Australian Dental Journal 2008; 53: 67–73

SCIENTIFIC ARTICLE
doi:10.1111/j.1834-7819.2007.00012.x

Attitudes of the Victorian oral health workforce to the

employment and scope of practice of dental hygienists
M Hopcraft,* C McNally,  C Ng,à L Pek,à TA Pham,à WL Phoon,à P Poursoltan,à W Yuà
*Cooperative Research Centre for Oral Health Sciences, School of Dental Science, The University of Melbourne, Victoria.
 Lecturer, Faculty of Dentistry, The University of Sydney, New South Wales.
àSchool of Dental Science, The University of Melbourne, Victoria.

ABSTRACT
Background: Increasing the number of dental hygienists and expanding their scope of practice are two policy directions that
are currently being explored to increase the supply of dental services in the context of projected oral health workforce
shortages in Australia. Understanding factors relating to the employment of hygienists and the attitudes of the oral health
workforce to dental hygiene practice are important in this policy debate.
Methods: A postal survey of a random sample of Victorian dentists, periodontists, orthodontists and hygienists was
undertaken in 2006. Dentists and specialists were grouped into those whose practice employed or did not employ a
hygienist. Data on the attitudes of dentists, specialists and hygienists towards various aspects of dental hygiene practice were
explored.
Results: A response rate of 65.3 per cent was achieved. Hygienists believed that their employment made dental care more
affordable (53.7 per cent) and improved access to dental care (88.1 per cent), while few dentists believed hygienists made
care more affordable. Most hygienists believed they were capable of diagnosing periodontal disease and dental caries and
formulating a treatment plan, but there was less support from employers and non-employers. Dentists were strongly
opposed to independent practice for dental hygienists, although there was qualified support from employers for increasing
the scope of practice for hygienists.
Conclusions: Dentists who worked with hygienists acknowledged their contribution to increasing practice profitability,
efficiency and accessibility of dental services to patients. Hygienists and employers supported increasing the scope of dental
hygiene practice, however the majority of non-employers opposed any expansion.
Key words: Dental hygienist, employment, workforce, attitudes.
(Accepted for publication 20 June 2007.)

the lack of education and potential compromises to

INTRODUCTION
public safety.
The clinical scope of practice for dental hygienists has Internationally, however, the practice of dental
expanded gradually since hygienists were first intro- hygiene has been shifting from traditional models of
duced into Australia in 1975, following international direct and indirect supervision by a dentist towards a
trends in practice and changes in the educational more collaborative approach to practice, where the
delivery of dental hygiene programs.1 In Victoria, dentist and hygienist work together to decide on the
dental hygienists are currently permitted to manage best approach to patient management and the services
periodontal disease within the context of an overall required.2 In Sweden, Denmark, Norway, Finland, the
treatment plan undertaken by a dentist, with permitted Netherlands and Colorado (USA), dental hygienists are
tasks including oral examination, intra- and extra-oral able to practise independently of dentists.3 Limited
radiographs, scaling and root planing and the admin- forms of independent practice or direct access in
istration of local analgesia. Broad-based expansion to restricted practice locations, for example in nursing
the scope of practice for allied dental personnel has homes and public health facilities, are permitted in
been vigorously opposed by professional dental associ- Germany, Latvia, Canada and a number of states in the
ations in Australia, with common concerns relating to USA. In most of the provinces in Canada, the profession
ª 2008 Australian Dental Association 67
M Hopcraft et al.

