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Some variables affecting dentists’ desire to use expanded duty dental auxiliaries
R ecent changes in the Rhode Island Dental Practice A ct have m ade possible the expansion of duties f o r assistants. This study was undertaken to d eterm in e which characteristics or attitudes m ight be associated with the willingness o f the dentists practicing in Rhode Island to use ex p a n d ed duty dental auxiliaries. A survey of all active practitioners h ad a resp on se ra te o f 74.6%.
Some variables affecting dentists’ desire to use expanded duty dental auxiliaries Leonard A. Cohen, DDS, MPH, MS, Jackson, Miss
A
the demand for dental care increases, it will be necessary for the dental profession to find more econom ical and efficient means of delivering this care to the public. Expanded duty dental auxili aries (EDDAs) represent one of the best potential means of achieving this goal.1,2 Recent changes in the Dental Practice Act of Rhode Island make it possible for the Board of Dental Exam iners to permit the expansion of duties for dental auxiliaries. This survey was done to determine if Rhode Island dentists want to use EDDAs. Additionally, various demographic and practice characteristics and knowledge and at titude variables were examined to determine their potential association with the desire to use this new type of auxiliary. An EDDA is defined in this survey as a person who performs those duties del egated by a dentist up to, but not including, diag nosis, treatment planning, cutting of hard and soft tissues, and the administration of local anesthe tics. 970 ■ JADA, Vol. 97, December 1978
Method A questionnaire was designed to obtain informa tion about the dentists and their practices. After the questionnaire was developed, it was pretested and amended as necessary. The questions may be arranged in six major categories of predictor vari ables (Table 1). The names of all active practitioners in Rhode Island were obtained from the Division of Profes sional Regulation, Rhode Island Department of Health. Questionnaires were mailed to these den tists on Jan 22, 1976, and a follow-up mailing was made on March 5. Respondents’ names were checked off the master list as questionnaires were returned. Individuals not checked off the master list were considered nonrespondents, and informa tion on these individuals was obtained from the 1975 edition of the A m erican Dental Directory.3 The original study group consisted of 491 den tists. However, 15 of these were no longer practic-
Table 1 ■ Categories of predictor variables. Demographic background Location of practice Type of practice, 30I0, partnership Years since graduation Existence of other dental offices in the same building Continuing education Number of days of dental meetings attended Indicators of how busy practice is Number of patients seen per week Hours worked per week Weeks worked per year Subjective estimation of how busy practice is Length of wait for nonemergency appointments Number of hours auxiliaries were employed Hours for dental assistants Hours for hygienists Practice efficiency indicators Dentist works seated/standing Dentist works with/without assistant at chair Assistant works seated/standing Training in DAU Training in TEAM Knowledge and attitudes Quality of work of EDDAs Productivity using EDDAs Legal requirements for supervision Scope of duties performed Patient acceptance Dentists’ duties and role Dentists’ prestige Impersonality of treatment Dentists’ enjoyment of practice
ing in Rhode Island. Therefore, the number in the study population was readjusted to 4 7 6 . Computer programs from the Statistical Package for the So cial Sciences w ere used in the analysis of the data. The chi square was used as indicated. An analysis has already been reported4 that in dicated how these same respondents perceived the need for and interest in continuing education in expanded auxiliary management.
Characteristics of study population A total of 355 (74.5% ) of the 4 76 dentists returned their questionnaires. This included 243 (51.1% ) who responded to the first mailing, and 112 (23.5% ) dentists who responded to the second. Providence (26% ) was the practice location most frequently listed, followed by Cranston (10% ), W arwick (9% ), Newport (6%), East Providence (6%), and Paw tucket (6%). Nine cities or towns were not listed as a practice location by any of the dentists. There were eight dentists (2%) who listed two or more practice locations. The majority of the respondents were general practitioners (80.6% ). An even larger percentage (93.1% ) of the nonrespondents were general prac titioners. Practitioners working alone made up 78% (N = 277) of those responding to the questionnaire.
Table 2 ■ Distribution of respondents by number of years since graduation from dental school. No. years since graduation No. of respondents (N=343) Percent of sample*
7-16
17-26
54
81
69
83
56
20.1
24.2
16.3
15.7
23.6
27-36
>36
<7
*Percentages in this table and others do not total 100% because of rounding error.
Of this total, 248 (70% ) did not share overhead costs with another dentist, and 29 (8%) did. There were 53 (15% ) dentists practicing in some form of partnership agreement. Twenty-three (5%) of the respondents were either employed or engaged in another practice arrangement. The largest group of respondents graduated from Tufts (30% ) (N = 104), 45 (13%) graduated from Maryland, 40 (12% ) from Georgetown, 31 (9%) from Pennsylvania, 22 (6%) from Temple, 20 (6%) from Harvard, and 19 (5%) from St. Louis. The remaining 19% graduated from a total of 22 additional dental schools. No differences were noted in the school of graduation for the nonrespondents. The respondents w ere fairly evenly distributed according to the number of years since graduation from dental school (Table 2). The number of years since graduation was used as a factor because it appears to be a better predictor of dentists’ at titudes toward innovations than is age.5 The number of years since graduation was greater for nonrespondents. Of the respondents, 15.7% had graduated from dental school within the past six years, but only 5.2% of the nonrespondents had graduated this recently. Furtherm ore, 30.5% of the nonrespondents graduated more than 36 years ago, compared with only 16.3% of those who re sponded to the questionnaire. Nearly three fourths (74.3% ) of those surveyed did not work in a building with other dental of fices. Only 25.7% of the respondents had that type of professional contact. The fact that the number of respondents con tained a disproportionate percentage of more re cent graduates and specialists probably biased the results in favor of a desire to use EDDAs.6-8
Results Each of the respondents was asked to answer “Y es” , “N o,” or “Maybe” to the following ques tion: Cohen : DENTISTS’ DESIRE TO USE EDDAS ■ 971
Table 3 ■ Association between type of practice and desire to use EDDAs. If permitted by your state dental practice act, would you use EDDAs? Type of practice
Yes
No
Maybe
Solo
78* (29.3%)
95 (35.7%)
93 (35.0%)
Partnership
27 (54.0%)
5 (10.0%)
18 (36.0%)
•Chi square 16.52; df 2; P < .01.
Table 4 ■ Association between years since graduation from dental school and desire to use EDDAs. . Years since graduation >36 27-36 17-26 7-16 <7
If permitted by vour state dental practice act, would you use EDDAs? _________________ ______________________ Yes No Maybe 6* (11.3%) 17 (20.7%) 18 (27.7%) 39 (48.1%) 31 (57.4%)
28 (52.8%) 37 (45.1%) 20 (30.8%) 12 (14.8%) 5 (9.3%)
19 (35.8%) 28 (34.1%) 27 (41.5%) 30 (37.0%) 18 (33.3%)
•Chi square 56.83; df 8; / ><.01.
— If perm itted by your state dental practice act, would you use EDDAs? The responses of the dentists were relatively evenly divided in their willingness to use EDDAs with 33.4% replying “Y es,” 30.5% “N o,” and 36.1% “M aybe.” The potential associations be tween a desire to use EDDAs and the different predictor variables listed in Table 1 are discussed.
