differences. This suggests that the dental auxiliary trained in this study is capable of performing restorative procedures of a standard comparable with that achieved by a senior dental student. Such an observation is in agreement with that reported by Hammons.2 Ludwick,5 Baird,6 and Abramowitz7 also concluded that the quality of dental care rendered by the auxiliaries and den tists was comparable. The usefulness of the auxiliary as a member of the dental team has been demonstrated in this pa per as well as by other investigators. The dental profession must now consider whether it is willing to accept such an addition. It then becomes the re sponsibility of dental educators and governmental representatives to work together toward the im plementation of training programs. The design of these programs should be made flexible enough to allow for changes in the lecture and laboratory cur riculum in order to prepare people in the shortest amount of time with the best possible background.
S u m m a ry
The performance of 20 experimental and 10 con trol teams in a pediatric dental clinic was compared for quality and quantity. Each experimental team consisted of a dental assistant, senior dental stu dent, and an auxiliary trained to perform expand ed functions. Each control team consisted of a sen ior dental student and an assistant. In addition, criteria for selection auxiliaries, the training time required, and the type of curriculum necessary were questioned. Procedures delegated to the auxiliary were the application of rubber dam; taking of alginate im pressions and preparation of study models; matrix adaptation; insertion, carving, and finishing of restorations; adaptation and cementation of stain less steel crowns; fabrication of space maintainers; performance of pumice prophylaxis, and fluoride application.
Over a nine-month period the experimental teams performed on the average 40% more proce dures than the control teams. In general, there was no significant difference in the quality and speed of performance between the senior dental student and auxiliary. The dental student was able to carve Class II and polish Class V amalgam restorations faster than the auxiliary. The auxiliary was superior in the application of rubber dam, insertion of matrix band, and polish ing Class II amalgam restorations. The dental stu dent was superior in polishing Class I amalgam restorations. In the placement of four different types of amalgam restorations there was no signifi cant difference in quality between the two teams. Of the criteria used in selection of auxiliary trainees, only the score achieved in the chalk carv ing test provided an indication of the auxiliary’s ability to perform clinical procedures. Records gained from high school appear to provide some indication of the trainee’s comprehension of lec ture material. The results of this present study suggest that a three-month course is adequate to educate previ ously trained dental assistants in the performance of expanded functions in pediatric dentistry.
This study was supported by US Public Health Service Grant No. 108-67-165. The author is indebted to Dr. Louise Brearly who devoted a great deal of tim e and effort in the evaluations and prepara tion of this paper. In addition, the author wishes to thank Mr. John Proshek, Gerri Reid, Norma Rust, Candy M iller, Annie Straka, and all the auxiliaries, assistants, and dental students involved in this research project. Doctor Rosenblum is clinical associate, division of pediat ric dentistry, University of Minnesota School of Dentistry, Minneapolis, 55455. 1. Miller, B.F. The constituent society's role in increasing the utilization and functions of dental hygienists and dental assistants. Presented before State Secretaries Management Conference. June 1967. 2. Hammons, P.E., and Jamison, H.C. Expanded functions for dental auxiliaries. JADA 75:658 Sept 1967. 3. Grayland, E. The role of the New Zealand dental nurse. CAL 30:6 Dec 1967. 4. Information and announcements. School for dental aux iliaries. Brit Dent J 109:323 Oct 18, 1960. 5. Ludwick, W.E.; Schnoebelen, E.O.; and Kroedler, D.J. Greater utilization of dental technicians. Report of clinical tests. Great Lakes, III, US Naval Training Center, 1964. 6. Baird, K.M.; Purdy, E.C.; and Protheroe, D.H. Pilot study on advanced training and employment of auxiliary den tal personnel in the Royal Canadian Dental Corps. Final report. J Canad Dent Assn 2 9:778 Dec 1963. 7. Abram owitz,J.Expandedfunctionsfordentalassistants: A prelim inary study. JADA 7 2 :386 Feb 1966. Rosenblum: PEDODONTIC AUXILIARY PROGRAM a 1089