Dental health aides in Alaska: A qualitative assessment to improve paediatric oral health in remote rural villages.

OBJECTIVE: Isolated villages in Alaska face disparities in oral health and access to care. Dental health aides such as the primary dental health aide (PDHA) and the dental health therapist (DHAT) fill a critical role for providing dental care in Alaska. Our objective was to describe strengths and barriers to paediatric dental care for children living in remote Alaska villages from the perspectives of the community and the health care system. METHODS: This qualitative study collected data through semi-structured key informant interviews with community members (n = 19) and healthcare workers (n = 19) and focus groups with patients (n = 31 adolescents and 16 caregivers of children under 12 years) living in or providing health care to 3 remote villages in Alaska. Using an inductively developed codebook and a narrative approach, 3 researchers independently read and thematically analysed the transcripts. RESULTS: Two themes emerged: (i) PDHAs and DHATs are perceived as sustainable and strongly positioned to meet the unique dental needs of the rural communities; (ii) PDHAs and DHATs face barriers that limit their effectiveness, and their distinct roles require clarification and administrative support. CONCLUSIONS: Dental health aides, both PDHAs and DHATs, are well accepted in Alaska villages. An innate understanding of cultural norms and continuity of care are key elements driving village satisfaction. The potential exists administratively to strengthen the model with the implementation of clinical and office-system strategies to increase efficiency of the dental team. Culturally adapted implementation strategies will be critical to the successful expansion of new workforce models that are addressing health disparities.

Evaluation of dental therapists undertaking dental examinations in a school setting in Scotland.

OBJECTIVE: To measure agreement between dental therapists and the Scottish gold-standard dentist undertaking National Dental Inspection Programme (NDIP) examinations. METHODS: A study of interexaminer agreement between 19 dental therapists and the national gold-standard dentist was carried out. Pre-calibration training used the caries diagnostic criteria and examination techniques agreed by the British Association for the Study of Community Dentistry (BASCD). Twenty-three 5-year-old children (Primary 1) and 17 11-year-old children (Primary 7) children were examined. Agreement was assessed using kappa statistics on d3 mft and D3 MFT for P1 and P7 children, sensitivity and specificity values, and kappa statistics on d3 t/D3 T and ft/FT. Calibration data on P1 and P7 children from 2009-2012 involving dentists as examiners were used for comparison. Economic evaluation was undertaken using a cost minimization analysis approach. RESULTS: The mean kappa score was 0.84 (SD 0.07) ranging from 0.69 to 0.94. All dental therapists scored good or very good agreement with the gold-standard dentist. This compares with historic NDIP calibration data with dentists, against the same gold-standard dentist, where the mean kappa value was 0.68 (SD 0.22) with a range of 0.35-1.00. The mean sensitivity score was 0.98 (SD 0.04) (range 0.88-1.0) and mean specificity score was 0.90 (SD 0.06) (range 0.78-0.96). Health economic analysis estimated that salary costs would be 33.6% lower if dental therapists were substituted for dentists in the year 2013, with an estimated saving of approximately £103 646 per annum on the national budget. CONCLUSION: We conclude that dental therapists show a high level of interexaminer agreement, and with the appropriate annual training and calibration, they could undertake dental examinations as part of the NDIP programme.

Alternative scenarios: harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research.