Table 5 ■ Association between desire to use EDDAs and existence of other dental offices in same building. Do you work in a building with other dental offices? Yes No
ASSOCIATION BETWEEN DEMOGRAPHIC VARI ABLES AND DESIRE TO USE EDDAs. The 39 cities and towns of Rhode Island were ranked in order by dentist/population ratio. They were then sepa rated into three equal groupings of cities and towns of high, medium , and low ratios. Crosstabulations of these three groups were made with those who wanted to use EDDAs. A nearly statisti cally significant association (P = .0 5 3 ) was found. Those dentists who were practicing in areas of high dentist/population ratios were most likely to say “Y es” to the use of EDDAs. In areas with high ratios, 35.3% said “Y es” and 31.7% said “No” ; in areas of low ratios, 10.0% said “Y es” and 50.0% said “N o.” The effect of the type of practice was examined. Two major categories were examined, nam ely solo and partnership. These results were cross tabulated with the results from willingness to use EDDAs and were significantly associated. In re gard to respondents’ willingness to use EDDAs, 29.3% of the dentists working alone said “Y e s” and 35.7% said “N o,” whereas dentists engaged in partnerships said “ Y es” 54.0% of the time and “N o” only 10.0% (Table 3). It appears that dentists who are more isolated, for exam ple, practitioners working alone and dentists in areas of low dentist/population ratios, are less likely to express an interest in using EDDAs. The number of years since graduation from den tal school was significantly associated with a de sire to use EDDAs. Those dentists graduating from dental school more than 36 years ago said “Y es” 972 ■ JADA, Vol. 97, December 1978
If permitted by your state dental practice act, would you use EDDAs? Yes
No
Maybe
37* (42.5%) 75 (30.1%)
31 (35.6%) 72 (28.9%)
19 (21.8%) 102 (41.0%)
*Chi square 10.47; df 2; P <.01.
11.3% of the tim e and “No” 52.8% , whereas those graduating within the past six years said “Y es” 57.4% and “No” only 9.3% of the time (Table 4). When this association was reexamined with the controlling factor of w hether the dentist worked sitting m ost of the time, frequently, occasionally, rarely, or never, it was no longer significant. This seems to indicate that age is not the only impor tant factor. Additional attention must be given to the manner in w hich the dentist actually practices. The existence of other dental offices in the building of the respondent was also significantly associated with a desire to use EDDAs. Those re spondents who were practicing in buildings with other dentists said “Y es” 42.5% of the time, whereas those not in a building with other dentists said “Y es” 30.1% (Table 5). This measure could also be related to the degree of isolation experi enced by the dentists, with those dentists most iso lated being less likely to use EDDAs. ASSOCIATION BETWEEN CONTINUING EDUCATION AND DESIRE TO USE EDDAs. A definite correlation was found between the number of days spent at tending dental meetings, study clubs, and re fresher courses in the preceding year, and the den tists’ willingness to use EDDAs. Those dentists who attended these activities for five days or less said “Y es” 22.6% of the time, and “No” 34.9% ; those attending for six to 12 days said “Y es”
Table 6 ■ Association between desire to use GDDAs and number of days spent attending dental meetings, study clubs, and refresher courses. If permitted by your state dental practice act, would you use EDDAs? No. days <6 6-12 >12
Yes
No
24* (22.6%) 52 (38.8%) 31 (47.7%)
37 (34.9%) 32 (23.9%) 15 (23.1%)
Maybe 45 (42.5%) • 50 (37.3%) 19 (29.2%)
*Chi square 13.24; df 4; P C .01.
Table 7 ■ Association between average number of patients seen per week and desire to use EDDAs. If permitted by your state dental practice act, would you use EDDAs?_____________ Average no. patients seen per week <46 46-59 60-79 80-100 >100
Yes 20* (26.3%) 21 (32.8%) 25 (29.1%) 19 (32.8%) 17 (68.0%)
No 29 (38.2%) 26 (40.6%) 27 (31.4%) 13 (22.4%) 4 (16.0%)
Maybe 27 (35.5%) 17 (26.6%) 34 (39.5%) 26 (44.8%) 4 (16.0%)
•Chi square 22.76; (if 8; P <.01.
38.8% of the time and “No” 23.9% ; and those at tending for more than 12 days said “Y e s” 47.7% and “No” 23.1% of the time (Table 6). Clearly, at least in this group of dentists, an involvement with continuing education was associated with a desire to use EDDAs. ASSOCIATION BETWEEN HOW BU SY THE PRACTICE WAS CONSIDERED AND DESIRE TO USE EDDAs. The
average number of patients seen per week by each respondent was significantly associated with a de sire to use EDDAs. Dentists who saw fewer than 46 patients per week said “Y es” 26.3% of the time and “No” 38.2% , whereas those who saw more than 100 patients said “Y es” 68.0% and “No” only 16.0% of the time (Table 7). Again, this general trend was seen w hen both the number of hours practiced per week and the number of weeks worked per year were compared. Those dentists who worked the fewest number of hours and weeks were more likely to say “No” to the question of using EDDAs, whereas those who worked longer hours and more weeks were more likely to say “Y es” (P c .0 1 ). To ascertain how busy the respondents consid ered their practices, they were asked to check one of the following statements: — Too busy to treat all people requesting ap pointments. — Provided dental care for all who requested appointments, but felt overworked. — Provided care for all who requested appoint ments, had enough patients, and did not feel overworked. — Not busy enough, would have liked more pa tients. Neither the dentist’s subjective estimation of how busy he considered his practice nor the length of time a patient had to w ait for a nonemergency visit was significantly associated with a desire to use EDDAs. This was unexpected,
especially because of the significant association found between the average number of patients seen per week and a desire to use EDDAs. To examine the internal validity of the survey, the fol lowing associations were considered: — The subjective estimation of how busy the dentist considered his practice was significantly associated (P<.01) with the length of wait for nonem ergency appointments. — The subjective estimation of how busy the dentist considered his practice was significantly associated (Pc.01) with the average number of pa tients seen per week. — The length of wait for a nonem ergency visit was significantly associated (P c .0 1 ) with the aver age number of patients seen per week. From these associations it was concluded that the findings were internally consistent; that is, the number of patients seen, the subjective estimation of how busy the practice was considered, and the length of w ait were each measuring aspects of the same phenomenon. Two possible explanations for the lack of associ ation between the length of wait for a nonem ergency visit and the subjective estimation of how busy the practice was considered, and a desire to use EDDAs were next com pared. First, it was possible that one confounding factor m ight be the number of hours per week that assistants were employed. As discussed later in this report, the number of hours per week that assistants were employed was significantly associated with a de sire to use EDDAs. It was thought that, although the subjective estimate of a busy practice was in fact associated with the number of patients seen, it was not necessarily associated with the number of hours that assistants were employed, this latter as sociation being the crucial one in determining a desire to use EDDAs. That is, dentists who exCohen : DENTISTS’ DESIRE TO USE EDDAS ■ 973
pressed a high subjective estimation of how busy their practice was did not also invariably employ dental assistants for a large number of hours. This suspicion was borne out. The estimate of how busy the practice was considered was not signifi cantly associated with the number of hours that assistants were em ployed. However, the number of patients seen was significantly associated (P < .05) with the number of hours that assistants were employed. Thus, it appears that dentists who con sider themselves busy, but do not employ assis tants for a large number of hours are less likely to favor the use of EDDAs than are their busy coun terparts who do. The second possible explanation for the lack of association between the desire to use EDDAs and the factors of length of wait and how busy the practice was involves the average number of hours worked per week. A dentist m ight work only a few days per week yet be “busy” during those days. However, this individual would probably not be interested in using EDDAs. The association between the subjec tive estimate of how busy the practice is and the number of hours worked per week was not signifi cant. However, the association between the number of patients seen and hours worked per week was significant (P c .0 1 ). Both of these findings taken together might be measuring similar phenomena, that is, the den tist’s “practice sp ace,” the equivalent of Kurt Lew in’s Life Space.9 A practice might have to reach some threshold of activity in terms of hours worked, number of auxiliaries used, and number of patients seen before the dentist would consider using EDDAs. ASSOCIATION BETWEEN HOURS AUXILIARIES WERE EMPLOYED AND DESIRE TO USE EDDAs. The
respondents were asked the total number of hours per week for w hich they employed various categories of auxiliaries, for exam ple, two assis tants each working 30 hours per week equals 60 hours per week of employment of assistants. This appears to be a more accurate measure of employ m ent of auxiliaries than simply asking the number of auxiliaries who w ere employed. In the latter in stance, three hygienists m ight be three individuals each working one day per week, or three individu als each working five days per week. The number of hours per week that dental assis tants were employed was found to be significantly associated with the desire to use EDDAs. The trend was in the expected direction, as those prac974 ■ JADA, Vol. 97, December 1978
Table 8 ■ Association between number of hours per week dental assistants were employed and desire to use EDDAs. If permitted by your state dental prac tice act, would you use EDDAs? No. hours per week dental assistants were employed <36 36-70 71-105 >105
Yes
No
Maybe
12* (23.1%) 58 (42.3%) 24 (66.7%) 13 (52.0%)
19 (36.5%) 30 (21.9%) 2 (5.6%) 4 (16.0%)
21 (40.4%) 49 (35.8%) 10 (27.8%) 8 (32.0%)
*Chi square 20.89; df 6; P < .01
Table 9 ■ Association between percentage of time dentist worked sitting down while performing restorative dentistry and his desire to use EDDAs. If permitted by your state dental practice act, would you use EDDAs?_____________ Percentage of time sitting Yes Maybe No 75* 57 15 Most of the time (51.0%) (10.2%) (38.8%) 6 4 7 Frequently (35.3%) (41.2%) (23.5%) 3 9 9 Occasionally (14.3%) (42.9%) (42.9%) 12 44 67 Rarely/never (9.8%) (54.5%) (35.8%) *Chi square 82.89; df 6; P <.01.
