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Prioritization of professional issues by Idaho dental hygienists.

Introduction

In 1995, during the strategic planning process of the Idaho Dental Hygienists' Association, it was evident that the professional issues which concerned licensed Idaho dental hygienists were not clearly defined and, to that point, anecdotal information was guiding association activities. Thus, an open-ended survey was developed and sent to Idaho dental hygienists to assess their opinions on issues being considered by the Idaho State Board of Dentistry. This initial survey focused on association membership trends, professional issues, and expanding the scope of practice of dental hygienists and dental assistants in Idaho. (1) As the strategic planning process progressed from 1996 to 1998, it was determined that information regarding a broader range of demographics and professional issues was necessary to guide association activities and adequately plan for the future of the dental hygiene profession in Idaho. Therefore, in 1998 a second, more comprehensive survey was implemented statewide. The results are being utilized by the state association to direct its efforts on behalf of dental hygienists licensed to practice in Idaho. This article addresses the objectives and results of the "1998 Idaho Dental Hygienists' Demographics and Issues Survey."

In Idaho, dental hygienists have worked under general supervision since 1970. Local anesthesia and nitrous oxide analgesia are administered under indirect supervision, and permanent restorative procedures by dental hygienists and dental assistants are prohibited. Currently, there are two dental hygiene members with full voting privileges on the Idaho State Board of Dentistry, also comprised of five dentists and one consumer. Twelve credits of continuing education are required for license renewal each year. Idaho is a member of the Western Regional Examining Board, and licensure can be obtained by credentialing. Credentialing is an option if the applicant has completed a comparable clinical board exam and has maintained 1,000 hours of practice in the two years preceding application.

Currently, Idaho has two dental hygiene programs. One program awards an associate of applied science degree and has "Accreditation Eligible" status from the Commission on Dental Accreditation (CODA). The other program awards a Bachelor of Science degree and is accredited by CODA. At the time of the "1998 Idaho Dental Hygienists' Demographics and Issues Survey," only the program awarding the baccalaureate degree existed.

Dental assistants in Idaho have no mandatory educational or credentialing requirements; optional certificates can be earned for specific, expanded functions. The five procedures for which dental assistants may earn certifications include pit and fissure sealant application, placement and removal of temporary restorations, amalgam polishing, monitoring the client while nitrous oxide analgesia is being administered, and coronal polishing. To earn these expanded function certificates, dental assistants must complete appropriate training, testing, and certification, although no record is maintained with the state board of dentistry.

The "1998 Idaho Dental Hygienists' Demographics and Issues Survey" was designed to assess dental hygienists' opinions about professional issues based on the scope of practice of dental hygienists and dental assistants as defined by Idaho law.

Review of the Literature

"This review of the literature related to professional issues of importance to the dental hygiene profession is divided into three major constructs: 1) entry-level dental hygiene education, 2) self-regulation, and 3) supervision requirements.

Entry-Level Dental Hygiene Education

One of the main issues facing the profession of dental hygiene today is maintaining adequate educational standards for entry into the profession. In 1998, there were 238 accredited or accreditation eligible dental hygiene programs in the United States, with 27 of those programs offering the baccalaureate degree as the professional entry-level degree. Fifty-five institutions offered baccalaureate degree completion programs, and 12 offered a master's degree in dental hygiene or a related area (2) The remaining programs awarded associate degrees (N=187) or certificates (N=9) offered through junior, community, and technical colleges and universities. By August 1999, the number of programs increased by 23, with 20 programs receiving accreditation eligible status and 3 receiving accreditation. (3) Four additional programs submitted applications for accreditation eligible status.

In 1986, participants at an ADHA-sponsored workshop on the future of dental hygiene education and practice recommended that the baccalaureate degree be the minimum entry-level degree for dental hygiene practice. (4) In fact, ADHA established policy stating the following:
   The American Dental Hygienists' Association supports all aspects of
   formal dental hygiene education which includes certificate,
   associate, baccalaureate, and graduate degree programs; however, the
   American Dental Hygienists' Association declares its intent to
   establish the baccalaureate degree as the minimum entry level for
   dental hygiene practice in the future and to develop the theoretical
   base for dental hygiene practice (5)


