Attitudes of New Zealand Dentists, Dental Specialists and Dental

Attitudes of New Zealand IN BRIEF • Provides an understanding of why New Zealand dentists/specialists may or may RESEARCH dentists, dental specialists not wish to employ Oral Health (OH) (dental hygiene/dental therapy) graduates and how this compares to the UK. • Increases awareness of the scopes of and dental students towards practice for New Zealand OH graduates and their legal requirements to practise. • Informs dental workforce planning in employing dual-trained New Zealand. Oral Health graduates

S. Moffat1 and D. Coates2

Aims To determine the attitudes of New Zealand dentists and dental specialists towards employing dual-trained Oral Health (dental therapy/dental hygiene) graduates, their knowledge of the scopes of practice and practising requirements for Oral Health (OH) graduates, and the barriers to employment of these graduates. Materials and methods A postal questionnaire was sent to 600 dentists randomly selected from the Dental Council of New Zealand register, as well as all dental specialists on the register. All fifth-year dental students in 2008 were also surveyed.Results The response rates for the questionnaires were 66.8% for dentists, 64.5% for dental specialists (specialists) and 72.9% for dental students. Knowledge of the scopes of practice and practising requirements for OH graduates was limited in some areas. Fifty-nine percent of private dental practitioners (PDP dentists) and 53% of specialists would consider employing an OH graduate. The main reason given for not employing an OH graduate was insufficient physical space in the practice. Conclusion New Zealand dentists and dental specialists were receptive to employing OH graduates. Knowledge of the OH scopes of practice and practising requirements is likely to improve as more OH students graduate and start work. The OH graduates have the potential to make a valuable contribution to the dental team.

INTRODUCTION in separate courses. In 1999, dental ther- dental therapists in the New Zealand SDS. New Zealand has been educating den- apy education moved from a polytechnic New Zealand hygienists have usually tal therapists (formerly known as dental course to the University of Otago. Dental worked part-time and in more than one nurses) since 1921. Dental therapists were hygiene education followed, moving from practice. With dual-trained graduates also traditionally employed in the public sec- the Otago Polytechnic to the University of being able to work in dental therapy, this tor, primarily in the School Dental Service Otago in 2001. The University of Otago may reduce the availability of hygienists (SDS). Since the Health Practitioners initially offered separate two-year diploma for private practice. Competence Assurance Act (2003), den- courses for hygiene and therapy; however, tal therapists can now also legally work it then introduced a three-year degree AIMS in private practice. Dental hygiene prac- programme for each in 2002. In 2002, the This study aims to: (1) determine whether tice has a shorter history in New Zealand. Auckland University of Technology (AUT) New Zealand registered dentists and spe- Although the New Zealand Army had also initiated a three-year dental therapy cialists would employ a dual-trained OH trained dental hygienists since 1974, it was degree, and then established a three- graduate and how they would utilise not until 1994 that a dental hygiene course year dual-degree in Oral Health (OH) in this employee; (2) explore the barriers to was established to train dental hygienists 2006. The University of Otago introduced employing a dual-trained graduate; and outside the Army. In New Zealand, the its dual-degree OH programme in 2007. (3) investigate dentists’, specialists’ and majority of dental hygienists work with OH students now graduate with both the fifth-year (final year) dental students’ dentists in private practice.1,2 dental therapy and dental hygiene scopes knowledge of the dual-trained practi- Until 2006, New Zealand dental thera- of practice and register with the Dental tioner’s practice and the associated legal pists and dental hygienists were educated Council of New Zealand (DCNZ) as a dental requirements. therapist and/or a dental hygienist.1,2 Although OH graduates are now enter- MATERIALS AND METHODS 1*Head of Dental Therapy, 2Assistant Research Fellow, ing the dental workforce in New Zealand, Ethics approval was obtained from the Department of Oral Sciences, Faculty of Dentistry, Uni- versity of Otago, P.O. Box 647, Dunedin, New Zealand the implications for the workforce remain University of Otago ethics committee. The *Correspondence to: Ms Susan Moffat unclear. There has been concern that now sample comprised 600 dentists, randomly Email: [email protected]; Tel: +64 3 479 7047 dental therapists are able to work in pri- selected from the DCNZ register, and all 220 Online article number E16 vate practice, and with the OH graduates registered dental specialists. All 70 fifth-year Refereed Paper - accepted 21 July 2011 DOI: 10.1038/sj.bdj.2011.870 also being able to work as hygienists, this dental students at the University of Otago ©British Dental Journal 2011; 211: E16 may exacerbate an ongoing shortage of in 2008 were also surveyed. Questionnaires