titioners who employed assistants for fewer than 36 hours per week replied “Y es” 23.1% of the time and “No” 36.5% , whereas dentists who employed assistants for 71 to 105 hours per week replied “Y es” 66.7% and “No” only 5.6% of the time (Ta ble 8). No significant association was observed between the number of hours per week that hygienists were employed and the desire to use EDDAs. All den tists who employed hygienists, regardless of the actual number of hours employed, expressed a de sire to use EDDAs. This interpretation was sup ported by the small number of “No” responses. Dentists who used hygienists for four to 24 hours per week said “No” only 10.3% of the time, whereas those who used hygienists for 26 to 40 hours said “N o” 5.9% , and those who used hygienists for more than 40 hours said “N o” 0.0% of the time. ASSOCIATION BETWEEN PRACTICE EFFICIENCY INDICATORS AND DESIRE TO USE EDDAs. All of the
variables in this group were significantly as sociated with a desire to use EDDAs (P < .0 1 ). The trends in each instance were definite. The associa tion between the percentage of time the dentist worked sitting down while he performed restora tive dentistry and his desire to use EDDAs is seen
Table 10 a Association between dentists who received train ing in DAU or TEAM while in dental school and desire to use EDDAs.
Table 1 1 a Dentists’ objective knowledge of EDDAs.
In dental school did you receive If permitted by your state dental practice training in:_________ act, would you use EDDAs?_____________ Maybe No Yes DAU 11 35 53* (35.4%) (11.1%) (53.5%) Yes 87 92 59 (36.6%) (24.8% (38.7%) No TEAM 5 9 19 (15.2%) (27.3%) (57.6%) Yes 92 86 80 (35.7%) (33.3%) (31.0%) No
‘There is no evidence indi cating that EDDAs can per form high quality work.
50.6*
25.6
23.7
“It has been demonstrated that dentists can produce more dentistry using EDDAs in a team approach.”
12.4
17.6
69.9*
“In some states, auxiliaries legally are practicing on their own, without super vision from licensed den tists.”
76.1*
11.8
12.1
“In some states, auxiliaries legally are performing irrever sible procedures (cutting tooth preparations) in private prac tice.”
74.7*
11.6
13.7
•Chi square 9.75; df 2; P <.01.
in Table 9. A sim ilar trend was found when com paring the percentage of time that an assistant worked with the dentist at the chair and the den tist’s desire to use EDDAs. Also, those dentists whose assistants worked at chairside while seated were more likely to indicate they would use EDDAs than those dentists who either worked without an assistant at chairside or whose assis tants stood while working at chairside. The former group of dentists said “Y es” 59.7% and “No” only 6.7% , whereas the latter group said “Y es” only 21.6% and “No” 41.1% of the time. Finally, those dentists who received training while in dental school in either four-handed sitdown dentistry (DAU) or in expanded auxiliary management (TEAM) were more likely to indicate a desire to use EDDAs (Table 10). ASSOCIATION BETWEEN KNOWLEDGE AND AT TITUDES AND DESIRE TO USE EDDAs. This section
consisted of nine items, four that were designed to test the objective knowledge of the respondents and five that were meant to assess their attitudes on the EDDA issue. Respondents were given nine statements and asked to circle a number from 1 (strongly disagree) to 5 (strongly agree) that most closely reflected their level of agreement with the statement. For purposes of analysis, categories 1 and 2 were combined to form a category of dis agreement as were 4 and 5 to form a category of agreement. Category 3 was left unchanged and was interpreted as undecided. The first four items of this section were objec tive. The statements and the percentage of distri bution of responses appear in Table 11. Of these first four statements, two were significantly as sociated (PC .01) w ith a desire to use EDDAs. These statements were: — There is no evidence indicating that EDDAs can perform high quality work. — It has been dem onstrated that dentists can
Level of agreement Disagree (%) Undecided (%) Agree (%)
•Correct responses.
produce more dentistry using EDDAs in a team approach. Those dentists who indicated a correct response were more likely to say “Y es” and those choosing incorrect responses were more likely to say “No” to the use of EDDAs. For exam ple, a com parison of the statement on quality of work and a desire to use EDDAs showed that those dentists who dis agreed (correct response) responded “Y e s” 54.5% , “No” 13.6% , and “Maybe” 31.8% . Of those who agreed with the statement (incorrect response), 17.8% responded “Y es,” 57.5% “N o,” and 24.7% “Maybe.” No significant associations were found with the following statements: — In some states, auxiliaries legally are practic ing on their own, without supervision from licensed dentists. — In some states, auxiliaries legally are perform ing irreversible procedures (cutting tooth prepara tions) in private practice. The next five questions were designed to assess the respondents’ attitudes on the issue of EDDAs. The statements and the percentage of distribution of the responses appear in Table 12. Each of these five statements was significantly associated with a desire to use EDDAs (Pc.01). There were three statements on w hich the largest group of dentists expressed negative attitudes toward EDDAs. These statements were: — In general, patients don’t want to be treated by EDDAs. — The use of EDDAs will increase the prestige of dentists in the public’s eye. — Dental care will be less personalized if EDDAs are used. Cohen : DENTISTS’ DESIRE TO USE EDDAS ■ 975
Table 12 ■ Dentists’ attitudès toward EDDAs. Level of agreement
“In general, patients don’t want to be treated by ED DAs.” “The use of EDDAs will increase the prestige of dentists in the public’s eye.” “Dental care will be less personalized if EDDAs are used.” “If more use is made of EDDAs, there won’t be anything left for dentists to do.” “Using EDDAs in a team approach will decrease the dentist’s enjoyment of his practice.”
Disagree (%)
Undecided (%)
Agree (%)
23.5
31.0
45.5*
45.4*
31.2
23.4
27.5
19.5
53.0*
69.0f
13.7
17.3
57.6t
21.2
21.2
•Questions on which the majority of respondents expressed favorable opinions toward EDDAs. tQuestions on which the largest percentage of respondents expressed un* favorable opinions toward EDDAs.