of dental hygiene is self-regulated, with hygienists and employ a dental hygienist. A random sample of 100
not dentists responsible for registration and licensing.3 dental hygienists, 100 dentists from practices that
Canadian dental hygienists have expressed a strong employed a hygienist and 100 dentists from practices
interest in expanding their scope of practice and their that did not employ a hygienist were selected for the
knowledge base to achieve greater professional inde- study. For orthodontists, all 36 who worked in a
pendence, however there is strong opposition to this practice that employed a hygienist and a random
from Canadian dentists who believe that hygienists are sample of 44 who worked in a practice that did not
not adequately trained to practice independently.4 employ a hygienist were selected, and all registered
A number of studies investigating dental hygienists periodontists were included in the study sample.
working in some form of independent practice have Dentists and specialists who worked in a practice that
found high levels of patient satisfaction with dental employed a hygienist were classified as employers, and
services provided and the ability of independent prac- those who worked in a practice without a hygienist
tices to attract new patients.5,6 There was no evidence were classified as non-employers.
of undue risk to public health and safety, and hygiene Three questionnaires were designed and mailed out
practices were superior to dental practices in a number to subjects, according to their category (dental hygien-
of comparable measures including infection control, ist, employer or non-employer) with a plain language
follow-ups to medical findings, updating the medical statement and self-addressed reply paid envelope to
history and documentation of periodontal and soft- return the questionnaire. A second mail-out to non-
tissue status. responders was undertaken approximately six weeks
Workforce planning research in Australia is predicting after the initial mail-out.9 All three questionnaires
future critical shortages in the supply of dental services.7 asked for basic socio-demographic data, dental practice
One policy direction to address workforce shortages is demographics, and attitudes towards the employment
targeting the number of dental hygienists currently being and scope of practice of hygienists.
trained. In the past five years, there has been an increase The data from the surveys was entered into a
both in the number of dental schools training dental spreadsheet, and transferred to SPSS v.14.0 for analysis.
hygienists, and the overall number of students being The University of Melbourne Human Research Ethics
trained. Expanding the clinical scope of practice for Committee approved the study, and participation was
hygienists to permit a wider range of duties has also been voluntary. The project was supported by the Dental
proposed as a mechanism to improve access to dental HygienistsÕ Association of Australia (Victorian Branch)
services, particularly in underserved populations such as Inc.
nursing homes.8 Aligning Australian regulations more
closely with the international practice of dental hygiene
RESULTS
are options that should be explored if improving access
to dental hygiene services is to be achieved. Understand- The overall response rate was 65.3 per cent, with a
ing the factors that are important in the employment of higher response rate for hygienists (77.0 per cent),
dental hygienists in Victoria, as well as the attitudes of followed by employers (general dentists –
various members of the dental team to aspects of dental 71.1 per cent, periodontists – 61.1 per cent, orthodon-
hygiene practice are important in the debate about the tists – 76.5 per cent) and non-employers (general
greater utilization of dental hygienists in Victoria. dentists – 45.7 per cent, periodontists – 75 per cent,
The aim of this study was to investigate the attitudes orthodontists – 59 per cent). Hygienists were predom-
of Victorian dentists, dental specialists and dental inantly female, while dentists and specialists were
hygienists to the employment of dental hygienists and predominantly male (Table 1). More than half of the
their scope of practice. dentists and specialists were more than 40 years old,
compared with only 31.9 per cent of the hygienists.
The employer group had considerable experience
METHOD
working with dental hygienists, with an average of
There were 179 dental hygienists, 2328 dentists, 37 7.7 years working with a hygienist.
periodontists and 118 orthodontists registered with the The main reasons for employing a dental hygienist
Dental Practice Board of Victoria on 30 June 2005. A were to provide more time for dentists to undertake
list of practice addresses was obtained from the Board. more complex work, for the quality of service provided
Practitioners with an interstate or overseas address and to reduce waiting times to see a dentist (Table 2).
were excluded from the sample. Dentists with a public Orthodontists were less likely to cite the quality of
dental clinic address were excluded from the sample. service provided and providing more time to provide
Dental hygienist practice addresses were cross-matched complex treatment compared with general practitio-
with dentists and specialists to derive two lists of ners, while general practitioners were more likely to cite
practitioners whose practice either employed or did not that patients prefer to be treated by a hygienist.
68 ª 2008 Australian Dental Association
 Attitudes to employment and scope of practice of hygienists

Table 1. Demographic profile of respondents

n Age group Gender

20–29 yrs (%) 30–39 yrs (%) 40–49 yrs (%) 50+ yrs (%) Male (%) Female (%)

Hygienists 67 28.8 39.4 25.8 6.1 4.5 95.5

Employers
Dentist 70 7.1 21.4 27.1 44.3 82.9 17.1
Periodontist 11 9.1 18.2 45.5 27.3 72.7 27.3
Orthodontist 26 0 11.5 53.8 34.6 100 0
Non-employers
Dentist 42 9.8 22 34.1 34.2 88.1 11.9
Periodontist 12 0 25 33.3 41.7 66.7 33.3
Orthodontist 23 0 17.4 34.8 47.8 82.6 17.4

Table 2. Reasons by employers for employing hygienists

Dentist (%) Periodontist (%) Orthodontist (%) Total (%)
(n = 63) (n = 10) (n = 23) (n = 96)

Patients prefer to be seen by a hygienist(a) 36.5 10.0 4.3 26.0

Quality of service provided(a) 85.7 70.0 56.5 77.1
More time for dentists to undertake complex treatment(a) 90.5 90.0 69.6 85.4
To reduce waiting time ⁄ manage patient workload 69.8 80.0 82.6 74.0
Improve practice profitability 41.3 30.0 52.2 42.7
Other reasons 15.9 20.0 17.4 16.7
(a)
Chi-squared p < 0.05.

