Abstract
Purpose The intent of this inquiry was to explore the lived experiences of dental hygienists who provide restorative patient care.
Methods Phenomenology was the qualitative approach used. Purposive sampling ensured participants had relevant experiences. An Interview Guide was emailed one week prior to the interview to help participants prepare responses. Informed consent included selecting a pseudonym, which was used throughout the interview and on the written transcript to protect the participants’ identities. One-hour semi-structured interviews were conducted and recorded on Zoom. Data collection and analysis occurred simultaneously. Verbatim transcription accuracy was verified. Data were initially coded and then focused coding created themes. Demographic data were analyzed using descriptive statistics.
Results After eight interviews data saturation was achieved. Seven females and one male participated. All participants experienced a restorative curriculum in their entry-level program and most felt well-prepared. The motivation for becoming a restorative dental hygienist included having positive restorative experiences during the entry-level program, wanting to keep restorative skills current after graduation, and having an opportunity to provide restorative care. Challenges experienced included the dentists’ negative attitudes, dental hygienists’ not valuing restorative abilities and not having a qualified dental assistant. Personal benefits were related to career fulfillment. Benefits to patients involved improving access, efficiency, and convenience. The benefit to the office was increased production. Differences between restorative and preventive care involved demands of care and patient care flow.
Conclusion The findings provide insight into the unique experiences of dental hygienists who provided restorative patient care and a foundation for future research.
- dental hygienists
- dental hygiene care
- restorative treatment
- expanded functions
- access to care
- qualitative research
INTRODUCTION
A global shortage of practitioners in the dental workforce has been an ongoing problem since the 1900s. An early solution to address the workforce problem and the high prevalence of oral diseases in New Zealand was the creation of the dental nurse.1 The dental nurse concept was the first to allow a dental auxiliary to perform procedures traditionally designated to the dentist. The two-year dental nurse program opened in 1921 and young women were recruited into the School Dental Service.2 Graduates provided preventive care, placed simple restorations, and performed simple extractions using local anesthesia. Supervision by a dental officer was required three times per year to evaluate the quality and comprehensiveness of the care provided to approximately 500 children once every six months.2
In the United States (US), the dental community projected an increase in the population and the demand for dental services due to the population’s increase in education, income, and employment offering dental insurance.3,4 One solution to increase the efficiency of providing dental treatment was using four-handed dentistry with a dental assistant. During the 1950s, the US Public Health Service’s Division of Dental Health instituted the Dental Auxiliary Utilization Program, which educated dental students to use dental auxiliaries to perform dental procedures to enhance efficiency and ease of effort.5 When federal support for this program was eliminated, the Training in Expanded Auxiliary Management (TEAM) program replaced it. The TEAM program was designed to teach dental students and expanded duties dental auxiliaries to work collaboratively in a team environment to provide dental treatment.5
In 1961, the American Dental Association requested that research be conducted on educating and expanding the responsibilities of dental auxiliaries, dental hygienists and assistants, to address the workforce shortage and the increased demand for care.4 Several studies conducted during the 1960s and 1970s reported details of auxiliary training programs and demonstrated increased production while maintaining the quality of the procedures completed by the auxiliaries.3,6-8
During the 1970s, legislation was passed in a few states to allow dental hygienists to provide local anesthesia and restorative care.9 Since that time the number of states has slowly increased to create this new practice model. Guidelines for teaching expanded functions to auxiliaries were published in 1972 by the Inter-Agency Committee on Dental Auxiliaries. These guidelines urged accredited dental assisting and dental hygiene programs to revise curricula to integrate expanded functions into modified programs to address the workforce shortage needs.10
Dental practitioner shortages still exist throughout the globe. New Zealand, The Netherlands, Malaysia, Australia, Canada, United Kingdom (UK), France, and Ireland, to name a few, continue to experience oral health inequities and dental workforce shortage problems.11,12 Ireland, France, and the UK, have a low average of 44 to 65 dentists per 100,000 people.12 Similarly, the dentist per capita ratio is 60 per 100,000 in the US.13
The surveillance of the workforce problem is reported by the US. Health Resources and Services Administration as dental health professional shortage areas (DHPSA) based on geographic areas, populations, or facilities.14 A geographic shortage area is a shortage of providers for an entire population within a defined geographic area; a population shortage area is based on the number of providers to serve a specific population (e.g. racial/ethnic group); and a facility shortage area is designated by less than adequate number of public or non-profit private facilities serving a population or geographic location. Dental health geographic and population shortage areas are calculated based on the number of dentists per geographic area or population. According to the latest calculations, an additional 12,000 dentists are needed in the workforce to address this problem.14 Furthermore, the insufficient number of dentists graduating each year will not overcome the dental workforce shortages.12,14
