An Evaluation of Permit L Local Anesthesia within Dental Hygiene Practice in Massachusetts

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1 Research A Evaluatio of Permit L Local Aesthesia withi Detal Hygiee Practice i Massachusetts Katherie A. Soal, CDA, RDH, MSDH; Lida Boyd, RDH, RD, EdD; Susa Jekis, RDH, MS, CAGS; Debra vember-rider, RDH, MSDH; Adrew Rothma, MS, EIT Abstract Purpose: The purpose of this descriptive study was to assess data pertiet to the Permit L local aesthesia licese amog practicig detal hygieists i Massachusetts, providig a overview of characteristics, practice behaviors, barriers for obtaiig the permit ad self-perceived competecy. Methods: A coveiece sample of detal hygieists (=6,167) idetified through a publically available data base were ivited to participate i a web-based survey. The survey cosisted of demographic ad Permit L specific questios. Items regardig opiios were rated usig a 5-poit Likert scale while frequecies ad percetiles were used to evaluate demographics ad practice-based iformatio. Spearma s Rak correlatio was performed to determie associatio betwee variables. Results: A 10% (=615) respose rate was attaied with (=245) o-permit L holders ad (=370) Permit L holders. Respodets reported sigificat differeces i demographics ad opiios betwee o-permit L holders ad Permit L holders (p<0.01) ad betwee those certified through cotiuig educatio or curriculum based programs (p<0.01). Sigificat relatioships were foud i demographics (p<0.01) ad practice (p<0.05) items i relatio to the legth of time the Permit L has bee held. Themes from the data ad commets idicate multiple factors ifluecig obtaiig or ot obtaiig the Permit L. Coclusio: The results of this study provide a overview of Permit L local aesthesia admiistratio that is geerally comparable to previous studies ad offers ew isights ito why some Massachusetts detal hygieists choose ot to pursue certificatio. This study highlights the potetial to icrease the prevalece of the Permit L, address barriers to pursuig the Permit L, ad further evaluate self-perceived barriers. Keywords: local aesthesia, detal hygieists, cotiuig educatio, professioal delegatio This study supports the NDHRA priority area, Professioal Educatio ad Developmet: Ivestigate curriculum models for traiig ad certificatio of competecy i specialty areas (e.g., aesthesiology, developmetally disabled, foresics, geriatrics, hospital detal hygiee, ocology, pediatrics, periodotology, ad public health). Itroductio It is widely kow that detal hygieists ca be effectively taught expaded fuctios ad those fuctios ca be delivered effectively ad safely. 1 Durig1972 to 1974, the Forsyth Experimet code amed Project Rotuda, gathered data demostratig safety ad efficacy of detal hygieist admiistered local aesthesia. A total of 19,173 local aesthetic admiistratios were give durig the project with oly 3 mior short-term adverse reactios ad a 92% first attempt success rate. 2 The body of literature relatig to the admiistratio of local aesthesia by detal hygieists is lackig i more recet studies. Early studies were aimed at evaluatig the safety ad efficacy of detal hygiee admiistered local aesthesia alog with use, impact, ad provider ad detist perceptios. I 1992, Cross-Polie et al coducted a survey of Colorado detal hygieists who completed a cotiuig educatio course i local aesthesia ad- miistratio. 3 Levels of educatio were reported as 8% certificate, 45% Associate, ad 45% Bachelor degrees with 76% i geeral practice ad 17% i a periodotal practice. I a self-reported post course questioaire 88% (=96) were admiisterig local aesthesia as eeded for patiet care ad the remaiig 12% (=12) stated reasos for ot admiisterig icludig; employer resistace, patiet resistace, ad practice type. 3 I 2000, DeAgelis ad Goral reported the results of a quatitative survey desiged to assess Arkasas detal hygieists use of local aesthesia. 4 Certificatio was held by 97% for at least 1 year, ad of those, 92% were i geeral practice ad 7% i periodotal practice. Levels of educatio were reported as 8% certificate, 23% Associates, 67% Bachelors ad 2% Master s degrees. Delegatio of local aesthesia for detal hygiee procedures was reported at 94% (=109) ad 68% Vol Jue 2016 The Joural of Detal Hygiee 181