BACKGROUND: In primary care dentistry, strategies to reconfigure the traditional boundaries of various dental professional groups by task sharing and role substitution have been encouraged in order to meet changing oral health needs. AIM: The aim of this research was to investigate the potential for skill mix use in primary dental care in England based on the undergraduate training experience in a primary care team training centre for dentists and mid-level dental providers. METHODS: An operational research model and four alternative scenarios to test the potential for skill mix use in primary care in England were developed, informed by the model of care at a primary dental care training centre in the south of England, professional policy including scope of practice and contemporary evidence-based preventative practice. The model was developed in Excel and drew on published national timings and salary costs. The scenarios included the following: "No Skill Mix", "Minimal Direct Access", "More Prevention" and "Maximum Delegation". The scenario outputs comprised clinical time, workforce numbers and salary costs required for state-funded primary dental care in England. RESULTS: The operational research model suggested that 73% of clinical time in England's state-funded primary dental care in 2011/12 was spent on tasks that may be delegated to dental care professionals (DCPs), and 45- to 54-year-old patients received the most clinical time overall. Using estimated National Health Service (NHS) clinical working patterns, the model suggested alternative NHS workforce numbers and salary costs to meet the dental demand based on each developed scenario. For scenario 1:"No Skill Mix", the dentist-only scenario, 81% of the dentists currently registered in England would be required to participate. In scenario 2: "Minimal Direct Access", where 70% of examinations were delegated and the primary care training centre delegation patterns for other treatments were practised, 40% of registered dentists and eight times the number of dental therapists currently registered would be required; this would save 38% of current salary costs cf. "No Skill Mix". Scenario 3: "More Prevention", that is, the current model with no direct access and increasing fluoride varnish from 13.1% to 50% and maintaining the same model of delegation as scenario 2 for other care, would require 57% of registered dentists and 4.7 times the number of dental therapists. It would achieve a 1% salary cost saving cf. "No Skill Mix". Scenario 4 "Maximum Delegation" where all care within dental therapists' jurisdiction is delegated at 100%, together with 50% of restorations and radiographs, suggested that only 30% of registered dentists would be required and 10 times the number of dental therapists registered; this scenario would achieve a 52% salary cost saving cf. "No Skill Mix". CONCLUSION: Alternative scenarios based on wider expressed treatment need in national primary dental care in England, changing regulations on the scope of practice and increased evidence-based preventive practice suggest that the majority of care in primary dental practice may be delegated to dental therapists, and there is potential time and salary cost saving if the majority of diagnostic tasks and prevention are delegated. However, this would require an increase in trained DCPs, including role enhancement, as part of rebalancing the dental workforce.

Increasing productivity in dental practice: the role of ancillary personnel.

Dentistry has achieved substantial improvements in productivity which have the effect of making more care available at reasonable cost. Data are presented documenting trends in productivity. These are analyzed with respect to number of dentists, hours worked by dentists, and the use of ancillary personal in dental offices. There is strong evidence linking increased productivity to the use of ancillary personnel. The history of creation, recognition, and integration of ancillary personnel into dental practice is also presented.

Basic principles of maximizing dental office productivity.

To maximize office productivity, dentists should focus on performing tasks that only they can perform and not spend office hours performing tasks that can be delegated to non-dentist personnel. An important element of maximizing productivity is to arrange the schedule so that multiple patients are seated simultaneously in different operatories. Doing so allows the dentist to work on one patient in one operatory without needing to wait for local anesthetic to take effect on another patient in another operatory, or for assistants to perform tasks (such as cleaning up, taking radiographs, performing prophylaxis, or transporting and preparing equipment and supplies) in other operatories. Another way to improve productivity is to structure procedures so that fewer steps are needed to set up and implement them. In addition, during procedures, four-handed dental passing methods can be used to provide the dentist with supplies or equipment when needed. This article reviews basic principles of maximizing dental office productivity, based on the author's observations of business logistics used by various dental offices.

Dental practitioner concepts of efficiency related to the use of dental therapists.

OBJECTIVES: Efficiency is concerned with producing maximum output with the minimum input, although what constitutes inputs and outputs within an organization is not always clear. Labour substitution is one method of achieving efficiency gains, although cost savings are found to be context dependent and may not be achieved in some situations. Because dental therapists (DTs) in England are permitted to work in dental practices, we set out to investigate how efficiency with respect to the use of DTs is conceptualized by practitioners to deepen our understanding of the potential for substitution to realize efficiency gains in dental practice. METHODS: Nine dental practices were selected using a purposive sampling methodology to give a range of practice size and DT employment arrangements. Semi-structured interviews were held with 26 dentists. Transcripts were coded and analysed thematically. RESULTS: Efficiency was perceived as optimum use of surgery time to generate intermediate outputs of (i) managing patient flow to give patient satisfaction and business cash flow and (ii) volume of work (procedures and numbers of patients). DT efficiency gains were evaluated according to whether lower labour costs were offset by a slower working pace and higher rate of failed appointments. Patient need and demand, and whether the practice had health improvement goals, influenced whether DTs were deemed to improve efficiency. CONCLUSIONS: Findings are in accord with skill mix reviews in wider health care that substitution may be effective in improving efficiency but this may be limited to particular situations where conditions are conducive. More studies are needed to explore these issues further in other dental practice contexts and with other groups of dental auxiliary.