Encouraging dental hygienists to use and expand their scope of practice has been a global priority since the 1900s and these initiatives remain important because the number of employed and graduating dentists cannot match the rising demand for dental services.12,15,16 One of the more successful expansions to dental hygiene’s scope of practice is the administration of local anesthesia. In a recent study, the scope of dental hygienists’ practice related to anesthesia and caries treatment was reviewed on a worldwide level.15 Bozia et al. found that 61% of the countries surveyed allowed dental hygienists to administer local anesthesia compared to only 15% allowing restorative patient care.15 Although anesthesia administration has expanded, the global absence of countries where dental hygienists are utilized to actively manage caries disease is evident.11 Currently in the US, 46 out of the 50 states allow dental hygienists to administer local anesthesia, while only 13 states permit placing and finishing composite or amalgam restorations.17,18 Therefore, the progressive need for dental hygienists to use their knowledge and skills to treat caries disease is obvious and the barriers preventing such treatment need to be examined.11,15
The intent of this qualitative inquiry was to explore the lived experiences of dental hygienists who provide restorative patient care. The research question guiding this inquiry was, “What are the experiences of dental hygienists who provide restorative patient care? The working definition of “dental hygienist who provides restorative patient care” was administering local anesthesia and providing treatment to repair damaged teeth, including the placement, finishing and adjustment of interim, composite, and amalgam restorations.
METHODS
The qualitative approach used for this inquiry was phenomenology. Phenomenology studies lived experiences from a subjective perspective based on the significance of events, time, self, and others, encountered in the real world of dental hygiene practice.19 This approach was appropriate for understanding the ways dental hygienists experience providing restorative patient care and the meaning of these experiences.19
Qualitative methodology and coding were part of the researchers’ graduate education. One researcher has extensive experience in conducting qualitative studies and has disseminated the results of these studies in professional journals. All three researchers were female and teach in a dental hygiene program with a restorative curriculum. Two of the researchers are significantly involved with student learning didactic, laboratory, and clinical restorative procedures and thus, were interested in discovering practitioners’ experiences using these skills.
Purposive sampling ensured that the limited number of selected participants had the experiences to appropriately inform data collection and analysis. This sampling method is widely used in qualitative research to identify and select participants who are experienced with the phenomenon of interest, which in this study was providing restorative patient care.20 The initial sample was selected from Idaho State University alumni from the Department of Dental Hygiene who were known to provide restorative patient care. Therefore, the researchers had previous relationships with the alumni of the program. Additional participants were recruited based on snowball sampling. This sampling method involved initial participants identifying other dental hygienists to the researchers who they knew provided restorative patient care.20 Recruitment was difficult as most participants did not know other colleagues providing restorative care.
The inclusion criteria for the participants were: 1) an active dental hygiene license in one of the states in the US, 2) at least 6 months experience providing restorative patient care, and 3) restorative care provided within the past year. Exclusion criteria were: 1) dental hygienists who are also dental therapists providing restorative patient care, 2) active dental hygiene license outside of the US, 3) less than 6 months experience providing restorative care, and 4) the provision of this care was not within the past year.
Maximum variation of the sample was a goal of the sampling procedure; achieving diversity in the sample provides a broad perspective of lived experiences related to the phenomenon.20 To facilitate this goal, potential participants completed a screening questionnaire to determine the age, gender, entry-level degree, years in practice, educational setting where restorative care was learned, and practice setting and location. Additionally, the questionnaire helped determine whether the potential participants met the inclusion criteria.
Prior to the implementation of research procedures, the qualitative study was approved as exempt by the Idaho State University Human Subjects Committee (IRB-FY2022-212). Once approval was granted, researchers conducted a pilot study to test the questions on the interview guide to determine the quality of the data collected and whether the data answered the research question. The pilot study was completed with a dental hygienist who met all of the inclusion criteria.