In contrast to the direction established by the dental hygiene profession, in 1994, an American Dental Association (ADA) advisory committee published The Dental Team in 2020: Future Roles and Responsibilities of Allied Health Personnel Draft Report. It became apparent that organized dentistry planned to reorganize dental hygiene by the year 2020. (6) This reorganized structure proposed a multi-tiered level of dental assistants and dental hygienists. In 1995, ADHA stated that it "does not support the findings of the 2020 study for good reasons." (7) ADHA had multiple concerns with these findings. First, the career ladder described in the 2020 report could circumvent formal dental hygiene education via regionally accredited colleges and universities. Second, the list of functions associated with the five categories of allied health personnel defined in this report would compromise the quality of preventive oral health care currently provided by licensed dental hygienists. Third, the 2020 report was produced without participation by dental hygienists. (7)

In addition to this report, for four consecutive years (1995-1999) the ADA adopted resolutions and actions that did not support quality entry-level dental hygiene education. (8) In 1996, ADA policy opposed the administration of local anesthesia by dental hygienists and general supervision for dental hygiene. At the same time, ADA policy urged constituent associations to develop new responsibilities for dental assistants such as coronal scaling and polishing under direct supervision. (8)

In 1997, an ADA report issued by the ADA Board of Trustees described the Alabama preceptor-ship program as "an excellent model for a state desiring to increase its ratio of dental hygienists to dentists through nonaccredited, state dental board administered programs." (8)

Preceptorship, as the term is used in dentistry, means having a practicing dentist train a worker on the job to perform dental hygiene duties. (9) Preceptorship does not require that this worker be educated via a two- or four-year accredited education program nor be licensed via national and regional examination.

Also in 1997, ADA urged CODA to establish standards to recognize nontraditional educational programs that use in-office training and requested that state dental boards review these types of programs for acceptance. (10) ADA policy 80 was amended in 1998 to clarify that although a two-year accredited dental hygiene program is typical, other programs, including those with in-office training, are acceptable. (10)

In response to the ADA actions, ADHA issued the following statement in 1998:
   The American Dental Hygienists' Association strongly supports
   quality dental hygiene programs that are fully accredited by the
   ADA Commission on Dental Accreditation. Actions taken by the ADA
   House of Delegates in October 1998 to create alternative pathway
   education models threaten the very foundations of dental and dental
   hygiene education and are in conflict with the mission and goals of
   the Commission on Dental Accreditation, a semiautonomous agency of
   the ADA. The maldistribution of dentists and dental hygienists in
   portions of the USA should not result in lowering the dental or
   dental hygiene education standards. Lowering of educational
   standards will jeopardize the health and safety of the public who
   seek oral health care. (10)


In 1999, four significant actions occurred. First, the Georgia dental practice act was changed to permit dental hygiene schools to offer clinical training at "affiliate sites" with nonfaculty dentists to supervise. Second, the Joint Commission on National Dental Examinations (JCNDE) amended its policy to say that graduates of nonaccredited dental hygiene schools could take the written national board exam if the board of dentistry in their state approved. In March 2000, this policy was rescinded for 2001 after a nationwide letter writing campaign took place.

The professions of dental hygiene and dentistry seem to be moving in two different directions, with dentistry setting the standards for minimal entry-level education and practice for dental hygienists because of its educational and regulatory authority over dental hygiene. (11) This regulatory control makes the profession of dental hygiene's ability to successfully adapt to change in the health care system difficult. (11)

As dental hygienists become aware of the aggressive movement by organized dentistry nationwide to decrease educational standards, concern is arising about maintaining reasonable entry-level education requirements. Many two-year (associate/certificate) dental hygiene programs have lengthened the time required to academically prepare a student, even though the minimum length of a dental hygiene program required by accreditation standards has not increased. (12,13) In fact, many associate/certificate dental hygiene programs have expanded their curriculums to longer than two years in order to prepare students for the economic, social, and political issues facing the dental hygiene profession today. (12-15) Granting of appropriate degrees for length of study and credits earned would seem to be more just for students pursuing a career in dental hygiene. (15) However, during the period 1983-1992, nine dental hygiene programs based in four-year institutions closed. (16) In 1991 alone, five baccalaureate programs faced threats of a significant change in administrative structure, relocation, or closure. (16)

This push to decrease entry-level dental hygiene education by organized dentistry is also ironic in light of recent dental education support for a mandatory postgraduate year that would increase dentists' educational preparation to five years. (17-23) Rationale for the postgraduate year includes increased interest in postdoctoral general dentistry programs (PGD), emphasis on competency-based education to stress outcomes versus the process, and a change in population demographics. In addition, other rationale includes trends in health care delivery and financing, and the need to increase the number of primary care providers capable of caring for socially diverse and medically complex populations. (18) Plans for dental hygiene education in the new millennium should reasonably focus on the same aforementioned issues dentistry is addressing with the proposed postgraduate year.

