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The Effectiveness and Efficiency of Hygienists in Carrying Out Orthodontic Auxiliary Procedures

Department of Dental Medicine and surgery, Orthodontic Unit, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, U.K.

	Abstract

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The aim of this study was to compare the ability and efficiency of dental hygienists, after preliminary training as orthodontic auxiliaries, with post-graduate orthodontists. The study was cross-sectional and prospective. The sample consisted of five second-year hygienists and five qualified orthodontists from Manchester University Dental Hospital. All subjects carried out a range of orthodontic exercises on phantom head typodonts. The ability and efficiency of each task was measured and comparison made between hygienist and orthodontic groups.

There was no statistically significant differences betwen hygienists and orthodontists in terms of their ability to carry out potential orthodontic auxiliary procedures. However, orthodontists were more efficient (P<0.05).

The ability of hygienists to carry out potential orthodontic auxiliary tasks after appropriate training is supported. Trained orthodontists are more efficient than newly trained hygienists in carrying out potential orthodontic auxiliary tasks.

Key words: Orthodontic Auxiliaries, Dental Hygienists, Ability, Efficiency

	Introduction

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Recently, some dental hospitals in the U.K. have piloted orthodontic auxiliary training courses (Turner and Pinson, 1993; Stephens, 1996). It may be argued that such steps are long overdue because the U.S.A. and many European countries already use orthodontic ancillary staff (Gottlieb et al.,1987; Moss, 1993). Furthermore, the use of such staff in this country was suggested over 10 years ago (Shaw, 1983).

In 1988, a proposal was made to introduce orthodontic auxiliaries into the U.K. (O'Brien and Shaw, 1988), with delegation of routine tasks such as separation, band and bond placement, ligation, and removal of archwires and impression taking. Shortly after, the Nuffield Inquiry was set up to examine whether and how far the role of auxiliaries could be expanded. The subsequent report (Nuffield Inquiry, 1993), recommended the development of training courses, a nationally approved certificate of training and development of orthodontic auxiliaries.

These recommendations were supported by the British Orthodontic Society (BOS) (1992). However, the BOS additionally stipulated that a suitably qualified orthodontist should supervise work. Furthermore, it would be important to determine the most efficient method of delivering high quality care and effective skill mix ratios for orthodontic practice. Further issues were highlighted by Stephens (1996) concerning details of training, and implications for patient access to care and NHS costing.

Perhaps the most pressing question at this stage is the competence and cost-effectiveness of potential orthodontic auxiliaries. Generally, dental ancillary staff have been shown to carry out simple restorative procedures and remove composite, following debond, to a similar level of competence to dentists (Hammons et al., 1971; Oliver and Griffiths, 1992). In addition, dental hygienists and therapists reliably diagnosed caries in an epidemiological survey when compared with dentists (Kwan et al., 1996). However, orthodontic tasks have not been assessed in this way.

It is important to consider not only the quality of the delegated procedure, but also the cost-effectiveness of ancillary personnel. In a simulated general practice situation at the University of Alabama, Overstreet et al. (1978) showed that addition of one unassisted auxiliary to a dental team increased patient load by 488 per cent and revenue by 50 per cent per day. However, the addition of a second auxiliary only increased the patient load by a further 97 per cent, and giving the auxiliary an assistant produced no productivity or revenue gain. It was thought that increasing the number of auxiliaries significantly would slow the dentist down and their work speed was the most important factor with respect to patient throughput.

	Aim

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The aims of this study were, first, to assess the ability of hygienists to carry out certain orthodontic procedures. Secondly, to make a preliminary investigation into the efficiency of newly trained orthodontic auxiliaries.

	Materials and Methods

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Sample
The hygienist sample consisted of all second year trainees at Manchester University Dental Hospital (n = 5). These hygienists had just completed a pilot course of proposed orthodontic auxiliary procedures. As a comparison group, five orthodontists were selected who had completed their 3-year specialist training. This comprised three registrars and two senior registrars.

Hygienist Training
A pilot orthodontic auxiliary training course was carried out at Manchester University Dental Hospital from October 1996 to April 1997. Five hygienists, entering their second year, completed a modular programme 1 day a week for two terms. This consisted of lectures and demonstrations followed by practical exercises on typodonts.

The Typodonts
The typodonts (Sankin Kogyo, Japan) consist of teeth (Rocky Mountain Morita Corporation) set up in wax in the form of a Class II division 1 malocclusion. The crowns and roots are made of metal, and the crown is covered with composite to simulate enamel. Pre-adjusted edgewise bands and brackets (022 slot) were bonded onto the arches by the two tutors (NM and MR). The typodonts were then attached to dental chairs via a customized metal attachment. Thus, the operators could work under conditions that resembled a patient position.

The typodonts were labelled 1–4. Each person successively moved from typodont 1–4 and completed the designated exercises for each (Table 1). When the person moved to the next typodont, the exercises that they had just completed were assessed. Following this, the typodont was returned to the original state for the next candidate.

Measure of Ability
Each exercise was assessed according to specific criteria. A mark was given for each criterion successfully carried out and a total score given for each task. The gold standard against which hygienist ability was measured was the average score of the five trained orthodontists who were assessed in the same way. The procedures assessed and criteria used are summarized in Table 1.

Measure of Efficiency
The time taken for each procedure in Table 1 was recorded to the nearest minute. The gold standard was the time taken for trained orthodontists to carry out the same procedures.

Intra-examiner Reliability
The reliability of the examiner (NM) was assessed for the procedures in Table 1 by recording scores on typodonts set up purely for that purpose. The same typodonts were re-assessed 3 weeks later.