Afterwards, researchers began recruiting participants by contacting dental hygiene alumni through text and email by sending a recruitment letter which introduced the researchers and the topic and outlined the purpose of the study. Other than communication through email, there was no relationship established prior to study, except the alumni status of some participants. Practitioners who met the inclusion criteria were invited to complete a one-hour semi-structured interview conducted via a video conferencing platform (Zoom; San Jose, CA, USA). The Interview Guide was emailed to the participants one week before the scheduled interview day to provide time for participants to formulate their responses. Additional participants were recruited through the snowball sampling method. Recruitment continued until data saturation was achieved; whereby, no new data were collected.20
Potential participants were requested to use a password protected private email account to ensure their confidentiality and anonymity was protected. A link for the interview session was emailed to the participant. As soon as the interviewer and interviewee were present, the “lock meeting” feature was enabled to prevent others from entering the session. Interviews were conducted by all three researchers, usually in dyads to ensure all questions were asked and responses were detailed. No interviews were repeated; no participants dropped out.
Data collection and analysis occurred simultaneously.21 Before data collection began, the informed consent procedures were conducted at the beginning of the interview; time was provided for the researcher to review content of the consent form and for the volunteer to ask questions. Verbal consent was gained from the person to participate in the study and the participant selected a pseudonym. The pseudonym was used throughout the interview and was used on the written transcript. After each interview, the recordings were transcribed through the online transcription feature into a written document then one of the researchers verified the accuracy of the document to ensure verbatim transcription.
Data analysis included two levels of coding: initial and focused. The data were deconstructed into small segments during initial coding, whereas, during focused coding the initial codes were combined to form themes representing larger amounts of data. One researcher coded the data, then two researchers verified the initial coding. Differences were rectified before conducting the focused coding phase. Demographic data from the screening questionnaire were analyzed using descriptive statistics.
After data saturation, the trustworthiness of the analysis was verified by member checks. Member checks is a method whereby the data analysis is reviewed by each participant to determine whether the researchers’ interpretation of the data aligned with their experiences. A one-week time frame was provided for them to send their feedback.20 No changes to the data analysis were made based on the participants’ feedback.
RESULTS
A sample size of eight produced data saturation. One male and seven females practiced in three states in the Pacific Northwest. All participants provided restorative care in dental health professional shortage areas. Additional demographic data are reported in Table I.
Demographic Data
Participants’ experiences in the restorative curriculum during their entry-level program included didactic, laboratory, preclinical (working on each other), and clinical practice throughout the entire professional program. One participant also completed a refresher course because it had been 10 years since graduation before providing restorative care. Seven of the 8 participants felt well prepared to enter restorative practice after graduation. All participants successfully completed the Western Regional Examining Board’s (WREB) restorative examination. Dental hygiene licensure requirements for the State of Washington include restorative education and passing a restorative board examination as a part of the Registered Dental Hygiene core license in order for a hygienist to practice traditional preventive hygiene. An additional and separate licensing application, Expanded Practice, in Oregon and restorative endorsement in Alaska, must be approved to practice restorative dental hygiene. In the state of Washington, no additional continuing education is required for restorative practice; however, in Oregon 36 hours of continuing education is required versus the 24 for the regular dental hygiene licensee; in Alaska the continuing education is 20 hours bi-annually, two of which must be related to restorative procedures.
All participants had similar compensation and were paid hourly. All but one was paid the same wage as dental hygienists who practiced traditional preventive care exclusively; one participant was paid more hourly when restorative care was provided.