Self-Regulation

Self-regulation for the dental hygiene profession implies that the persons making the decisions regarding educational and licensure requirements and disciplinary actions are dental hygienists rather than dentists. (24-26) Currently, Arizona, California, Delaware, Florida, Maryland, Texas, Washington, New Mexico, and Iowa have forms of self-regulation. Results from key research studies indicate that dental hygienists support the professional goals of self-regulation and more independence as licensed professionals. (1,26,-29) In general, all the health professions are motivated internally to set standards, regulate themselves, and maintain autonomy in an increasingly competitive health care environment. (30) Today, dental hygiene remains unique in that it is the only health occupation in which both practice and education are still regulated by the primary employer group. (11,31) Brutvan suggests that dental hygiene educators prepare future practitioners to value and actively support dental hygiene self-regulation in education and practice. (11)

State dental hygiene associations have surveyed dental hygienists to assess their perceptions of self-regulation. Gleber and Gluch-Scranton determined the level of support for dental hygiene practice and legislative issues among licensed dental hygienists in Pennsylvania. (27) From the 56.56% (N-1023) response rate, 86% of responding dental hygienists supported self-regulation. Interestingly, dental hygienists holding a baccalaureate degree were more likely to belong to ADHA and support having a dental hygiene licensing board. In a similar study, Calley found that Idaho dental hygienists placed high importance on autonomy, self-regulation, and responsibility within the dental hygiene profession. (1) Although Idaho and Pennsylvania are in different geographic regions, both studies demonstrate that the importance of self-regulation is recognized. Also, these studies confirm the importance of surveying licensed dental hygienists to assess professional opinions for strategic planning activities.

The ability to control quality of care has been cited as a primary reason for dental hygienists pursuing self-regulation. (26) Beatty and Boyer surveyed Iowa dental hygienists who were members and nonmembers of ADHA to determine their perceptions about education, practice, and licensure issues related to self-regulation. (26) They determined that half of the Iowa dental hygienists preferred that dental hygienists control licensure by a separate dental hygiene licensure board. Subsequently, in 1998 nearly 90% of Iowa dental hygienists signed a petition supporting self-regulation after the IDHA spent time educating dental hygienists about the benefits of self-regulation. If fact, this information proved valuable when presented to the state legislature. (32)

It is evident that many dental hygienists desire and support self-regulation. As early as the 1960s, it was recognized that dental hygienists should assume the responsibility of regulating their profession. (29) However, the dental hygiene profession still falls under the control of organized dentistry via regulation and supervision restrictions.

Supervision Requirements

Individual state requirements for practice may include direct, indirect, and general supervision. Each state might have these levels of supervision defined in their individual rules and regulations. In Idaho, direct supervision requires that a dentist diagnose the condition to be treated; authorize the procedure to be performed; remain in the dental office while the procedure is performed and before the patient dismissal; and approve the work performed by the dental hygienist or dental assistant. (33) Indirect supervision in Idaho stipulates that the dental hygienist can practice only when the dentist is present in the dental office and the dentist has authorized a procedure. (33) However, in many states, dental hygienists are allowed to provide oral health education to school children, community groups, and/or oral screenings in long-term care facilities without this indirect supervision requirement.

Over the years, the legal requirements for dentist supervision of dental hygienists have become an issue. Dental hygienists increasingly favor the reduction or elimination of supervision requirements while dentists continue to support these requirements. (12,26,28,34-36) Supporters of less restrictive supervision requirements believe that they would increase access to oral health care, especially for underserved or special population groups; increase dentists' and dental hygienists' income; and continue safe delivery of dental hygiene care. (12,26,35,37,39)

Opponents to changes in supervision requirements believe that lessening supervision could potentially put the public at great risk for harm, "constitute a breech of professional ethics," (34,37) and affect the CODA's ability to accredit dental hygiene programs. (37) In an eight-month pilot study to gather data in the offices of six independently practicing Colorado dental hygienists, documentation of patient visits, services provided, general office procedures, and patient record audits were assessed. Researchers found that the care provided did not pose any risk to the health and safety of clients. (37)

The legal requirement for dentist supervision of dental hygienists has changed since dental hygiene was first conceptualized. General supervision requirements, in some form, have been adopted by the majority of states. General supervision requires that a dentist must authorize the dental hygienist to perform procedures but need not be present in the treatment facility during the performance of those procedures. (24) Settings where dental hygienists can provide services under general supervision may include extended care facilities (e.g., nursing homes), schools, hospitals, public health facilities, or prisons. Some states allow general supervision in all settings but limit the specific procedures that can be performed. These excluded procedures usually include the administration of local anesthetic or nitrous oxide analgesia.