In each instance, dentists who expressed unfa vorable attitudes were more likely to say “No” and those who expressed favorable attitudes to say “Y es” to the question of the use of EDDAs. For exam ple, considering the statement that dealt with the prestige of dentists and the respondents’ desire to use EDDAs, those dentists who disagreed (unfa vorable attitude) responded “Y es” 21.6% , “No” 45.5% , and “M aybe” 32.8% . Those dentists who agreed with the statem ent (favorable attitude) re sponded “Y es” 55.1% , “No” 18.8% , and “Maybe” 26.1% . Interestingly, each of these three items on w hich the largest group of respondents expressed nega tive attitudes involved statements dealing with pa tients. It appears that these dentists have doubts about the attitudes of patients toward the use of EDDAs. On both of the remaining statements, the largest percentage of respondents showed positive at titudes. These statements were: — If more use is m ade of EDDAs, there w on’t be anything left for dentists to do. — Using EDDAs in a team approach will de crease the dentist’s enjoyment of his practice. In both instances, those dentists who showed positive attitudes were more likely to say “Y es” to the question of the use of EDDAs.
Discussion The use of EDDAs represents one of the best means of meeting the growing demand for dental care. For this potential to be realized, dentists m ust first be willing to use these auxiliaries. 9 76 ■ JADA, Vol. 97, December 1978
Roughly a third (33.4% ) of the dentists indicated that they would use EDDAs if they were legally permitted to do so, but another 30.5% indicated that they would not. The largest percentage (36.1% ) was undecided. It would not be expected that all dentists would want to use EDDAs, nor would this necessarily be desirable. W hat is im portant, however, is the ability to identify those dentists who are m ost likely to use EDDAs so that scarce resources could be concentrated where they would be m ost valuable. In this way, funds spent on recruitm ent and training will have their greatest impact. One of the m ost consistent findings in the litera ture is the association of a practitioner’s age (or years since graduation) and his desire to use ED DAs.6'8 The tendency for this association to di minish when the controlling variables for practice efficiency were used is important. If this is con firmed, it will m ean that resources should not necessarily be concentrated on recent graduates, but rather on those individuals who are currently using four-handed techniques. Indeed, a fourhanded dentistry profile was one com ponent of a recently published checklist designed to help practitioners decide if they should add an ex panded function dental auxiliary to their staff.10 More research is needed to confirm this finding. The inference by McKenzie and Born7 and W al ler11 that experience with TEAM programs may prove instrumental in forming favorable attitudes toward EDDAs was supported by this study. Expo sure to DAU programs in dental school also was found to be important. As more dentists are graduated, having had these experiences, the pool of practitioners likely to be favorable to EDDAs will be increasing. As mentioned earlier, not all dentists are likely to use EDDAs. In certain types of practices located in particular areas, the transition to a team ap proach will be more beneficial. The nearly signifi cant association between practice location ranked according to dentist/population ratio and a desire to use EDDAs is important in this regard. Most rural practices probably would not have the flow of patients necessary to support an EDDA finan cially; most inner city, high-volume practices would. Much of the rancor surrounding the issue of EDDAs would probably dissipate if practitioners realized that, in the future, dental practice will en compass many different organizational schemes. Reports on the association of how busy a prac tice is considered and a desire to use EDDAs have sometimes been perplexing. Koerner and Os-
terholt6 found those dentists who were least busy, were most likely to favor expanded roles for dental auxiliaries. Common sense seems to indicate that busy dentists would be more likely to want to use EDDAs. These differences might be resolved by considering the role a busy practice had in this study. It will be remembered that a subjective es timation of how busy the practice was considered was only indirectly related to a desire to use ED DAs, the more direct measures being either the number of patients seen or the number of hours per week the dental assistants were employed. This finding casts doubt on the wisdom of plan ning based on any subjective estimation of how busy a practice is considered. The associations previously outlined between knowledge and attitudes and a desire to use EDDAs are particularly important. Tryon12 examined the attitudes of dentists toward EDDAs and found them generally favorable. Unlike Rhode Island dentists, Connecticut practitioners tended to disagree with the statement that patients do not want to be treated by EDDAs. In the Connecticut study, the largest percentage of respondents (42.4% ) disagreed with this statement (36.5% agreed and 21.1% were undecided), whereas in Rhode Island the largest percentage (45.5% ) agreed (23.5% disagreed and 31.0% were unde cided). It is difficult to determine what might ac count for this difference. However, it is clear that favorable attitudes are important in fostering a de sire to use EDDAs. The negative appraisal by den tists from Rhode Island of their patients’ accep tance of EDDAs is a major obstacle to their own acceptance of EDDAs. This is one area in which education and perhaps desensitization are needed. Some dentists have difficulty in accepting the fact that their patients will receive services from aux iliaries as readily as from the dentist. The increas ing exposure of dental students to DAU and TEAM programs will undoubtedly help to allay these feelings in future graduates.
Summary A survey of all active practitioners in Rhode Island was conducted to determine w hich demographic or practice variables or knowledge or attitude vari ables, or both, might be associated with a desire to use EDDAs. A total of 355 (74.6% ) dentists re sponded to the questionnaire. Of these, 33.4% in dicated a desire to use EDDAs, 36.1% were unde
cided, and another 30.5% did not wish to use ED DAs. A desire to use EDDAs was associated with the following variables: demographic background, continuing education profile, indicators of how busy the practice is, number of hours auxiliaries were employed, practice efficiency indicators, and knowledge and attitude indicators.
This research was supported by Public Health Residency Traineeship grant 1A08-AH00102. This report is based on a paper presented at the 105th Annual Meeting of the Am erican Public Health Association, Nov 2, 1977, W ashington, DC. The author thanks Drs. Jacob Silversin, Gerard Kress, and Joseph Yacovone for their contribution to this project. 1. Lotzkar, S.; Johnson, D.W.; and Thom pson, M.B. Experim ental pro gram in expanded functions for dental assistants: phase 1 base line and phase 2 training. JADA 82:101 Jan 1971. 2. Abramowitz, J., and Berg, L.E. A four-year study of the utilization of dental assistants w ith expanded functions. JADA 87:623 Sept 1973. 3. Am erican Dental Directory. Chicago, Am erican Dental Association, 1975. 4. Cohen, L.A., and others. Correlates of dentists’ attitudes toward continuing education in TEAM. J Dent Educ 41:677 Nov 1977. 5. Leske, G.S., and Leverett, D.H. Variables affecting attitudes of den tists toward the use of expanded function auxiliaries. J Dent Educ 40:79 Feb 1976. 6. Koerner, K.R., and Osterholt, D.A. Student survey report: W ashing ton dentists questioned on expanded duties. JADA 86:995 May 1973. 7. McKenzie, N., and Born, D.O. D entists’ attitudes toward expanded duties auxiliaries. JADA 86:1001 May 1973. 8. Martens, L.V.; M eskin, L.H.; and Proshek, J.M. New dental care concepts: perceptions of dentists and dental students. Am J Public Health 61:2188 Nov 1971. 9. Lewin, K. Field theory in social sciences. New York, Harper & Bros, 1951. 10. U S Department of Health, Education, and W elfare Public Health Service, Bureau of Health Manpower. Should you add an expanded function dental auxiliary to your staff? DHEW Publication no. (HRA) 76-14. U S Government Printing Office, 1975. 11. W aller, R.R. Expanded duties of auxiliaries: a survey of opinions of Georgia dentists. JADA 86:1009 May 1973. 12. Tryon, A.F. Connecticut dentists’ views on expanded duty dental auxiliaries— prelim inary report. J Conn State Dent Assoc 47:69 April 1973.
THE AUTHOR
Dr. Cohen is assistant professor of community and oral health, University of M ississippi School of Dentistry, Jackson, Miss 39216. In January, he w ill be with the University of Maryland School of Dentistry, Baltimore, 21201, as assistant professor of oral health care delivery.