Motivation Theme
Experiences related to the motivation for becoming a restorative dental hygienist were explored (Figure 1). Motivating factors included having positive restorative experiences during the entry-level curriculum, desiring to keep restorative skills current after graduation, and being presented with an opportunity to provide restorative care. Positive experiences during the participants’ education were articulated as:
Motivation Theme
“When I was in hygiene school restorative was one thing I was not anticipating the hygiene career to entail, and it ended up being one of my favorite aspects of hygiene school. It’s a lot of fun that’s why I pursued it.” (Joe)
“Having been trained in restorative during my hygiene education, I knew that it was something that I enjoyed.” (Layla)
Another motivating factor was keeping restorative skills current after graduation:
“I didn’t want to lose the skills after school. I had been out of school for about a year and needed to pick up some time. So, I started part-time and then, ended up loving it and took on more days there.” (Renae)
“The big reason why I wanted to do restorative so badly is because I didn’t want to lose the skill after learning it from school.” (Joe)
The last motivating factor was being presented with a restorative opportunity in practice:
“I ended up temping in general practice and they called me for this restorative position. Apparently, I did well enough that they offered me a job part-time job at the end of that week and asked, would you stay with us? About 4 months later that turned into a full-time thing, and I learned to really, really love it and appreciate it”. (Gordy)
“When I started, I went there with the knowledge that I was going to be a restorative hygienist, but they weren’t prepared. They had to create a role for me. So, I was doing preventive for the first three months. But after that, I was full-time restorative hygienist for three and a half years.” (Rachel)
“I was looking at states that allow it, where a hygienist can actually perform those duties. I ended up pursuing a job that offered restorative. When I moved, I had 12 interviews, and I ultimately settled on the one that allowed me to place restorations.” (Joe)
Challenges Theme
One theme related to challenges experienced by restorative dental hygienists influenced by dentist’ negative attitudes, dental hygienists not valuing restorative skills and not having an effective dental assistant (Figure 2). Dentists’ attitudes about hygienists fulfilling this role in their practice was seen as a challenge and influences the number of restorative positions available for hygienists.
Challenges Theme
“In private practice, the attitude of dentists is still, “You can’t do that. That’s something I need to do.” After leaving the community health center, restorative became a non-option. In the office that I work in now, my doctor won’t even let me adjust a filling.” (Rachel)
“Not all dentists feel comfortable letting someone take over the restorative aspect of patient care. It’s a really big responsibility, and not everyone’s comfortable relinquishing that control, especially if they’re hiring you as a restorative hygienist, and you’re someone they don’t know and they don’t know what your standards of care are, what your restorations look like. It’s hard to be able to just trust somebody is going to take as good of care of your patients as the dentist does.” (Alexandria)
“In Oregon and Washington, both states have restorative licenses, but not a lot of opportunities for hygienists to use that and especially on a daily basis. I think that would be the biggest challenge.” (Layla)
Some dental hygienists do not value this unique skill set.
“I think a lot of hygienists are intimidated by restorative dentistry. You have to be an artist, sculpting teeth anatomy. I’ve heard other hygienists say that they are not very good at it and know that they would not be a good fit for it.” (Sam)
“When I was in school not a lot of hygienists wanted to do restorative. It was very challenging placing the restorations and passing the WREB exam. Pass rates weren’t that good. It just didn’t seem worth it to them. They just wanted to practice clinical hygiene.” (Alexandria)
Another challenge experienced by restorative hygienists was not having an effective dental assistant to perform four-handed dentistry procedures.
“My main issue is probably getting good isolation. I don’t have an assistant to help me with my placement of the restoration, so making sure everything’s nice and isolated and the tooth is not contaminated while mixing up the glass ionomer in the triturator. All that stuff is kind of hard to do on your own.” (Alexandria)
“My practice had extreme turnover, and I was almost constantly working with an incompetent assistant. Very few times did I get to work with an assistant who had been there for more than six months.” (Stephanie)
Benefits Theme
Other experiences explored related to the benefits of providing restorative patient care. The themes of personal benefits related to career fulfilment, to patients and practice (Figure 3). The personal benefits of career fulfilment were based on using the full extent of their education, having more gratifying and positive experiences in practice, feelings of being a valuable team member and being respected more. The first aspect of career fulfilment was using the full extent of their entry-level preparation.
Benefits Theme
“Being able to use all of my education and knowledge that I was taught. It was nice to be able to apply what I had learned and know that I could do restorative.” (Rachel)
Having a more positive experience in practice included factors such as enjoying the creative aspect of restorative procedures and keeping practice interesting as represented in these quotes:
“I really like the artistic aspect of it. You don’t usually get to be very creative or create anything with regular dental hygiene. So that was a big plus and a lot of fun.” (Alexandria)
“I like it because it is something different. Each patient is a new challenge. I feel like I get to use my creativity because it’s not just black and white. It’s just something that is a little more exciting to me and challenging after practicing hygiene for the last 15 or so years.” (Layla)
“It’s what fires me up. I get joy from it.” (Gordy)
“It definitely provides more career satisfaction for me. I also think that it breaks up the monotony of clinical hygiene and spices up the work life.” (Sam)
Career fulfilment was also expressed as feelings of being a valuable team member when providing collaborative care.