A 1985 national study of ADHA member and nonmember dental hygienists regarding trends in the dental hygiene profession also addressed supervision requirements. (12) Two-thirds of the respondents were currently working under indirect supervision and the other one-third were working where general supervision was permitted. When asked which type of supervision was preferred, 54% selected general supervision. The respondents in favor of general supervision were more likely to be more than 24 years of age, have a baccalaureate degree, and work more than 30 hours per week. These dental hygienists believed that they were qualified to assume more responsibility and felt that general supervision would increase access to care.

In 1992, a sample of Iowa dental hygienists was surveyed regarding their opinions about the dental hygiene profession and changes that were occurring or might occur in the profession. (26) At the time of the survey, dental hygiene practice in Iowa was allowed under general supervision. When questioned regarding the outcomes of dental hygiene general supervision, 85% of respondents indicated that it increased access to dental hygiene care. Sixty percent of respondents indicated that general supervision increased dental hygienists' income, while 80% indicated that dentists' income was increased. Respondents did not believe that general supervision increased the patient's risk for adverse oral or general health outcomes.

Differences in opinions regarding supervision requirements according to membership status in the professional association have been studied. The Iowa study found that Iowa's ADHA members did not believe that general supervision reduced dental hygienists' involvement in office activities, whereas 16% of nonmembers felt that involvement in office activities was reduced. (26) In Virginia, where 88% of dental hygienists studied strongly favored general supervision, professional association members were slightly more likely to favor general supervision (93%) than nonmembers (87%). (28)

Opinions regarding level of supervision for specific dental hygiene procedures were also solicited. The majority of respondents wanted to perform gingival curettage, placement of sutures, and placement of temporary restorations under general supervision, while less than half of respondents wanted to perform local anesthesia and/or administer nitrous oxide analgesia under general supervision. (28)

The literature reviewed indicates that dental hygienists have concerns regarding the education, regulation, and supervision of their profession. Therefore, the purpose of this study was to determine the range of factors that concern Idaho dental hygienists. Also, two research questions were asked: 1) Does attaining an entry-level baccalaureate degree in dental hygiene affect the ranking of professional concerns by those licensed to practice in Idaho? 2) Does being a member of ADHA affect the ranking of professional concerns by those licensed to practice in Idaho? This study's results contribute information to the existing body of knowledge by identifying professional issues and practice concerns that dental hygienists might consider during state strategic planning sessions and discussions with state regulatory agencies.

Methods and Materials

The measuring instrument used in this study, the "1998 Idaho Dental Hygienists' Demographics and Issues Survey," was developed by the authors using results of an open-ended pilot survey administered to all attendees (N=175) during the Idaho Dental Hygienists' Annual Session in 1997. Responses from this pilot survey (N=92) helped guide the construction of the questions included in the 1998 survey. The instrument was reviewed by experienced dental hygiene practitioners and educators to establish clarity and content validity. It was pilot tested by a group of practicing dental hygienists (n=15), revised, and submitted to the institutional human subjects committee for approval.

The coded survey contained two sections. Section I was composed of 11 questions that concerned demographic and employment characteristics. Section II included definitions of general supervision, self-regulation, independent practice and unsupervised practice, 14 professional issues, and an additional open-ended response for "other" concerns. Other questions in Section II sought to determine factors respondents felt facilitated and limited their ability to provide comprehensive care, and identify procedures outside the legal parameters of practice that respondents or dental assistants were asked or expected to perform in practice. When assessing professional issues, respondents were asked to rank their five most important concerns about dental hygiene practice in Idaho. This article focuses on the professional issue questions.

The sample for this study included all dental hygienists holding active Idaho licenses (N=652) as listed in the Idaho State Board of Dentistry records. The survey and cover letter were mailed to each of these individuals, and three weeks were allowed for a response. A second mailing was sent to all nonrespondents.