There was a range of reasons why dentists and per cent of non-employers believing that hygienists
specialists did not employ a hygienist (Table 3). General made dental practice less profitable.
practitioners and orthodontists did not believe that the Subjects were asked to rate their attitudes regarding a
quality of service provided by a hygienist was a factor, number of statements relating to the practice of dental
but one-third of periodontists cited this as a reason for hygiene on a 5-point Likert scale (1-strongly disagree to
not employing a hygienist. Although 54.3 per cent of 5-strongly agree), and mean values are reported in
the non-employers reported that they would consider Table 5. There were statistically significant differences
employing a hygienist in the future, only 4.4 per cent in the mean responses for hygienists, employers and
reported that their practice was currently seeking to non-employers for all statements, with post hoc tests
employ one. (TukeyÕs HSD) showing that these differences were
Regarding the impact of employing a hygienist on a between hygienists and employers, and between hygien-
range of factors, more than half of the hygienists ists and non-employers, with no differences between
believed that their employment made dental care more employers and non-employers except for the statement
affordable, compared with only 34.9 per cent of ÔDental hygienists should be able to increase their scope
employers and 28.0 per cent of non-employers of practiceÕ. Most hygienists believed that they were
(Table 4). The majority of respondents thought the capable of diagnosing periodontal disease and dental
employment of hygienists improved access to dental caries and formulating a treatment plan, but employers
services, and made dental practices more efficient. and non-employers varied in their opinions.
Hygienists were virtually unanimous in agreeing that There was not unanimous support for independent
their employment made dental practices more profit- practice from hygienists, with only 58.3 per cent believ-
able, with 61.3 per cent of employers agreeing but 14.5 ing that they were capable of practising independently

Table 3. Reasons by non-employers for not employing hygienists

Dentist (%) Periodontist (%) Orthodontist (%) Total (%)
(n = 40) (n = 9) (n = 21) (n = 70)

No chairs 35.0 55.0 23.7 34.3

No available hygienists 17.5 11.1 0.0 11.4
No demand 20.0 22.2 23.8 21.4
Not cost effective 30.0 11.1 38.1 30.0
Patients prefer dentist 37.5 22.2 14.3 28.6
Quality of service provided(a) 5.0 33.3 0.0 7.1
(a)
Chi-squared p < 0.05.

ª 2008 Australian Dental Association 69

M Hopcraft et al.

Table 4. Impact of the employment of dental hygienists on various aspects of dental practice
Employers (%) Non-employers (%) Hygienists (%)
(n = 106) (n = 75) (n = 67)

Impact on affordability(a)
More affordable 34.9 28.0 53.7
No change 61.3 61.3 40.3
Less affordable 3.8 10.7 6.0
Impact on access(a)
Improved access 81.3 67.1 88.1
No change 18.7 31.6 11.9
Less access 0.0 1.3 0.0
Impact on profitability(a)
More profitable 61.3 42.1 95.5
No change 30.2 43.4 4.5
Less profitable 8.5 14.5 0.0
Impact on efficiency(a)
More efficient 86.9 57.3 98.5
No change 9.3 33.3 1.5
Less efficient 3.7 9.3 0.0
(a)
Chi-squared p < 0.05.

Table 5. Mean agreement of dentists and hygienists towards aspects of dental hygiene practice (1 – strongly disagree
to 5 – strongly agree)
Employer Non-employer Hygienist
(n = 107) (n = 76) (n = 67)

Dental hygienists should be able to increase the scope of practice(a) 3.3 2.5 4.2
Dental hygienists are capable of diagnosing periodontal disease(a) 3.8 3.6 4.6
Dental hygienists are capable of diagnosing caries(a) 3.3 3.3 4.1
Dental hygienists are capable of treatment planning(a) 2.7 2.5 4.2
Dental hygienists are capable of treating patients without prescription(a) 2.2 2.0 3.6
Dental hygienists are capable of practising independently(a) 2.2 1.9 3.6
Dental hygienists should be allowed to practice independently(a) 1.8 1.6 3.5
Dental hygienists require a degree of supervision(a) 3.7 3.9 2.7
Dental hygienists can make a meaningful contribution to dental team(a) 4.5 4.0 4.8
Training more dental hygienists can help with workforce shortage(a) 3.6 2.9 3.9
(a)
One-way ANOVA p < 0.001.