“I felt more like a team member in this situation, rather than feeling like I’m the hygienist and this is the rest of the team. It was more like we all worked together.” (Renae)
“I actually felt closer to the dental team because I was working in tandem with a dentist and an assistant.” (Stephanie)
Furthermore, more respect was offered from the dental team based on the dental hygienists’ ability to provide restorative patient care.
“Other dental professionals’ value me and respect me more in the practice.” (Sam)
“There might be a small difference in the respect the assistants and dentist give me. It helps me to feel more valued just because I’m able to help with more.” (Layla)
The theme of patient benefits was revealed as improving access to care, enhancing efficiency of treatment and increasing patient comfort and convenience. Interestingly, no disadvantages for the patients were reported. Improving access to care was articulated as:
“In the community health setting, a lot of patients didn’t have access to care, so they were just grateful that a dental hygienist was able to see more patients and more of the community.” (Rachel)
“In my experience with my office it helps to increase our access, because now there’s two providers, myself and the doctor, who can provide restorative treatment. We can see patients in tandem and see twice as many patients each day, so that improves the patients’ accessibility for appointments.” (Layla)
Enhancing efficiency of patient care stemmed from having multiple providers functioning at the top of their scope of practice to provide coordinated care.
“It makes it more efficient, because every provider, from the assistant to the dentist, was focused on the things that only they could do. For the dentists, they were doing exams, prepping, and delivering appliances. Everything that I could do, I was doing. The assistants were utilized to their full scope of care. We were able to see a lot more patients without sacrificing quality.” (Renae)
Other benefits for the patient were expressed as comfort due to previous rapport with the dental hygienist and the convenience of having restorative care during a preventive appointment. No participants reported patients questioning their ability or refusing restorative care provided by the participants.
“Some patients feel very comfortable with their hygienist placing composite fillings and other restorative materials due to already being acquainted with and comfortable with their hygienist for routine hygiene treatment.” (Sam)
“Patients are happy because we don’t have to reschedule them months down the road. The patient and parent are usually happy to know that I can place the restoration the same day, and that they don’t have to come back for restorative care later on.” (Alexandria)
The benefit to the practice was the financial aspect. Increased production and the cost effectiveness of paying a hygienist less than another dentist to provide restorative care and freeing the dentist’s time to concentrate on treatment not within the hygienist’s scope of practice.
“A practice can benefit financially greatly because you’re paying a hygienist significantly less than you’re paying a dentist. Not to mention that the dentist is able to spend their time on higher priced services such as crowns and root canals.” (Stephanie)
“Increased production because the dentist can be working a case and doing crowns, implants, extractions. Those lower dollar procedures, where it almost isn’t beneficial to utilize the dentist’s time for a simple filling, can fall in my column and make it just a little bit more cost effective.” (Joe)
Differences Theme
This qualitative inquiry also revealed the theme of differences between restorative and preventive care, which included the demands of patient care and the patient care flow (Figure 4). The difference in demands related to the emotional and physical aspects of restorative care. Participants reported more emotional health.
Differences Theme
“I could even say my emotional well-being is affected. I’m just more stressed out on those preventive days.” (Layla)
“There was less burnout because there was a little bit more art to it. I found that satisfying. Also, where I worked we saw a lot of state insurance people. It felt good to know that I was helping people in need.” (Renae)
Most participants agreed that restorative care was less physically demanding on their bodies.
“Most definitely restorative is less demanding. It was less because you’re using a hand piece more. I had less neck pain and back pain and my spirits were up.” (Rachel)
“Overall, it’s been easier on my body. Not as much repetition. The scaling leads to carpal tunnel sorts of things. There’s not as much strain, not as much power required [for restorative care].” (Renae)
The patient care flow for restorative care differed from traditional care. Two approaches to restorative care were experienced by the participants; restorative care was provided in collaboration with the dentist and assistants or restorative care was integrated into the preventive appointment. During collaborative care appointments, the assistants stayed with the patient and the dentist and hygienist worked as a tag team alternating between two or three patients each hour.