With the SPSS 7.5 package for Windows, frequency distributions were used to determine mean values and variances for respondents' demographic characteristics and professional issues. (40) Correlations between selected pairs of variables were investigated using chi-square tests of association. All statistical tests were analyzed using a 0.05 level of significance.

Results

Out of 652 questionnaires mailed, 477 surveys were returned, resulting in a 73.9% response rate; however, 46 surveys were excluded because 28 respondents did not live in Idaho and 18 surveys were returned blank. Therefore, 431 (66%) surveys were used and analyzed.

Demographic and Employment Characteristics

Although the predominant subsets of respondents were between the ages of 42 and 47 (21.3%; n=92) and had 0 to 4 years of experience (22.9%; n=98), 81% (n=350) were between the ages of 24 and 47. Meanwhile, 70.6% (n=302) had 0 to 19 years experience. The majority of respondents received a bachelor's degree as their entry-level dental hygiene degree (72.6%; n=308), obtained Idaho licensure by examination (89.7%; n=382), and were not ADHA members (62.8%; n=265). The largest group of respondents were from the southwestern or urban portion of the state (39.3%; n=168), which also corresponds to the distribution of dental hygienists in that region of the state. The most frequently reported employment characteristics of responding dental hygienists showed that respondents worked in one practice setting (71.5%; n=304) and were employed more than 24 hours per week (61.3%; n=263). (See Figure 1.)

Professional Issues

The section of the survey related to professional issues asked respondents to rank in order of priority the top five concerns about dental hygiene practice in Idaho. Table I lists frequencies and percentage response for the 14 professional issues that were possible choices on the questionnaire. Three of the listed professional issues were identified among the top five concerns by at least half of the responding dental hygienists. Respondents identified the "national trend to reduce entry-level education for dental hygienists" (64.9%; n=266) as the number one concern. "Dental assistants illegally performing dental hygiene services" (61.1%; n=250) was the concern that was the second most frequently cited. Next, "legalizing self-regulation" was identified as the third most important concern by 49.8% of respondents (n=204). The remaining two concerns from the top five concerns, "legalizing diagnosis of periodontal disease by dental hygienists" (42.4%; n=174), and "legalizing local anesthesia administration with, general supervision by dental hygienists" (37.3%; n=153), were not ranked as high as the three most frequently chosen issues. The remaining practice concerns listed were not ranked in the top five by 20-34% of the respondents.

Two null hypotheses were tested using the Mann Whitney U test at the 0.05 level of significance. The first hypothesis was that there is no statistically significant difference in how professional issues were ranked by respondents entering the profession with a baccalaureate degree or without a baccalaureate degree. This null hypothesis was accepted for 12 professional issues and rejected in relation to 2 of the 14 professional concerns listed (see Table II). The issue of dental assistants illegally performing dental hygiene services was identified as a top concern more frequently by respondents entering the profession with a baccalaureate degree than respondents without a baccalaureate degree (p=.006). Respondents without a baccalaureate entry-level degree identified self-regulation as more important than those who entered the profession with a baccalaureate degree (p=.019).

The second null hypothesis was that there is no statistically significant difference in how professional issues were ranked by respondents who were or were not ADHA members. This null hypothesis was accepted for 10 professional issues and rejected in relation to 4 of the 14 professional concerns listed (see Table II). There was a statistically significant difference in how members and nonmembers viewed legalizing local anesthesia administration for dental hygienists with general supervision. Members identified this issue as more important than nonmembers (p=.009). There was also a statistically significant difference in the ranking of the issue of self-regulation, with members ranking it higher than nonmembers (p=.034). There were statistically significant differences in how the negative impact of managed health care and insurance reimbursement restrictions for dental hygiene services were ranked by members versus nonmembers; in fact, nonmembers ranked these issues of more importance than members (p=.048 and p=.018).

Discussion

The results obtained in this study determined that key issues associated with dental hygiene education, regulation, and supervision were of concern to Idaho dental hygienists. Demographic information revealed that the majority of Idaho dental hygienists held an entry-level baccalaureate degree and worked more than 24 hours per week in one office setting. These findings suggest that Idaho dental hygienists value a four-year academic education and providing client care full-time.