and 52.3 per cent believing that hygienists should be tooth whitening (13.4 per cent) and the placement of
allowed to practice independently. Few employers and temporary restorations (9.0 per cent). The vast majority
non-employers agreed that hygienists were capable of of all subjects thought that hygienists made a mean-
independent practice and even less were in favour of ingful contribution to the dental team, with 86.6 per
allowing independent practice for dental hygienists. cent of all respondents agreeing or strongly agreeing.
Hygienists thought they should be able to increase Employers and hygienists believed that training more
their scope of practice, with 82.0 per cent in favour, hygienists could help with the oral health workforce
while only 26.9 per cent of employers and 52.6 per cent shortage, but this was not supported by non-employers.
of non-employers disagreed ⁄ strongly disagreed. When
asked specifically about changes to the Dental Practice
DISCUSSION
Board of VictoriaÕs Code of Practice for dental hygien-
ists, 56.5 per cent of hygienists and 40.8 per cent of An acceptable overall response rate of 65.3 per cent
employers were in favour of changes to the clinical was obtained, particularly from hygienists and employ-
scope of practice for dental hygienists, while 82.9 per ers, hence the data presented in this study would closely
cent of non-employers were in favour of the status quo represent the opinions of these two groups. Fifty-six per
(Chi-squared, p < 0.001). Employers were interested in cent of employers have worked with hygienists for more
an expanded scope of practice that allowed hygienists than five years, and this substantial amount of experi-
to undertake activities such as in-surgery tooth whit- ence validates their opinions regarding the capabilities
ening (11.2 per cent) and further orthodontic proce- of hygienists. However, the response rate from the non-
dures (5.6 per cent), while hygienists wanted changes employer group was much lower, particularly the
that allowed them to work more independently, general practitioners. This might be due to a lack of
including the provision of care directly to residents of interest, time to complete the questionnaire or experi-
nursing homes (25.4 per cent), permitted in-surgery ence with dental hygienists. Therefore, data obtained
70 ª 2008 Australian Dental Association
 Attitudes to employment and scope of practice of hygienists

from this group may not be representative of the non- Since the majority of employers reported that
employer population. employing a hygienist increased the profitability and
Female dentists and specialists are underrepresented efficiency of their practice, support for an expansion of
in this study, with only 15.2 per cent of the sample the scope of practice for hygienists may be interpreted
being female, compared to 31.6 per cent of Victorian as an avenue to further increase their profitability and
dentists and specialists.10 The proportion of dental efficiency. This links in with a broader argument
practitioners aged above 45 years in this sample was regarding projected increases in the demand for dental
slightly higher than that of the Victoria population services and oral health workforce shortages in Austra-
(57.1 per cent and 49.0 per cent, respectively). The lia, and the expansion of the role of allied dental
majority of these older respondents had graduated personnel as one mechanism to manage this disparity in
before dental hygienists commenced training in Victoria supply and demand. Spencer et al.7 argue that increas-
in 1996. Consequently, they may have limited knowl- ing dental productivity as a means of addressing
edge of, and exposure to, dental hygienists, resulting in increasing demand can be achieved by the reconfigura-
a potential bias against hygienists. tion of the traditional dental team through the substi-
Employers and hygienists acknowledged the positive tution of services normally provided by a dentist being
impact of employing a dental hygienist, with strong provided by allied dental personnel such as a dental
beliefs that a hygienist improved access to dental care hygienist.7 They also argue that the utilization of a
and increased practice profitability and efficiency. hygienist within a dental practice can create a comple-
However, fewer than half of the non-employers mentary effect, with more complex procedures able to
believed that a hygienist would have a positive impact be undertaken by the dentist, although this may result
on practice profitability, and nearly two-thirds of in the creation of additional demand for services and
employers and non-employers believed that there may not necessarily reduce projected workforce short-
would be no changes to the affordability of services. ages. This increase in demand may be created by the
The issue of affordability of dental services and practice practice because the opportunity exists to service new
profitability is complex, and is dependent on a number demand, or because of increased patient awareness and
of factors such as practice workload, fees, materials and expectations. Nonetheless, substitution of dental ser-
consumables, and employment costs associated with vice provision may provide incremental improvements
the hygienist and any additional support staff. The in productivity and access to dental care. At the practice
employment of a hygienist provides more time for the level, expanding the role of the dental hygienist may
dentist to undertake more complex and profitable lead to an overall increase in profitability due to its
treatment. While the employment costs of a hygienist complementary effect, while at a population level,
to undertake preventive and periodontal treatment may substitution may address the increasing demand for
generally be less than that of a dentist, this is likely to be dental services.
offset by longer appointment times for hygienists to Previous studies have shown a relatively uniform and
provide treatment compared with a dentist. A number strong opposition from dentists to the expansion of
of respondents indicated that fees for treatment pro- roles and scope of practice for dental hygienists, and
vided by a hygienist were the same as those provided by particularly to the concept of independent practice.4,11
a dentist. This supports the contention from the However, this is not necessarily matched by the general
respondents that the employment of a hygienist would public, who may be more supportive of independent
not impact on the affordability of services. dental hygiene practices.12 The present study found
The attitude of dentists and dental hygienists varied that although there was opposition from dentists
considerably regarding the scope of practice of dental and specialists towards expanding scope of practice,
hygienists. Most dental hygienists and employers sup- reducing supervision and allowing independent prac-
ported expanding the scope of practice for hygienists, tice, employers were generally less opposed than
whereas the majority of non-employers opposed any non-employers. The greater level of support from the
expansion. Procedures such as in-office tooth whitening employers is likely to be a reflection of their more
and bonding of orthodontic brackets were suggested by intimate understanding of the capabilities of a hygienist
many employers and hygienists as procedures that than their non-employing colleagues, who may not
could be undertaken by a dental hygienist. Many have the same level of knowledge or experience, and
hygienists also expressed an interest in being able to may be basing their opinions on outdated notions of
work in nursing homes without the presence of a hygienist education and training.
supervising dentist. This model of practice may improve Another reason why many dentists may have been
access to that section of the community who currently opposed to any expansion in the scope of practice for
have difficulty obtaining preventive dental services, and dental hygienists is that they may have identified it as an
is a model that has been adopted in a number of avenue which would lead to independent practice for
jurisdictions internationally. dental hygienists. Most dentists disagreed with dental
ª 2008 Australian Dental Association 71
M Hopcraft et al.