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were mailed to the dentists and specialists; the students received theirs in their Dental Table 1 Characteristics of PDP dentists and specialists School mail boxes. Respondents were entered PDP dentists Specialists Characteristic into a random prize draw. Information was n (%) n (%) sought on the general characteristics of Sex respondents and their practices, their knowl- Female 101 (30.4) 32 (23.5) edge of the dental hygiene/dental therapy scopes of practice and legal requirements for Male 231 (69.6) 104 (76.5) practice, and whether they would employ a Age dual-trained OH graduate. Responses were Up to 40 yrs 126 (38.0) 29 (21.3) analysed using the Statistical Package for the Social Sciences (SPSS, version 17 41‑54 yrs 142 (42.8) 63 (46.3) Chicago Il, USA). Associations between cat- 55 yrs or above 64 (19.3) 44 (32.4) egorical variables were tested for statistical Practice type significance using the Chi-square test with the alpha level set at 0.05 and 0.01. Other 0 (0.0) 53 (39.0) Private practice 332 (100.0) 83 (61.0) RESULTS Number of dentists in practice The response rates were 66.8% for dentists, 64.5% for specialists and 72.9% for dental 1 69 (20.8) 36 (28.6) students. Of the 390 dentists, 58 identified 2‑3 186 (56.0) 54 (42.9) that they worked within one or more of the 4+ 77 (23.2) 36 (28.6) following: teaching institution (11); public health dentist within the SDS (5); hospi- Number of hygienists in practice tal dental department (29); Māori health 0 185 (55.7) 84 (65.1) provider (3); or other (15). Subsequent 1+ 147 (44.3) 45 (34.9) analyses for the dentists are restricted to the remaining 332 private dental practi- Number of therapists in practice tioners (PDP dentists). The characteristics 0 316 (95.2) 97 (75.2) of the PDP dentists and specialists are pre- 1+ 16 (4.8) 32 (24.8) sented in Table 1. Most PDP dentists and specialists were male, in the 41‑54 year TOTAL 332 (100.0) 136 (100.0) age group, and worked in practices of two For specialists, the number of dentists in practice has 10 missing values, while the number of hygienists and number of therapists in practice have 7 missing values each. to three dentists. They were more likely to work in practices that employed dental hygienists than dental therapists. The 70 majority of dental students were female 60 (66.7%) and aged 23 years or less (64.7%). If respondents answered 80% or more 50 80% or more questions of the questions correctly on the scopes of on scopes of practice practice in which dual-trained OH gradu- 40 correctly answered ates can register, they were considered to 5 or more statements on practising requirements

ercentage 30

have a good knowledge of these scopes P correctly answered of practice (Fig. 1). Only 44.2% of PDP 20 dentists answered 80% or more of these questions correctly, while 50.8% of spe- 10 cialists answered the questions correctly. Specialists were more likely to answer 0 correctly if their practice had an adoles- PDP Dentists Specialists All dentists 5th year surveyed dental students cent contract, employed dental hygienists, or if they were in a practice with four or Fig. 1 Knowledge of scopes of practice and the legal requirements to practise for registered Bachelor of Oral Health graduates more dentists (p <0.05). Dental students answered less well, with only 36.0% being able to answer 80% or more questions accident compensation, construct and fit Participants were also given statements correctly. Questions most often answered mouthguards, do pin-retained amalgam on the DCNZ registration requirements for incorrectly by all groups included whether restorations, remove sutures, or carry out practising as a dental therapist or dental OH graduates could register patients for a pulpectomy for a primary tooth (Fig. 2). hygienist in New Zealand. Identifying

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five out of eight statements as correct PDP dentists Specialists 5th year dental students indicated that respondents had a good 100 knowledge of these requirements (Fig. 1). 90 60.1% of all PDP dentists and specialists 80 surveyed (n = 526) were able to identify 70 five or more statements correctly. The 60 statements most likely to be identified as 50 correct were ‘registered dental hygienists 40 ercentage correct treat patients in a team situation with P 30 clinical guidance provided by a registered 20 dentist’ (81.3% correctly scored as true) 10 0 and ‘registered dental therapists practise s independently regardless of the age of the

ciduous) tooth* patient’ (78.5% correctly scored as false). Fissure sealantsTake impressions e Fluoride application Oral health education Suture/dressing removal The statement least likely to be answered Take and read radiographsRegister patients for ACC* Extract permanent teeth* Administer local anaesthesia Construct and t mouthgaurds Extract primary (deciduous) teeth correctly was ‘registered dental therapists Pin-retained amalgam restorations* Take intra and extra oral photograph Restoration of primary (deciduous teeth) Pulpotomy in primary (deciduous) tooth must work under the clinical guidance Pulpectomy in a primary (d Scaling, debribement and prophylaxis of teeth of a registered dentist for the treatment