“I was double-booked with a dentist and we were staggered with hour blocks of time. I would give anesthesia and the doctor would come in and prep that tooth. While she was prepping, I was giving anesthetic to the next patient. We were just bouncing back and forth.” (Rachel)
“The assistant stayed with the patient. The doctor and I tag teamed.” (Renae)
The second approach to collaborative care was experienced as restorative care integrated during a preventive appointment. When the dentist was prepping the tooth, the dental hygienist assisted with four-handed dentistry.
“If the patients are coming in for an appointment we scheduled it 6 months ago to get this filling done, they could also be coming in for a prophy and exam. I do probe readings and x-rays, then I usually talk with the dentists, where I will have them come in first after I’ve gotten health histories and I’ve numbed the patient. They’ll do the periodic exam and drill at the same time. And then I will place the filling and then finish it, check their bite, get everything done, and then clean their teeth. At the end, the dentists come to make sure it all looks good, and then they’re on their way. If patients have a filling scheduled the same time as their cleaning it’s like 90 min, if it’s a class one or class 2. If it’s two fillings or a MOD, then it could be 2 hours. The dentist is usually in there for like 5 or 10 min max that whole time.” (Joe)
All participants administered local anesthesia for the patients receiving restorative treatment. The types of restorative materials and procedures which the participants reported using included: interim materials, glass ionomers, intermediary materials, composite, amalgam, and placing and finishing the materials. Furthermore, all cavity preparation types, according to Black’s classification of cavities Class I, II, III, IV, V, and VI, were restored by the participants.22
Quality assurance was determined by a senior dental hygienist or the dentist evaluating completed restorations during an initial period and then once confidence in the hygienists’ skills was established restorations were assessed at the next appointment.
“In the first two months as I was being mentored by a more senior hygienist, she would come in and evaluate my restorations and let me know how I was doing. The first two months, I had a lighter schedule, so I had more time to complete my restorations and she had more time to come in and evaluate them. Then we would look six months down the road when they came back for their recare, we would look at the x-rays and see the margins and contour.” (Stephanie)
“The dentist did not check my work once he had confidence in me.” (Gordy)
“Originally when I first started practicing restorative, each restoration had to be checked. Once I completed it, the doctor would come in and check my restoration, check the contacts and margins. Now the only check would be when that patient returns for their recare because I’ve been doing restorations for so long.” (Layla)
Self-evaluation using critical thinking was also important for quality assurance.
“When you get into private, it’s self-evaluation, and you have to learn to critically think and evaluate yourself.” (Gordy)
“The first six months I was finally feeling more confident in my restorative. Then I got super deflated seeing my original work from the first couple months seeing extremely light contacts, underfilled, and overfilled restorations.” (Stephanie)
The last experiences explored was advice to future dental hygienists considering working in an office providing restorative care. Advice was categorized as not having a self-limiting mindset, choosing your work setting wisely, giving yourself the grace to grow and eliminating a perfectionism mentality. Advice related to refraining from having a self-limiting mindset was:
“Don’t limit yourself. Don’t be afraid. I was afraid. I actually had to be talked into the job because I never saw myself as a restorative hygienist. I never thought that was going to be part of my skillset. Now I look back on that it was a silly, self-limiting mindset that I had.” (Stephanie)
“I think the best advice is to not allow yourself to get closed into a box of preventive hygiene. There are so many aspects of dentistry that can make the career more exciting and less monotonous. If we develop our skill sets, we can actually increase our joy in practice.” (Layla)
“Just try it. I would encourage anybody coming out of school to just do it. If you have an opportunity to jump into it. That’s the best time to do it, because everything is fresh.” (Gordy)
Further advice related to allowing oneself time for restorative skills to grow included:
“Allow yourself the ability to get your feet wet slowly and build up to doing more and more. I guess maybe giving yourself the grace to grow and get better.” (Renae)
“Be confident. Be aware that you’re going to struggle at the beginning. That doesn’t make you a bad clinician or a bad person. It’s part of the skill acquisition model. We all start a little rough, but be willing to ask questions and recognize that sometimes your work is going to have to be redone in the beginning, and that’s okay.” (Stephanie)
The last piece of advice related to eliminating a perfectionism mentality.