Professional Issues

Professional issues--such as the national trend of reducing dental hygiene education, dental assistants performing dental hygiene services beyond legal practice, and legalizing self-regulation of dental hygienists--are important issues for Idaho dental hygienists. Idaho dental hygienists value the importance of quality-oriented and comprehensive dental hygiene education, as evidenced by the fact that the national trend to reduce entry-level education was the primary concern. This finding may be due to the fact that the majority of Idaho dental hygienists hold baccalaureate entry-level degrees and because nationally, the number of baccalaureate dental hygiene programs closing is increasing and a plethora of associate degree programs is opening. Also, this finding may be due to a heightened awareness about ADA's resolutions and the revised, more general dental hygiene accreditation standards. IDHA has taken an active role in informing dental hygienists of these current issues through statewide newsletters and at state and local component meetings.

The issue of the entry-level degree is somewhat controversial. In 1990, Paarmann, Herzog, and Christie summarized the rational for the movement toward an entry-level baccalaureate degree around three themes: 1) keeping pace with changes in health care delivery, 2) awarding of appropriate academic degrees commensurate with students' educational background, and 3) enhancing the credibility of dental hygiene as a profession. (15) Clearly, as the profession enters a new millennium, these concerns are echoed by dental hygienists as they expand their roles in private practice, community settings, home-based oral health care, and research. Quality client-centered care is the outcome consumers deserve; thus a dental hygiene student, regardless of any educational setting, must be offered and must acquire an extensive scientific and medical background, education in liberal arts and social sciences, and interdisciplinary experiences with other health professionals. (15)

Idaho dental hygienists also are concerned about the extent that dental assistants are performing dental hygiene services outside the legal parameters of practice. As previously stated, placement of pit and fissure sealants, coronal polishing, amalgam polishing, temporary crown fabrication, and aiding in the administration of nitrous oxide analgesia are dental assistants' expanded function procedures requiring formalized training, testing, and certification. The Idaho State Board of Dentistry, however, has no registry of dental assistants certified to provide these services, nor do they require dentists to report the names of their dental assistant employees to the board of dentistry. It is evident that without a formalized means of monitoring and registering dental assistants, these services will continue to be provided by individuals who have not undergone a formalized training and testing process.

Idaho dental hygienists also value the importance of regulating their own profession. In the "1998 Idaho Dental Hygienists' Demographic and Issues Survey," self-regulation was clearly defined so respondents had an understanding of its meaning, and the results show that Idaho dental hygienists support self-regulation. Respondents who were members of ADHA supported self-regulation more frequently than nonmembers. This finding may indicate that members have greater access to related information through journals, newsletters, and other printed material. It also might mean that members network more frequently than nonmembers.

In regard to supervision requirements, the 1998 survey provided concise definitions for general supervision, unsupervised practice, and independent practice. The most frequently reported concern regarding supervision was related to legalizing local anesthesia administration under general supervision instead of indirect supervision, as is currently the law. Idaho dental hygienists may feel that because they received didactic and clinical education, were examined in local anesthesia procedures to be eligible for dental hygiene licensure, and were tested by a written and a clinical examination by the Western Regional Examination Board, they are qualified to administer local anesthetic agents under general supervision. Unsupervised and independent practice were not ranked as high as self-regulation; therefore, Idaho-licensed dental hygienists support self-regulation over unsupervised practice.

Conclusions

It is concluded that oral health care educators, dental hygienists, dentists, and the Idaho State Board of Dentistry should continue to work on professional issues in order to maintain the high standards of education that exist in Idaho, as reduced entry-level requirements were the primary concern of Idaho dental hygienists. Recently, dental hygiene educators and practitioners presented the results of this survey to the Idaho State Board of Dentistry, dental hygienists attending the IDHA annual session, and to readers of the statewide dental hygiene newsletter. Also, the IDHA has invested time and energy informing and clarifying the relationship between quality academic courses in the dental hygiene curriculum and the quality of services offered to the public. In addition, the association has been working with the state board of dentistry to further clarify the official rules and regulations regarding an acceptable level of accreditation required for licensure and the terminology in the Idaho code referring to dental hygiene programs being "approved" by the state board.

Several recommendations arise to address the professional concern about assistants performing dental hygiene services outside the legal parameters of practice. First, education about practice act parameters for the oral health team should be shared at meetings that dental assistants attend as well as in the practice setting. Second, the state board of dentistry, through newsletters and other communication, should continue to educate practitioners about the board's complaint process for consumers and other practitioners, as well as the types of complaints that are addressed. Finally, continued requests should be made to the Idaho State Board of Dentistry for the required registration of dental assistants who are certified to perform identified oral health procedures.