Restoration of permanent teeth in children and adolescents of 0‑18 year olds’ (only 31.9% correctly Restore primary (deciduous) teeth with stainless steel crowns scored as false). The specialists were more likely to answer correctly if they were older Fig. 2 PDP dentists’ (n = 332), specialists’ (n = 136) and 5th year dental students’ (n = 51) knowledge of the dental therapy/dental hygiene scopes of practice. (Percentage of questions (p <0.05), if their practice had an adoles- answered correctly when missing responses removed.) Dental therapists/hygienists are not cent contract (p <0.01), if they worked registered to undertake the procedures marked with an asterisk with therapists (p <0.05) or if they worked in practices with a number of dentists 60 (p <0.01). 35.3% of dental students were 50 able to identify five or more statements as correct. 40 59.0% of PDP dentists would consider PDP dentists 30 employing a dual-trained OH graduate. Specialists ercentage P PDP dentists were more likely to consider 20 employing an OH graduate if they worked in a practice employing a dental hygienist 10

(72.6%) than if they had no hygienist in 0 the practice (48.1%; p <0.01). This was also true for the practices that already employed Lack of demand Patient attitude a dental therapist; all PDP dentists in these Insuf cient space Cost recovery concerns Special nature of Nopractise reason/would employ practices would consider employing an OH Concerns regarding clinical graduate, while only 56.9% of PDP dentists in practices without a dental therapist Fig. 3 Reasons PDP dentists (n = 330) and specialists (n = 130) gave for not wanting to employ an OH graduate. Respondents could choose more than one reason would consider employing one (p <0.01). 53.2% of specialists indicated that they would consider employing a dual-trained OH graduate. Specialists were more likely would employ a dual-trained OH graduate an OH graduate by approximately one to employ an OH graduate if they had an to work in both scopes. The majority of fifth of the respondents. PDP dentists adolescent contract (p <0.01) or were in a specialists would employ an OH graduate were also concerned about the lack of practice that already employed therapists to work as both a hygienist and therapist demand for a dual-trained OH graduate and hygienists (p <0.01). Specialist prac- (46.4%) with 42.0% indicating that they (28.2%). However, 22.4% had no con- tices with 4+ dentists were also more likely would employ the graduate as a hygienist cerns about employing an OH gradu- to employ an OH graduate than those with only, or therapist only (11.6%). ate. Specialists had less concerns about fewer dentists (p <0.01). The primary reason for PDP dentists employing an OH graduate; however, 35.5% of PDP dentists indicated that not employing an OH graduate was insuf- most would not employ an OH gradu- they would employ a dual-trained OH ficient space, with 40.0% indicating that ate due to the specialist nature of their graduate to work as a hygienist only, space was an issue (Fig. 3). Concerns about practice (57.7%). while only 5.5% suggested that they cost-recovery (23.3%), patient attitude The majority of PDP dentists, special- would employ this graduate to work as a (21.8%), and clinical skills (18.5%) were ists and dental students believed that OH dental therapist only. Fifty-nine percent also given as reasons for not employing graduates are most suited to working with

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children, adolescents, and adults (in that 100 order), with a remarkable level of consist- 90 ency between the groups (Fig. 4). 80 70 PDP dentists DISCUSSION 60 Specialists 5th year dental students This study set out to determine New 50 rcentage