“Don’t beat yourself up if the restoration is not perfect.” (Alexandria)
“Be comfortable with being uncomfortable. Have a sense of you can’t control the universe and find that self-evaluation piece to figure out what is good enough, not that it has to be perfect. I’ve seen some really crappy fillings that dentists have done. Be realistic about the situation. Don’t take yourself too seriously. Make mistakes, and you’re going to make a lot of them and just be good with it because you’re going to learn a lot. Maybe you’ll try something differently next time and learn to communicate that it wasn’t my best work, or what did I learn and what might I try next time?” (Gordy)
Additionally, participants shared advice about wisely choosing a work setting.
“Build a questionnaire to ask questions during the interviews. A lot of times the dentists or office managers weren’t expecting to be interviewed themselves. Asking my questions set the tone and showed I was invested in doing restorative procedures.” (Joe)
“My advice would be to practice with a patient dentist who can help you grow. I would recommend seeing if you could do a temporary position with the dentist or a working interview prior to committing to working with that particular dentist, because she or he might not be that great of a fit.” (Alexandria)
DISCUSSION
This study aimed to explore the experiences of dental hygienists who provided restorative patient care. The qualitative nature of the study allowed for a richer understanding and valuable insights into the educational preparation and practice implementation of these services. The overall findings are beneficial to help educators who teach restorative procedures, in promoting other dental hygienists to practice restorative care, and to explore pathways to overcome challenges providers face, all of which might help decrease dental health professional shortage areas and increase access to care. Moreover, this research lays the foundation for future studies to explore dentists’ attitudes and knowledge of the benefits and advantages of employing a restorative hygienist.
One of the primary findings was that the participants’ entry-level hygiene programs emphasized restorative education and prepared them well for practice. This finding suggests that substantial education is essential for laying the foundation for restorative practice. Well prepared graduates who have confidence and competence in their restorative skills are crucial to using these skills in practice. Progressive restorative curricula include high-quality didactic, laboratory, preclinical, and clinical experiences throughout the professional program (Table II). Self-evaluation integrated into course grades at multiple times during each semester, may develop critical thinking and lifelong learning to support ongoing professional development.
Restorative Curriculum Example
Considerations for designing a restorative curriculum include having sufficient clinical experiences, quality standards for treatment protocols, evaluation criteria, and specific requirements related to restorative surfaces and materials.23 Clinical experiences involved students providing direct patient care, students who performed assistant duties using four-handed dentistry and alternated with student operators; and an optimal dentist-to-student ratio of one to four.23
In many states, a critical part of licensure to practice requires the successful completion of a restorative examination. Therefore, curricula must also address restorative board preparation. In the US, two regional testing agencies offer restorative examinations, the WREB and the Central Regional Dental Testing Services.24,25 Both boards require the placement of two Class II restorations, one amalgam and one composite, in posterior molars on a dentoform as a simulated patient.24,25 Therefore, experiences with a “mock” board examination during the last semester is essential for preparing students for licensure. Using similar procedures as the testing agency is important including the same simulated-patient teeth and same criteria for evaluating the quality of the restorations. Some states, such as Minnesota, require significant experience with the number, classification, and types of restorations to grant restorative functions certification.26
The participants’ experiences of feeling well prepared from their education seems to correlate with the motivating factors of having positive restorative experiences and wanting to keep their restorative skills current after graduation. Participants’ motivation also stemmed from restorative practice opportunities, including the legal scope of practice at the state level and the availability of jobs at a local level. The lack of restorative job opportunities was possibly influenced by the dentists’ negative attitudes.
Dentists’ negative attitudes was one of the challenges experienced by participants. According to Reinders et al,16 possible explanations for the perceived negative attitudes are fear, lack of experience with restorative dental hygienists, loss of control, and lack of confidence in the skills and competence of dental hygienists. Previous research indicated that dentists prefer to perform most restorative functions themselves, therefore, they do not delegate these procedures to auxiliaries.27,28 Furthermore, studies reported that the age and education of dentists influenced their decision to delegate restorative procedures to other team members; younger dentists who had previous training and experience in employing an auxiliary were more open to delegation.27,29,30 In an international study by Jerkovic-Cosic,31 factors influencing dentists’ unwillingness to delegate caries treatment to hygienists included time limitations for supervision and feedback, the dental hygienists’ caries treatment time was slow, and the ultimate responsibility for the clinical outcome was the dentist’s and not all dentists wanted to assume that risk. More education of dentists and the entire team might enhance the delegation of restorative care. Additionally, dentists sharing their positive experiences with this practice model with their colleagues might influence others.27 Furthermore, dentists’ attitudes were more positive when they participated in restorative procedure training during their education.29 The final suggestion is to share the findings of the current study with the dental community related to the dental hygienists’ personal benefits of career fulfillment and the benefits to patients and practice. Sharing these findings has the potential to educate dentists, thus increasing their awareness of the multiple benefits of this practice model and overcoming their misconceptions of delegating restorative care. Changing the dental practitioners’ attitudes has the potential to impact the workforce shortage problem, which in turn influences access to care.