Statistical Analysis

The median, mean, and standard deviation were calculated for each exercise score, and the time taken by hygienists and orthodontists. The orthodontist and hygienist groups were then compared using the Mann–Whitney test for non-parametric data at the P < 005 level. Weighted kappa was used to assess intra-examiner reliability. Lastly, since the sample size was small and restricted by the number of hygienists in their second year, a power calculation was carried out that is addressed in the discussion.

	Results

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No statistically significant differences were found in the ability of the hygienists and orthodontists to carry out potential orthodontic auxiliary procedures. The mean and median scores for each exercise and probability (P) values are shown in Table 2. When the efficiency, (time taken in minutes) of the two groups was compared, the orthodontists were between approximately two and four times more efficient than the hygienists. This varied according to the type of procedure (Table 3). The group difference was statistically significant for all procedures (P < 005) except (i) placement of two canine lacebacks, and (ii) placement of power chain on the four upper incisors.

	Discussion

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Ability of Potential Orthodontic Auxiliaries
This study has suggested that certain orthodontic tasks can be carried out by hygienists to a similar level to orthodontists. This is indirectly supported by previous findings of the competence of general dental auxiliaries compared with dentists (Hammons et al., 1971; Oliver and Griffiths, 1992; Kwan et al., 1996). However, comparison with previous publications is made with care for two reasons; (i) orthodontic tasks are different to general dental procedures, and (ii) this was an in vitro study and is not necessarily indicative of the patient situation.

Subjectively, procedures such as band placement appeared to be carried out much quicker on the typodonts compared with clinical experience of band placement and clinical expertise on patients needs investigation. Consideration should also be given to the relatively small sample size in this and previous studies. It may be that the study lacked power to detect a difference between the ability of the two operator groups. To investigate this, a power calculation was carried out. With a sample size of five per group, if the scores for orthodontists are mutually exclusive of the hygienist group, a statistically significant difference between groups could be detected with a power of 80 per cent (P < 005). For example, if the orthodontists all scored 7 or 8 out of 8 marks, and the hygienists scored 4 or 5 out of 8 marks, their marks would be mutually exclusive. In any event, the actual marks achieved by the hygienists were as good as the orthodontists and there is no reason to suggest that their ability would be below that of the orthodontists.

Efficiency of Potential Orthodontic Auxiliaries
Orthodontists were found to be approximately 2–4 times more efficient than a newly trained orthodontic auxiliary and this may have clinical implications. An interpretation of this could be that a ratio of orthodontist:auxiliary of 1:4 would be required to maintain productivity and income assuming the orthodontist is purely supervising. It might be predicted that if the orthodontist is treating patients and working with one auxiliary, then an increase in patient throughput of 25 per cent may be reached and this may well increase as the auxiliary speeds up. Arguably, an orthodontist and two auxiliaries should increase productivity by 50 per cent. However, the data of Overstreet et al. (1978) may guard against this assumption, since it seems that the speed of the orthodontist (which will be affected by the numbers needing supervision) may be the key factor in overall productivity.

Of course, the hygienists had only had a limited training, while the orthodontists had daily activity, and this is likely to reflect in differences in efficiency at this stage. With increased experience, hygienists may well work at similar rates to more experienced clinicians.

	Conclusions

Top Abstract Introduction Aim Materials and Methods Results Discussion Conclusions References

 

1. The ability of hygienists to carry out potential orthodontic auxiliary tasks on typodonts after appropriate training is supported.
   
2. Trained orthodontists are more efficient than newly trained hygienists in carrying out potential orthodontic auxiliary tasks. However, with increased patient contact this difference is likely to reduce.
   

	References

Top Abstract Introduction Aim Materials and Methods Results Discussion Conclusions References

 
British Orthodontic Societies (1992) The joint response of the British Orthodontic Societies to the Nuffield Inquiry into personnel auxiliary to dentistry,British Journal of Orthodontics , 19,334 –342. [Abstract]

Gottleib, E. L., Nelson, A. H. and Vogels, D. S. (1987) 1987 JCO Orthodontic Practice Study. Part 1 Trends, Journal of Clinical Orthodontics, 21,507 –515.

Hammons, P. E., Jamison, H. C. and Wilson, L. L. (1971) Quality of service provided by dental therapists in an experimental program at the University of Alabama, Journal of American Dental Association,82 , 1060–1065.[Medline]

Kwan, S. Y. L., Prendergast, M. J. and Williams, S. A. (1996) The diagnostic reliability of clinical dental auxiliaries in caries prevalence surveys— a pilot study, Community Dental Health,13 , 145–149.[Medline]

Moss, J. P. (1993) Orthodontics in Europe 1992, European Journal of Orthodontics,15 , 393–401.[Abstract/Free Full Text]

Nuffield Inquiry (1993) Education and Training of Personnel Auxiliary to Dentistry, The Nuffield Foundation.

O'Brien, K. D. and Shaw, W. C. (1988) Expanded function orthodontic auxiliaries: a proposal for their introduction in the U.K., British Journal of Orthodontics, 15,281 –286.

Oliver, R. G. and Griffiths, J. (1992) Different techniques of residual composite removal following debonding—time taken and surface enamel appearance, British Journal of Orthodontics,19 , 131–137.

Overstreet, G. A., Dilworth, J. B. and Legler, D. W. (1978) Productivity and economic implication of a simulated practice using expanded duty dental assistants, Community Dentistry and Oral Epidemiology,6 , 233–239.[Medline]

Shaw, W. C. (1983) Improving British Orthodontic Services, British Dental Journal, 155,131 –135. [Medline]

Stephens, C. D (1996) Guest Editorial: orthodontic auxiliaries, British Journal of Orthodontics,23 , 367–368.[Medline]

Turner, P.J. and Pinson, R.R.1993 Training hygienists for an auxiliary role in Orthodontics British Dental Journal175 ,209 –213[Medline]

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