Pe 40 Zealand dentists’, specialists’ and fifth-year 30 dental students’ knowledge of OH gradu- 20 ates’ scopes and conditions of practice, and 10 whether dentists and specialists would be 0 prepared to employ these graduates. Six Adults hundred registered dentists and all 220 reg- All age groups istered specialists, as well as all fifth-year Children 2-12 years Adults and children Adolescents 13-18 years with special needs dental students, were surveyed in 2008. Fewer than half of the combined group Fig. 4 The groups that PDP dentists, specialists and 5th year dental students think OH graduates are most suited to work with. Participants could choose more than one group. PDP of PDP dentists and specialists answered dentists (n = 327), specialists (n = 125), 5th year dental students (n = 51) 80% or more questions correctly in rela- tion to the OH graduates scope of practice. Overall, knowledge of the legal require- a good understanding of their scopes of dental therapist must have with a dentist, ments to practise was better; approximately practice and practising conditions (unpub- with dental hygienists having a similar 60% of PDP dentists and specialists were lished data). PDP dentists and specialists professional agreement. It is, therefore, able to identify five or more statements on were more likely to answer questions on essential that dentists have an understand- this topic as being correct. Dental students scopes of practice correctly if they already ing of the legal practising requirements performed less well in both categories. employed a hygienist. This suggests that for dental therapists and dental hygien- Fifty-nine percent of dentists and 53.2% working with an OH graduate would also ists, and that both parties understand their of specialists indicated that they would be improve their knowledge of the dental ther- responsibilities under these agreements willing to employ a dual-trained gradu- apy and dental hygiene scopes of practice. before signing them. ate. They were more likely to employ a Ross et al.3 found that practitioners OH graduates in New Zealand can graduate if they were already working were unsure about some of the practis- register in both the dental hygiene and with dental hygienists or dental therapists. ing requirements for a hygienist-therapist, dental therapy scopes of practice. This Barriers to PDP dentists employing an OH with over 60% identifying incorrectly further complicates the issue of dentists graduate included concerns about insuffi- that a hygienist-therapist was only able and specialists understanding their legal cient space, the demand for an OH gradu- to treat patients if a dentist was on the practising requirements. An OH graduate, ate, patient attitudes, and clinical skills. premises. New Zealand PDP dentists and practising as both a dental therapist and However, 22.4% had no concerns at all specialists were also unclear about some dental hygienist, can work independently about employing an OH graduate. Overall, of the practising requirements for New in the dental therapist scope of practice specialists had less concerns with employ- Zealand’s OH graduates. While most were (0‑18 years).4 In the hygiene scope of ing a graduate than the PDP dentists. able to identify that a hygienist works in practice, the graduate must work under New Zealand PDP dentists’ and special- a team situation under the clinical guid- the clinical guidance of a dentist, and the ists’ knowledge of the scopes of practice ance of a dentist, and were able to iden- dentist should be the first team member for the dual-trained OH graduate appears tify that dental therapists do not generally to examine, diagnose and treatment plan to be limited in some areas. Ross et al.3 had treat adults (only 15 New Zealand dental for the patient.5 OH graduates cannot treat similar findings in their survey of general therapists are registered in the ‘Scope for adults in the therapy scope, as they do not dental practitioners and concluded that the adult care in dental therapy practice’), they graduate with the ‘scope for adult care in practitioners in South-East Scotland had were mostly unaware that dental therapists dental therapy practice’;6 however, they only ‘…partial knowledge of the clinical ‘practise independently’ on patients up to are able to treat all ages in the hygiene remit of dually-qualified hygienist-thera- the age of 18 years. There may have been, scope of practice.7 Furthermore, some pists.’ While it is important that a dentist however, some confusion surrounding this clinical activities in the hygiene scope of understands the OH graduate’s scope of statement. While dental therapists practise practice, including the administration of practice when employing such a graduate, independently for this age-group, they do local anaesthetic and application of pre- not knowing in detail should not affect so within a consultative relationship with scription preventive agents, require direct practice, as the OH graduates themselves a dentist. This allows for referrals to and clinical supervision (dentist must be on the should be able to communicate their advice from a dentist, and also covers the premises), while the same activities can be scopes of practice to their employers. A legal requirements for access to prescrip- carried out independently of the dentist survey of all OH students in New Zealand tions and radiography in New Zealand. within the therapy scope of practice.4,5 in 2008 (response rate 100%) showed This working relationship is described in The DCNZ plans to consult further that by their final year, OH students had a written professional agreement that each on implementing a combined scope of