COHEN
Cohen : DENTISTS’ DESIRE TO USE EDDAS ■ 977
Some variables affecting dentists’ desire to use expanded duty dental auxiliaries Leonard A. Cohen, DDS, MPH, MS, Jackson, Miss
A
the demand for dental care increases, it will be necessary for the dental profession to find more econom ical and efficient means of delivering this care to the public. Expanded duty dental auxili aries (EDDAs) represent one of the best potential means of achieving this goal.1,2 Recent changes in the Dental Practice Act of Rhode Island make it possible for the Board of Dental Exam iners to permit the expansion of duties for dental auxiliaries. This survey was done to determine if Rhode Island dentists want to use EDDAs. Additionally, various demographic and practice characteristics and knowledge and at titude variables were examined to determine their potential association with the desire to use this new type of auxiliary. An EDDA is defined in this survey as a person who performs those duties del egated by a dentist up to, but not including, diag nosis, treatment planning, cutting of hard and soft tissues, and the administration of local anesthe tics. 970 ■ JADA, Vol. 97, December 1978
Method A questionnaire was designed to obtain informa tion about the dentists and their practices. After the questionnaire was developed, it was pretested and amended as necessary. The questions may be arranged in six major categories of predictor vari ables (Table 1). The names of all active practitioners in Rhode Island were obtained from the Division of Profes sional Regulation, Rhode Island Department of Health. Questionnaires were mailed to these den tists on Jan 22, 1976, and a follow-up mailing was made on March 5. Respondents’ names were checked off the master list as questionnaires were returned. Individuals not checked off the master list were considered nonrespondents, and informa tion on these individuals was obtained from the 1975 edition of the A m erican Dental Directory.3 The original study group consisted of 491 den tists. However, 15 of these were no longer practic-
Table 1 ■ Categories of predictor variables. Demographic background Location of practice Type of practice, 30I0, partnership Years since graduation Existence of other dental offices in the same building Continuing education Number of days of dental meetings attended Indicators of how busy practice is Number of patients seen per week Hours worked per week Weeks worked per year Subjective estimation of how busy practice is Length of wait for nonemergency appointments Number of hours auxiliaries were employed Hours for dental assistants Hours for hygienists Practice efficiency indicators Dentist works seated/standing Dentist works with/without assistant at chair Assistant works seated/standing Training in DAU Training in TEAM Knowledge and attitudes Quality of work of EDDAs Productivity using EDDAs Legal requirements for supervision Scope of duties performed Patient acceptance Dentists’ duties and role Dentists’ prestige Impersonality of treatment Dentists’ enjoyment of practice
ing in Rhode Island. Therefore, the number in the study population was readjusted to 4 7 6 . Computer programs from the Statistical Package for the So cial Sciences w ere used in the analysis of the data. The chi square was used as indicated. An analysis has already been reported4 that in dicated how these same respondents perceived the need for and interest in continuing education in expanded auxiliary management.
Characteristics of study population A total of 355 (74.5% ) of the 4 76 dentists returned their questionnaires. This included 243 (51.1% ) who responded to the first mailing, and 112 (23.5% ) dentists who responded to the second. Providence (26% ) was the practice location most frequently listed, followed by Cranston (10% ), W arwick (9% ), Newport (6%), East Providence (6%), and Paw tucket (6%). Nine cities or towns were not listed as a practice location by any of the dentists. There were eight dentists (2%) who listed two or more practice locations. The majority of the respondents were general practitioners (80.6% ). An even larger percentage (93.1% ) of the nonrespondents were general prac titioners. Practitioners working alone made up 78% (N = 277) of those responding to the questionnaire.
Table 2 ■ Distribution of respondents by number of years since graduation from dental school. No. years since graduation No. of respondents (N=343) Percent of sample*
7-16
17-26
54
81
69
83
56
20.1
24.2
16.3
15.7
23.6
27-36
>36
<7
*Percentages in this table and others do not total 100% because of rounding error.
Of this total, 248 (70% ) did not share overhead costs with another dentist, and 29 (8%) did. There were 53 (15% ) dentists practicing in some form of partnership agreement. Twenty-three (5%) of the respondents were either employed or engaged in another practice arrangement. The largest group of respondents graduated from Tufts (30% ) (N = 104), 45 (13%) graduated from Maryland, 40 (12% ) from Georgetown, 31 (9%) from Pennsylvania, 22 (6%) from Temple, 20 (6%) from Harvard, and 19 (5%) from St. Louis. The remaining 19% graduated from a total of 22 additional dental schools. No differences were noted in the school of graduation for the nonrespondents. The respondents w ere fairly evenly distributed according to the number of years since graduation from dental school (Table 2). The number of years since graduation was used as a factor because it appears to be a better predictor of dentists’ at titudes toward innovations than is age.5 The number of years since graduation was greater for nonrespondents. Of the respondents, 15.7% had graduated from dental school within the past six years, but only 5.2% of the nonrespondents had graduated this recently. Furtherm ore, 30.5% of the nonrespondents graduated more than 36 years ago, compared with only 16.3% of those who re sponded to the questionnaire. Nearly three fourths (74.3% ) of those surveyed did not work in a building with other dental of fices. Only 25.7% of the respondents had that type of professional contact. The fact that the number of respondents con tained a disproportionate percentage of more re cent graduates and specialists probably biased the results in favor of a desire to use EDDAs.6-8
Results Each of the respondents was asked to answer “Y es” , “N o,” or “Maybe” to the following ques tion: Cohen : DENTISTS’ DESIRE TO USE EDDAS ■ 971
Table 3 ■ Association between type of practice and desire to use EDDAs. If permitted by your state dental practice act, would you use EDDAs? Type of practice
Yes
No
Maybe
Solo
78* (29.3%)
95 (35.7%)
93 (35.0%)
Partnership
27 (54.0%)
5 (10.0%)
18 (36.0%)
•Chi square 16.52; df 2; P < .01.
Table 4 ■ Association between years since graduation from dental school and desire to use EDDAs. . Years since graduation >36 27-36 17-26 7-16 <7
If permitted by vour state dental practice act, would you use EDDAs? _________________ ______________________ Yes No Maybe 6* (11.3%) 17 (20.7%) 18 (27.7%) 39 (48.1%) 31 (57.4%)
28 (52.8%) 37 (45.1%) 20 (30.8%) 12 (14.8%) 5 (9.3%)
19 (35.8%) 28 (34.1%) 27 (41.5%) 30 (37.0%) 18 (33.3%)
•Chi square 56.83; df 8; / ><.01.
— If perm itted by your state dental practice act, would you use EDDAs? The responses of the dentists were relatively evenly divided in their willingness to use EDDAs with 33.4% replying “Y es,” 30.5% “N o,” and 36.1% “M aybe.” The potential associations be tween a desire to use EDDAs and the different predictor variables listed in Table 1 are discussed.