For the dental hygiene profession to progress in a more independent and self-regulated direction, states should begin working proactively to educate and inform all dental hygienists about current professional issues, regardless of ADHA membership status. Perhaps dental hygienists who are not currently ADHA members might see the value of professional association membership if they are educated about the issues facing the dental hygiene profession. Because a majority of Idaho dental hygienists who responded to this survey were not ADHA members, the IDHA will enhance its efforts and strategies to increase member recruitment, renewal, and retention. Replication of this survey every five years has been recommended to IDHA, and implementation of a similar survey is also suggested for other states in order to identify and assess professional issues.

Today dental hygienists require more knowledge and experience than ever before to care for the changing population of consumers with multiple social and cultural backgrounds, compromised health, complex periodontal diseases that may be linked to systemic diseases, and more complex caries risks. Also, today's dental hygiene curriculums increasingly include evidence-based decision making and case-based education as well as varied clinical experiences. All of the aforementioned concerns point to the need for entry-level dental hygiene education to be enhanced, or at the very least maintained, and for supervision and regulation of the profession to be reevaluated.
42-47 years of age         n=92
0-4 years of experience    n=98
Bachelor's degree          n=308
Licensure by exam          n=382
Southwest Idaho            n=168
One office setting         n=304
>24 hours worked           n=135
ADHA nonmember             n=265

Figure 1. Demographic and employment
characteristics of Idaho dental hygienists.

Table I. Dental hygiene practice concerns ranked
in the top five by Idaho licenced dental hygienists

Concern                                               n      N       %

National trend to reduce the entry level education
for dental hygienists                                266    410    64.9

Dental assistants performing dental hygiene
services beyond legal practice                       250    409    61.1

Legalizing self-regulation of dental hygienists      204    410    49.8

Legalizing diagnosis of periodontal disease by
dental hygienists                                    174    410    42.4

Legalizing local anesthesia administration by
dental hygienists with general supervision           153    410    37.3

Establishing practice standards to encourage
the provision of quality dental hygiene services     141    410    34.4

Dental assistants performing services without
formal training and/or instruction                   138    410    33.7

The negative impact of managed health care           131    410    32.0

Legalizing the placement/finishing of restorations
by dental hygienists                                  92    409    22.5

Legalizing nitrous oxide administration by dental
hygienists with general supervision                   91    410    22.2

Legalizing unsupervised practice for dental
hygienists                                            87    410    21.2

Noncertified dental assistants performing dental
assisting expanded functions without required
certification                                         85    410    20.7

Legalizing independent practice for dental
hygienists                                            84    410    20.5

Third party/insurance reimbursement restrictions
for dental hygiene services                           80    410    19.5

n = number of respondents ranking concern in top five category

N = number of respondents completing question

Table II. Statistical relationships between entry-level degree,
ADHA membership, and professional issues

Category                 Professional Issue                   P-value *

Bachelor's degree        Dental assistants performing            0.006
                         dental hygiene services which are
                         beyond the legal practice regulations
                         for dental assistants

Non-bachelor's degree    Legalizing self-regulation of dental    0.019
                         hygienists

ADHA member              Legalizing local anesthesia             0.009
                         administration by dental hygienists
                         with general supervision

                         Legalizing self-regulation              0.034
                         of dental hygienists

ADHA nonmember           The negative impact of managed          0.048
                         health care

                         Third party/insurance reimbursement
                         restrictions for dental hygiene         0.018
                         services

* alpha [less than or equal to] 0.05


Acknowledgments

This study was supported by funding from the Idaho Dental Hygienists' Association. The authors acknowledge Denise M. Bowen, RDH, MS, for her critical review of this manuscript and Teri Peterson, MS, Idaho State University Faculty Statistics Consultant, for data entry and assistance during statistical analysis.

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Kristin Hamman Calley, RDH, MS, is an associate professor, Kathleen O. Hodges, RDH, MS, is an associate professor, and Renee Johnson, RDH, MS, is an affiliate faculty member, all in the Department of Dental Hygiene, Kasiska College of Health Professions, Idaho State University;, Pocatello, Idaho.
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Author:Calley, Kristin Hamman; Hodges, Kathleen O.; Johnson, Renee
Publication:Journal of Dental Hygiene
Geographic Code:1U8ID
Date:Jun 22, 2001
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