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practice for OH graduates. However, it may to undertake treatment in both the therapy with children, then adolescents and finally also be useful to more closely align the and hygiene scopes of practice. This sug- adults. This may partly be due to New existing dental therapy and dental hygiene gests that dental practitioners are inter- Zealand dental therapists having tradition- scopes of practice and supervisory require- ested in employing OH graduates and ally worked with primary-school-aged chil- ments, in order for dental practitioners to utilising all their skills. dren (0‑13 years) and dental hygiene being better understand the practising require- The main reason for PDP dentists not a relatively new profession there. ments for both groups, and for the new being able to employ an OH graduate While the New Zealand Health Strategy OH graduates. was insufficient space in their practices of 200011 suggested that dental therapists Only about a third of dental students had (40.0%). In New Zealand, the majority of could be used to treat low-income adults, a good knowledge of the scopes of practice PDP dentists work in practices of two to the current strategic vision for oral health and practising requirements for OH gradu- three dentists so there may be no surger- concentrates on reorienting the school and ates. A study of final-year dental students ies available for an OH graduate. Other adolescent dental services to a commu- in 10 UK dental schools found that those concerns included cost-recovery, patient nity team-based service.12 However, fewer students who had been given information attitude to the OH graduate, clinical skills than 50% of adults attend a dentist,13–15 about hygienist-therapists, or who had and lack of demand for an OH graduate. with cost often cited as a reason for not shared clinical treatment of patients with However, overall, 22.4% of PDP dentists attending,13 and there are significant eth- hygienist-therapists, were more likely to had no concerns about employing an OH nic and socio-economic inequalities in oral know more about the scopes of practice graduate. Ross et al.3 had similar find- health.16–19 If OH graduates were to gradu- for these professionals.8 Dental students ings for dentists in South-East Scotland ate with the adult scope of practice for and OH students at Otago may thus benefit employing hygienist-therapists. Those dental therapy, services in the reoriented from working more closely together. dentists who already employed hygien- community clinics could be extended Fifty-nine percent of PDP dentists and ists cited insufficient space as to why they accordingly, particularly to low-income 53.2% of specialists in New Zealand would could not employ a hygienist-therapist, young mothers and to low-income young consider employing a dual-trained OH while those who did not already employ adults. In private practice, OH graduates graduate. Ross et al.3 reported that 64% of a hygienist were more likely to be con- are already treating adults in the hygiene dentists surveyed in South-East Scotland cerned about clinical skills, knowledge or scope and could provide routine restora- indicated that they would consider employ- patient preference. Jones et al.9 also found tive care to patients, including those with ing a dental hygienist-therapist. These that insufficient space was a concern for low-incomes. Enabling OH graduates to practitioners were more likely to employ practitioners in Wales. Dentists there were treat adults in the therapy scope of practice one if they had a good knowledge of the also not sure of the cost-effectiveness of could make dental care more accessible to remit of a hygienist-therapist, already employing a hygienist-therapist or whether low-income groups. Furthermore, develop- employed a hygienist or therapist in prac- they would be accepted by their patients. ing more suitable oral health services is an tice or worked in a practice with more In recent years, the emphasis in dentistry important strategy for reducing inequali- dentists. New Zealand PDP dentists and has turned to team work. Routine dental ties in oral health.16 specialist were also more likely to employ care can be carried out by therapists and This study has indicated that New an OH graduate if they had already worked hygienists, leaving dentists to carry out the Zealand PDP dentists and specialists are with a dental hygienist and/or a dental more complex care increasingly required willing to employ dual-trained OH gradu- therapist. Jones et al.9 surveyed general by ageing populations. Welsh practitioners ates in their practices. This may affect the dental practitioners in Wales and reported generally acknowledged that dental care is recruitment of dental therapists to the SDS. that 43% would employ a hygienist-thera- best delivered by a team with the appro- While New Zealand workforce data showed pist. While this study did not indicate what priate skill mix,9 while those in South-East that, in 2008, only 6.2% of dental thera- would make practitioners more likely to Scotland commented on the advantages of pists worked in private practice,20 research consider employing a hygienist-therapist, the complementary role of the hygienist- in Victoria, Australia has shown that dental the authors reported that 54.2% of respond- therapist for relieving the problems caused therapists are increasingly opting for pri- ents already employed a hygienist and 9% by dentist shortages.3 A recent UK study also vate practice, with the number of dental employed a hygienist-therapist as part of concluded that a ‘considerable proportion therapists working in practice outside the their team. The majority of respondents of work’ in general dental practice could SDS doubling between 2003 and 2006.21 in this study also acknowledged that the be delegated to hygienists and therapists In conclusion, dentists and dental spe- use of a hygienist-therapist would likely and that, if ‘diagnostic powers’ were given cialists in New Zealand are interested in improve access to dentistry for patients and to UK dental therapists, even more work employing dual-trained OH graduates and reduce the workload of dentists. could be delegated.10 In New Zealand, den- most would expect them to work in both Fifty-nine percent of PDP dentists and tal therapists are educated to independently the dental therapy and dental hygiene 46.4% of specialists surveyed in New diagnose and plan treatment, but most are scopes of practice. While there are barriers Zealand would employ an OH graduate limited by their scope of practice to treat- to employing OH graduates, the concept to work as both a hygienist and therapist. ing 0‑18-year-olds.6 Furthermore, most of of team working in dentistry has become Jones et al.9 found that 82.5% of the Welsh this study’s respondents believed that OH increasingly relevant and the OH graduates dentists would require a hygienist-therapist graduates are most suited to working first have much to contribute to the dental team.

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