Table 5 ■ Association between desire to use EDDAs and existence of other dental offices in same building. Do you work in a building with other dental offices? Yes No
ASSOCIATION BETWEEN DEMOGRAPHIC VARI ABLES AND DESIRE TO USE EDDAs. The 39 cities and towns of Rhode Island were ranked in order by dentist/population ratio. They were then sepa rated into three equal groupings of cities and towns of high, medium , and low ratios. Crosstabulations of these three groups were made with those who wanted to use EDDAs. A nearly statisti cally significant association (P = .0 5 3 ) was found. Those dentists who were practicing in areas of high dentist/population ratios were most likely to say “Y es” to the use of EDDAs. In areas with high ratios, 35.3% said “Y es” and 31.7% said “No” ; in areas of low ratios, 10.0% said “Y es” and 50.0% said “N o.” The effect of the type of practice was examined. Two major categories were examined, nam ely solo and partnership. These results were cross tabulated with the results from willingness to use EDDAs and were significantly associated. In re gard to respondents’ willingness to use EDDAs, 29.3% of the dentists working alone said “Y e s” and 35.7% said “N o,” whereas dentists engaged in partnerships said “ Y es” 54.0% of the time and “N o” only 10.0% (Table 3). It appears that dentists who are more isolated, for exam ple, practitioners working alone and dentists in areas of low dentist/population ratios, are less likely to express an interest in using EDDAs. The number of years since graduation from den tal school was significantly associated with a de sire to use EDDAs. Those dentists graduating from dental school more than 36 years ago said “Y es” 972 ■ JADA, Vol. 97, December 1978
If permitted by your state dental practice act, would you use EDDAs? Yes
No
Maybe
37* (42.5%) 75 (30.1%)
31 (35.6%) 72 (28.9%)
19 (21.8%) 102 (41.0%)
*Chi square 10.47; df 2; P <.01.
11.3% of the tim e and “No” 52.8% , whereas those graduating within the past six years said “Y es” 57.4% and “No” only 9.3% of the time (Table 4). When this association was reexamined with the controlling factor of w hether the dentist worked sitting m ost of the time, frequently, occasionally, rarely, or never, it was no longer significant. This seems to indicate that age is not the only impor tant factor. Additional attention must be given to the manner in w hich the dentist actually practices. The existence of other dental offices in the building of the respondent was also significantly associated with a desire to use EDDAs. Those re spondents who were practicing in buildings with other dentists said “Y es” 42.5% of the time, whereas those not in a building with other dentists said “Y es” 30.1% (Table 5). This measure could also be related to the degree of isolation experi enced by the dentists, with those dentists most iso lated being less likely to use EDDAs. ASSOCIATION BETWEEN CONTINUING EDUCATION AND DESIRE TO USE EDDAs. A definite correlation was found between the number of days spent at tending dental meetings, study clubs, and re fresher courses in the preceding year, and the den tists’ willingness to use EDDAs. Those dentists who attended these activities for five days or less said “Y es” 22.6% of the time, and “No” 34.9% ; those attending for six to 12 days said “Y es”
Table 6 ■ Association between desire to use GDDAs and number of days spent attending dental meetings, study clubs, and refresher courses. If permitted by your state dental practice act, would you use EDDAs? No. days <6 6-12 >12
Yes
No
24* (22.6%) 52 (38.8%) 31 (47.7%)
37 (34.9%) 32 (23.9%) 15 (23.1%)
Maybe 45 (42.5%) • 50 (37.3%) 19 (29.2%)
*Chi square 13.24; df 4; P C .01.
Table 7 ■ Association between average number of patients seen per week and desire to use EDDAs. If permitted by your state dental practice act, would you use EDDAs?_____________ Average no. patients seen per week <46 46-59 60-79 80-100 >100
Yes 20* (26.3%) 21 (32.8%) 25 (29.1%) 19 (32.8%) 17 (68.0%)
No 29 (38.2%) 26 (40.6%) 27 (31.4%) 13 (22.4%) 4 (16.0%)
Maybe 27 (35.5%) 17 (26.6%) 34 (39.5%) 26 (44.8%) 4 (16.0%)
•Chi square 22.76; (if 8; P <.01.
38.8% of the time and “No” 23.9% ; and those at tending for more than 12 days said “Y e s” 47.7% and “No” 23.1% of the time (Table 6). Clearly, at least in this group of dentists, an involvement with continuing education was associated with a desire to use EDDAs. ASSOCIATION BETWEEN HOW BU SY THE PRACTICE WAS CONSIDERED AND DESIRE TO USE EDDAs. The
average number of patients seen per week by each respondent was significantly associated with a de sire to use EDDAs. Dentists who saw fewer than 46 patients per week said “Y es” 26.3% of the time and “No” 38.2% , whereas those who saw more than 100 patients said “Y es” 68.0% and “No” only 16.0% of the time (Table 7). Again, this general trend was seen w hen both the number of hours practiced per week and the number of weeks worked per year were compared. Those dentists who worked the fewest number of hours and weeks were more likely to say “No” to the question of using EDDAs, whereas those who worked longer hours and more weeks were more likely to say “Y es” (P c .0 1 ). To ascertain how busy the respondents consid ered their practices, they were asked to check one of the following statements: — Too busy to treat all people requesting ap pointments. — Provided dental care for all who requested appointments, but felt overworked. — Provided care for all who requested appoint ments, had enough patients, and did not feel overworked. — Not busy enough, would have liked more pa tients. Neither the dentist’s subjective estimation of how busy he considered his practice nor the length of time a patient had to w ait for a nonemergency visit was significantly associated with a desire to use EDDAs. This was unexpected,
especially because of the significant association found between the average number of patients seen per week and a desire to use EDDAs. To examine the internal validity of the survey, the fol lowing associations were considered: — The subjective estimation of how busy the dentist considered his practice was significantly associated (P<.01) with the length of wait for nonem ergency appointments. — The subjective estimation of how busy the dentist considered his practice was significantly associated (Pc.01) with the average number of pa tients seen per week. — The length of wait for a nonem ergency visit was significantly associated (P c .0 1 ) with the aver age number of patients seen per week. From these associations it was concluded that the findings were internally consistent; that is, the number of patients seen, the subjective estimation of how busy the practice was considered, and the length of w ait were each measuring aspects of the same phenomenon. Two possible explanations for the lack of associ ation between the length of wait for a nonem ergency visit and the subjective estimation of how busy the practice was considered, and a desire to use EDDAs were next com pared. First, it was possible that one confounding factor m ight be the number of hours per week that assistants were employed. As discussed later in this report, the number of hours per week that assistants were employed was significantly associated with a de sire to use EDDAs. It was thought that, although the subjective estimate of a busy practice was in fact associated with the number of patients seen, it was not necessarily associated with the number of hours that assistants were employed, this latter as sociation being the crucial one in determining a desire to use EDDAs. That is, dentists who exCohen : DENTISTS’ DESIRE TO USE EDDAS ■ 973
pressed a high subjective estimation of how busy their practice was did not also invariably employ dental assistants for a large number of hours. This suspicion was borne out. The estimate of how busy the practice was considered was not signifi cantly associated with the number of hours that assistants were em ployed. However, the number of patients seen was significantly associated (P < .05) with the number of hours that assistants were employed. Thus, it appears that dentists who con sider themselves busy, but do not employ assis tants for a large number of hours are less likely to favor the use of EDDAs than are their busy coun terparts who do. The second possible explanation for the lack of association between the desire to use EDDAs and the factors of length of wait and how busy the practice was involves the average number of hours worked per week. A dentist m ight work only a few days per week yet be “busy” during those days. However, this individual would probably not be interested in using EDDAs. The association between the subjec tive estimate of how busy the practice is and the number of hours worked per week was not signifi cant. However, the association between the number of patients seen and hours worked per week was significant (P c .0 1 ). Both of these findings taken together might be measuring similar phenomena, that is, the den tist’s “practice sp ace,” the equivalent of Kurt Lew in’s Life Space.9 A practice might have to reach some threshold of activity in terms of hours worked, number of auxiliaries used, and number of patients seen before the dentist would consider using EDDAs. ASSOCIATION BETWEEN HOURS AUXILIARIES WERE EMPLOYED AND DESIRE TO USE EDDAs. The
respondents were asked the total number of hours per week for w hich they employed various categories of auxiliaries, for exam ple, two assis tants each working 30 hours per week equals 60 hours per week of employment of assistants. This appears to be a more accurate measure of employ m ent of auxiliaries than simply asking the number of auxiliaries who w ere employed. In the latter in stance, three hygienists m ight be three individuals each working one day per week, or three individu als each working five days per week. The number of hours per week that dental assis tants were employed was found to be significantly associated with the desire to use EDDAs. The trend was in the expected direction, as those prac974 ■ JADA, Vol. 97, December 1978
Table 8 ■ Association between number of hours per week dental assistants were employed and desire to use EDDAs. If permitted by your state dental prac tice act, would you use EDDAs? No. hours per week dental assistants were employed <36 36-70 71-105 >105
Yes
No
Maybe
12* (23.1%) 58 (42.3%) 24 (66.7%) 13 (52.0%)
19 (36.5%) 30 (21.9%) 2 (5.6%) 4 (16.0%)
21 (40.4%) 49 (35.8%) 10 (27.8%) 8 (32.0%)
*Chi square 20.89; df 6; P < .01
Table 9 ■ Association between percentage of time dentist worked sitting down while performing restorative dentistry and his desire to use EDDAs. If permitted by your state dental practice act, would you use EDDAs?_____________ Percentage of time sitting Yes Maybe No 75* 57 15 Most of the time (51.0%) (10.2%) (38.8%) 6 4 7 Frequently (35.3%) (41.2%) (23.5%) 3 9 9 Occasionally (14.3%) (42.9%) (42.9%) 12 44 67 Rarely/never (9.8%) (54.5%) (35.8%) *Chi square 82.89; df 6; P <.01.