Another challenge expressed by the respondents was dental hygienists not valuing their restorative abilities, which was a surprise finding. Possible explanations could be the lack of available jobs and minimal encouragement to use new skills in the dental field. In a study conducted by Virtanen et al.,32 lack of confidence was reported as a major barrier for dental hygienists performing expanded treatments. In another study, self-efficacy due to lack of competence, lack of positive feedback and assurance from the dentist, and personal uncertainty in caries disease treatment, were identified as reasons dental hygienists avoided extended tasks.31 Further research is necessary to determine the root causes of devaluing restorative skills and to discover ways to improve dental hygienists’ perspectives.
The personal benefits related to career fulfillment reported by the participants could lead to greater career satisfaction levels, reduce career-burnout, and improve career longevity. The findings in this study align with a dental auxiliary survey conducted in Minnesota; dental auxiliaries who provided restorative care indicated greater professional satisfaction.27 Participants in the present study experienced stronger dental team relationships and dynamics, including feelings of being valued and respected. These relationships and feelings might also perpetuate career fulfillment. These findings are similar to the results of a systematic review which related extended scope of practice use by dental hygienists to higher job gratification and enhanced professional identity.16
Another influencing factor related to career fulfillment might be the participants’ experiences of less emotional and physical demands when providing restorative care, compared to preventive care. Dental hygienists often contemplate decreasing the number of weekly clinical hours, changing employment settings, or exploring new career paths due to the physical demands of traditional care.33 A literature review found that as high as 96% of dental hygienists reported musculoskeletal pain and injuries. The main contributing factors were lack of procedure variety, cumulative work hours and psychosocial stressors. Participants in the current study achieved variety while performing restorative treatment and decreased emotional strain, thereby increasing career satisfaction and longevity.
An interesting finding was the integrated approach to providing preventive and restorative care during the same appointment. This approach supports the benefits to patients cited by the participants as improving access, efficiency, and convenience of care by offering both services at the same time and not requiring an additional appointment for restorative treatment. One challenge experienced was not having a dental assistant to perform four-handed dentistry. The collaborative approach to restorative care supports the benefits to patients as well because more procedures can be completed when the dentist and dental hygienist use a tag team approach with the dental assistant remaining with the patient.
Limitations and Future Research
One limitation of this study pertains to interviewing dental hygienists from three states from the Western US. Dental hygiene restorative practice might be different in these states compared to other states. The small sample size might seem to be a limitation; although, the data analysis from eight participants reached saturation and yielded rich, detailed data and insight into dental hygienists’ restorative experiences. Qualitative findings are not intended to be generalizable; however, the goal is to generate valuable information to help understand others’ experiences.20
Future research might focus on the experiences of restorative dental hygienists and dental therapists practicing around the globe. Further investigation of restorative curricula, mock board preparation for licensing examinations, and requirements for licensure and re-licensure are also warranted. Exploring patients’ perspectives of receiving restorative treatment from dental hygienists and dentists’ perspectives of employing restorative hygienists would also add to the literature.
CONCLUSION
The results of this study identified factors that can either motivate or deter hygienists in practicing restorative patient care. Implementing restorative education into both dental hygiene and dental programs may address the challenges revealed. Utilizing the restorative practice model discussed could help to address the dental professional shortage and dental inequities and lead to career endurance and enjoyment. These findings can be beneficial to dental educators and professionals who want to practice at the height of their scope and who seek to provide comprehensive and efficient patient care.
Footnotes
NDHRA priority area, Professional development: Regulation (scope of practice).
DISCLOSURES
The authors have no conflicts of interest to disclose. No outside funding was received for this research.
- Received May 4, 2023.
- Accepted July 24, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