hygienists being able to engage in independent practice, thought that hygienists made their practice less profit-
which may be attributed to a fear of losing control over able and 77.1 per cent employed a hygienist because of
patient management, potential loss of income or the quality of dental care provided.
concerns for the quality of dental care provided by
hygienists. Comments from dentists and specialists
CONCLUSIONS
regarding increasing scope of practice and independent
practice reflected the view that dentists believed that There has been no previous research on dental hygien-
hygienists did not possess adequate training and ists in Victoria and this study has provided an insight
education in examination, diagnosis and treatment into the attitudes of the oral health workforce towards
planning to practice independently, particularly with the role of dental hygienists in Victoria. The increased
regard to the diagnosis of oral pathology. Many utilization of dental hygienists as part of the multi-
dentists and specialists also argued that dental hygiene disciplinary team has been clearly recognized as an
services would not be more affordable to patients in an approach to improve dental service delivery but there
independent practice setting, since practice overheads are still barriers to their employment. In coming years,
would be the same for a hygienist regardless of whether the disparity between an increasing demand for dental
they were employed or operating in an independent services and the ability of the oral health workforce to
practice. supply services will place greater pressure on workforce
Hygienists have become an integral part of dental planning initiatives to increase the number of dental
practice overseas, with 73 per cent of practitioners in hygienists and increase their scope of practice.
the United Kingdom believing that hygienists have an
important role to play in preventive dentistry.13 Similar
ACKNOWLEDGEMENTS
support was expressed by Victorian dentists for the
positive role hygienists have to play in dental practice, The authors wish to acknowledge the Dental Hygien-
with the majority of all subjects believing that dental istsÕ Association of Australia (Victorian Branch) Inc
hygienists made a meaningful contribution to the dental for its financial support of this research. The work
team in terms of efficiency, profitability and access to described in this paper was supported by the Cooper-
dental care. ative Research Centre for Oral Health Sciences (CRC-
Despite half of the non-employers stating they would OHS). The CRC-OHSÕs activities are funded by the
consider employing a hygienist, less than 5 per cent Australian GovernmentÕs Cooperative Research Centres
were actively looking to employ one. The main reasons program.
provided for not employing a hygienist were limited
chairs and the lack of available hygienists, reasons often
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ª 2008 Australian Dental Association 73