titioners who employed assistants for fewer than 36 hours per week replied “Y es” 23.1% of the time and “No” 36.5% , whereas dentists who employed assistants for 71 to 105 hours per week replied “Y es” 66.7% and “No” only 5.6% of the time (Ta ble 8). No significant association was observed between the number of hours per week that hygienists were employed and the desire to use EDDAs. All den tists who employed hygienists, regardless of the actual number of hours employed, expressed a de sire to use EDDAs. This interpretation was sup ported by the small number of “No” responses. Dentists who used hygienists for four to 24 hours per week said “No” only 10.3% of the time, whereas those who used hygienists for 26 to 40 hours said “N o” 5.9% , and those who used hygienists for more than 40 hours said “N o” 0.0% of the time. ASSOCIATION BETWEEN PRACTICE EFFICIENCY INDICATORS AND DESIRE TO USE EDDAs. All of the
variables in this group were significantly as sociated with a desire to use EDDAs (P < .0 1 ). The trends in each instance were definite. The associa tion between the percentage of time the dentist worked sitting down while he performed restora tive dentistry and his desire to use EDDAs is seen
Table 10 a Association between dentists who received train ing in DAU or TEAM while in dental school and desire to use EDDAs.
Table 1 1 a Dentists’ objective knowledge of EDDAs.
In dental school did you receive If permitted by your state dental practice training in:_________ act, would you use EDDAs?_____________ Maybe No Yes DAU 11 35 53* (35.4%) (11.1%) (53.5%) Yes 87 92 59 (36.6%) (24.8% (38.7%) No TEAM 5 9 19 (15.2%) (27.3%) (57.6%) Yes 92 86 80 (35.7%) (33.3%) (31.0%) No
‘There is no evidence indi cating that EDDAs can per form high quality work.
50.6*
25.6
23.7
“It has been demonstrated that dentists can produce more dentistry using EDDAs in a team approach.”
12.4
17.6
69.9*
“In some states, auxiliaries legally are practicing on their own, without super vision from licensed den tists.”
76.1*
11.8
12.1
“In some states, auxiliaries legally are performing irrever sible procedures (cutting tooth preparations) in private prac tice.”
74.7*
11.6
13.7
•Chi square 9.75; df 2; P <.01.
in Table 9. A sim ilar trend was found when com paring the percentage of time that an assistant worked with the dentist at the chair and the den tist’s desire to use EDDAs. Also, those dentists whose assistants worked at chairside while seated were more likely to indicate they would use EDDAs than those dentists who either worked without an assistant at chairside or whose assis tants stood while working at chairside. The former group of dentists said “Y es” 59.7% and “No” only 6.7% , whereas the latter group said “Y es” only 21.6% and “No” 41.1% of the time. Finally, those dentists who received training while in dental school in either four-handed sitdown dentistry (DAU) or in expanded auxiliary management (TEAM) were more likely to indicate a desire to use EDDAs (Table 10). ASSOCIATION BETWEEN KNOWLEDGE AND AT TITUDES AND DESIRE TO USE EDDAs. This section
consisted of nine items, four that were designed to test the objective knowledge of the respondents and five that were meant to assess their attitudes on the EDDA issue. Respondents were given nine statements and asked to circle a number from 1 (strongly disagree) to 5 (strongly agree) that most closely reflected their level of agreement with the statement. For purposes of analysis, categories 1 and 2 were combined to form a category of dis agreement as were 4 and 5 to form a category of agreement. Category 3 was left unchanged and was interpreted as undecided. The first four items of this section were objec tive. The statements and the percentage of distri bution of responses appear in Table 11. Of these first four statements, two were significantly as sociated (PC .01) w ith a desire to use EDDAs. These statements were: — There is no evidence indicating that EDDAs can perform high quality work. — It has been dem onstrated that dentists can
Level of agreement Disagree (%) Undecided (%) Agree (%)
•Correct responses.
produce more dentistry using EDDAs in a team approach. Those dentists who indicated a correct response were more likely to say “Y es” and those choosing incorrect responses were more likely to say “No” to the use of EDDAs. For exam ple, a com parison of the statement on quality of work and a desire to use EDDAs showed that those dentists who dis agreed (correct response) responded “Y e s” 54.5% , “No” 13.6% , and “Maybe” 31.8% . Of those who agreed with the statement (incorrect response), 17.8% responded “Y es,” 57.5% “N o,” and 24.7% “Maybe.” No significant associations were found with the following statements: — In some states, auxiliaries legally are practic ing on their own, without supervision from licensed dentists. — In some states, auxiliaries legally are perform ing irreversible procedures (cutting tooth prepara tions) in private practice. The next five questions were designed to assess the respondents’ attitudes on the issue of EDDAs. The statements and the percentage of distribution of the responses appear in Table 12. Each of these five statements was significantly associated with a desire to use EDDAs (Pc.01). There were three statements on w hich the largest group of dentists expressed negative attitudes toward EDDAs. These statements were: — In general, patients don’t want to be treated by EDDAs. — The use of EDDAs will increase the prestige of dentists in the public’s eye. — Dental care will be less personalized if EDDAs are used. Cohen : DENTISTS’ DESIRE TO USE EDDAS ■ 975
Table 12 ■ Dentists’ attitudès toward EDDAs. Level of agreement
“In general, patients don’t want to be treated by ED DAs.” “The use of EDDAs will increase the prestige of dentists in the public’s eye.” “Dental care will be less personalized if EDDAs are used.” “If more use is made of EDDAs, there won’t be anything left for dentists to do.” “Using EDDAs in a team approach will decrease the dentist’s enjoyment of his practice.”
Disagree (%)
Undecided (%)
Agree (%)
23.5
31.0
45.5*
45.4*
31.2
23.4
27.5
19.5
53.0*
69.0f
13.7
17.3
57.6t
21.2
21.2
•Questions on which the majority of respondents expressed favorable opinions toward EDDAs. tQuestions on which the largest percentage of respondents expressed un* favorable opinions toward EDDAs.
In each instance, dentists who expressed unfa vorable attitudes were more likely to say “No” and those who expressed favorable attitudes to say “Y es” to the question of the use of EDDAs. For exam ple, considering the statement that dealt with the prestige of dentists and the respondents’ desire to use EDDAs, those dentists who disagreed (unfa vorable attitude) responded “Y es” 21.6% , “No” 45.5% , and “M aybe” 32.8% . Those dentists who agreed with the statem ent (favorable attitude) re sponded “Y es” 55.1% , “No” 18.8% , and “Maybe” 26.1% . Interestingly, each of these three items on w hich the largest group of respondents expressed nega tive attitudes involved statements dealing with pa tients. It appears that these dentists have doubts about the attitudes of patients toward the use of EDDAs. On both of the remaining statements, the largest percentage of respondents showed positive at titudes. These statements were: — If more use is m ade of EDDAs, there w on’t be anything left for dentists to do. — Using EDDAs in a team approach will de crease the dentist’s enjoyment of his practice. In both instances, those dentists who showed positive attitudes were more likely to say “Y es” to the question of the use of EDDAs.
Discussion The use of EDDAs represents one of the best means of meeting the growing demand for dental care. For this potential to be realized, dentists m ust first be willing to use these auxiliaries. 9 76 ■ JADA, Vol. 97, December 1978
Roughly a third (33.4% ) of the dentists indicated that they would use EDDAs if they were legally permitted to do so, but another 30.5% indicated that they would not. The largest percentage (36.1% ) was undecided. It would not be expected that all dentists would want to use EDDAs, nor would this necessarily be desirable. W hat is im portant, however, is the ability to identify those dentists who are m ost likely to use EDDAs so that scarce resources could be concentrated where they would be m ost valuable. In this way, funds spent on recruitm ent and training will have their greatest impact. One of the m ost consistent findings in the litera ture is the association of a practitioner’s age (or years since graduation) and his desire to use ED DAs.6'8 The tendency for this association to di minish when the controlling variables for practice efficiency were used is important. If this is con firmed, it will m ean that resources should not necessarily be concentrated on recent graduates, but rather on those individuals who are currently using four-handed techniques. Indeed, a fourhanded dentistry profile was one com ponent of a recently published checklist designed to help practitioners decide if they should add an ex panded function dental auxiliary to their staff.10 More research is needed to confirm this finding. The inference by McKenzie and Born7 and W al ler11 that experience with TEAM programs may prove instrumental in forming favorable attitudes toward EDDAs was supported by this study. Expo sure to DAU programs in dental school also was found to be important. As more dentists are graduated, having had these experiences, the pool of practitioners likely to be favorable to EDDAs will be increasing. As mentioned earlier, not all dentists are likely to use EDDAs. In certain types of practices located in particular areas, the transition to a team ap proach will be more beneficial. The nearly signifi cant association between practice location ranked according to dentist/population ratio and a desire to use EDDAs is important in this regard. Most rural practices probably would not have the flow of patients necessary to support an EDDA finan cially; most inner city, high-volume practices would. Much of the rancor surrounding the issue of EDDAs would probably dissipate if practitioners realized that, in the future, dental practice will en compass many different organizational schemes. Reports on the association of how busy a prac tice is considered and a desire to use EDDAs have sometimes been perplexing. Koerner and Os-
terholt6 found those dentists who were least busy, were most likely to favor expanded roles for dental auxiliaries. Common sense seems to indicate that busy dentists would be more likely to want to use EDDAs. These differences might be resolved by considering the role a busy practice had in this study. It will be remembered that a subjective es timation of how busy the practice was considered was only indirectly related to a desire to use ED DAs, the more direct measures being either the number of patients seen or the number of hours per week the dental assistants were employed. This finding casts doubt on the wisdom of plan ning based on any subjective estimation of how busy a practice is considered. The associations previously outlined between knowledge and attitudes and a desire to use EDDAs are particularly important. Tryon12 examined the attitudes of dentists toward EDDAs and found them generally favorable. Unlike Rhode Island dentists, Connecticut practitioners tended to disagree with the statement that patients do not want to be treated by EDDAs. In the Connecticut study, the largest percentage of respondents (42.4% ) disagreed with this statement (36.5% agreed and 21.1% were undecided), whereas in Rhode Island the largest percentage (45.5% ) agreed (23.5% disagreed and 31.0% were unde cided). It is difficult to determine what might ac count for this difference. However, it is clear that favorable attitudes are important in fostering a de sire to use EDDAs. The negative appraisal by den tists from Rhode Island of their patients’ accep tance of EDDAs is a major obstacle to their own acceptance of EDDAs. This is one area in which education and perhaps desensitization are needed. Some dentists have difficulty in accepting the fact that their patients will receive services from aux iliaries as readily as from the dentist. The increas ing exposure of dental students to DAU and TEAM programs will undoubtedly help to allay these feelings in future graduates.
Summary A survey of all active practitioners in Rhode Island was conducted to determine w hich demographic or practice variables or knowledge or attitude vari ables, or both, might be associated with a desire to use EDDAs. A total of 355 (74.6% ) dentists re sponded to the questionnaire. Of these, 33.4% in dicated a desire to use EDDAs, 36.1% were unde
cided, and another 30.5% did not wish to use ED DAs. A desire to use EDDAs was associated with the following variables: demographic background, continuing education profile, indicators of how busy the practice is, number of hours auxiliaries were employed, practice efficiency indicators, and knowledge and attitude indicators.
This research was supported by Public Health Residency Traineeship grant 1A08-AH00102. This report is based on a paper presented at the 105th Annual Meeting of the Am erican Public Health Association, Nov 2, 1977, W ashington, DC. The author thanks Drs. Jacob Silversin, Gerard Kress, and Joseph Yacovone for their contribution to this project. 1. Lotzkar, S.; Johnson, D.W.; and Thom pson, M.B. Experim ental pro gram in expanded functions for dental assistants: phase 1 base line and phase 2 training. JADA 82:101 Jan 1971. 2. Abramowitz, J., and Berg, L.E. A four-year study of the utilization of dental assistants w ith expanded functions. JADA 87:623 Sept 1973. 3. Am erican Dental Directory. Chicago, Am erican Dental Association, 1975. 4. Cohen, L.A., and others. Correlates of dentists’ attitudes toward continuing education in TEAM. J Dent Educ 41:677 Nov 1977. 5. Leske, G.S., and Leverett, D.H. Variables affecting attitudes of den tists toward the use of expanded function auxiliaries. J Dent Educ 40:79 Feb 1976. 6. Koerner, K.R., and Osterholt, D.A. Student survey report: W ashing ton dentists questioned on expanded duties. JADA 86:995 May 1973. 7. McKenzie, N., and Born, D.O. D entists’ attitudes toward expanded duties auxiliaries. JADA 86:1001 May 1973. 8. Martens, L.V.; M eskin, L.H.; and Proshek, J.M. New dental care concepts: perceptions of dentists and dental students. Am J Public Health 61:2188 Nov 1971. 9. Lewin, K. Field theory in social sciences. New York, Harper & Bros, 1951. 10. U S Department of Health, Education, and W elfare Public Health Service, Bureau of Health Manpower. Should you add an expanded function dental auxiliary to your staff? DHEW Publication no. (HRA) 76-14. U S Government Printing Office, 1975. 11. W aller, R.R. Expanded duties of auxiliaries: a survey of opinions of Georgia dentists. JADA 86:1009 May 1973. 12. Tryon, A.F. Connecticut dentists’ views on expanded duty dental auxiliaries— prelim inary report. J Conn State Dent Assoc 47:69 April 1973.
THE AUTHOR
Dr. Cohen is assistant professor of community and oral health, University of M ississippi School of Dentistry, Jackson, Miss 39216. In January, he w ill be with the University of Maryland School of Dentistry, Baltimore, 21201, as assistant professor of oral health care delivery.
COHEN
Cohen : DENTISTS’ DESIRE TO USE EDDAS ■ 977