2 (=109) for detal procedures. Whe the detal hygieists were asked their opiio regardig the statemet, Local aesthesia is ot eeded for detal hygiee procedures, 90% (=284) of those certified either disagreed or strogly disagreed. A sigificat correlatio (p<0.001) was foud whe the same questio was asked of those with ad without certificatio. 4 Aderso evaluated use of local aesthesia by detal hygieists who completed cotiuig educatio course i Miesota durig The selfreported data revealed a 95% delegatio rate for detal hygiee procedures ad a 65% delegatio rate for the detist patiets with 89.6% (=242) i geeral practice ad 7.8% (=21) i periodotal practice. Associate degrees were held by 90% (=204) ad Bachelor degrees by 9% (=25) with o sigificat relatioship betwee educatioal level ad successful ijectios (p=0.87). The value of local aesthesia admiistratio i practice was reported as very valuable by 58%, ad 87% believed the skill would have value whe seekig employmet. Success was measured by achievig adequate aesthesia, ad rates of 90 to 100% were reported by 76% with o sigificat relatioship betwee years sice graduatio ad level of success (p=0.24). The most frequetly reported complicatio was hematoma by 5.9% (=16) with 87.8% (=239) reportig o complicatios ad 86% aspirate all the time. 5 I a 2005 survey by Schofield et al, iformatio was requested from state licesig boards (=26) regardig discipliary actios agaist detal hygieists ivolvig the admiistratio of local aesthesia. 6 The umber of discipliary actios agaist detal hygieists ivolvig the admiistratio of local aesthetics reported by all participatig state licesig boards (=18) was zero. 6 I 2011, Boyes et al coducted a radomized atiowide survey of detal hygieists (=1,200) evaluatig detal hygiee local aesthesia educatio ad admiistratio. 7 The results reveal 86.4% (=431) detal hygieists perceived a eed for local aesthesia for detal hygiee procedures with 76.1% i geeral practice, 7.8% periodotal practice ad 8.4% i a academic settig. Of those admiisterig local aesthetics, 67.3% were traied i a curriculum-based program ad 32.3% i a cotiuig educatio program. 7 The study established 5 regios i the U.S. to evaluate local aesthesia use. Regio 5 icluded the wester states of Alaska, Arizoa, Califoria, Hawaii, Idaho, Nevada, Orego, Utah ad Washigto. This regio reported 93.8% of detal hygieists admiister local aesthesia ad 61% also admiistered aesthesia to the detist s patiets. Regio 1 cosistig of the ortheaster states of Coecticut, Delaware, Massachusetts, Marylad, Maie, New Hampshire, New Jersey, New York, Pesylvaia, Rhode Islad ad Vermot reported 32.1% of detal hygieists admiisterig ad 30.4% admiisterig for the detists patiets. 7 The mea year of implemetatio of detal hygiee admiistered local aesthesia for regio 5 is 1978 ad 2003 for regio 1. Despite the fidigs of several studies demostratig safety ad efficacy of detal hygiee admiistered local aesthesia, 3-5,8 Massachusetts remaied behid the majority of states i legalizig the practice. Washigto State was the first to pass legislatio allowig the admiistratio of local aesthetics by a detal hygieist i 1971, followed by New Mexico i 1972 ad the majority of states west of the Mississippi River by the late 1990s. 9 It was ot util 2004 that Massachusetts approved detal hygiee admiistered local aesthesia uder direct supervisio via the Permit L local aesthesia licese. 9 The Permit L local aesthesia licese allows detal hygieists to admiister local aesthesia by erve block ad ifiltratio ad is obtaied after successful completio of a cotiuig educatio or curriculum-based traiig course. A miimum of 35 hours of istructio icludig o less tha 12 cliical hours are required to satisfy the requiremets set forth by the Massachusetts Board of Registratio i Detistry. 10 To date, there has ot bee a statewide evaluatio of the Permit L except for a sigle local aesthesia questio posed i the 2007 A Report o the Commowealth s Detal Hygiee Workforce. 11 This survey revealed 12% (=381) of detal hygieists are Permit L holders. Of the o-permit L holders (=4,114) 64.4% (=2,650) reported they did ot ited to become certified. The mai reasos cited were lack of iterest (32.9%, =871), icreased liability (28.2%, =747), o moetary compesatio (14.1%, =373), cost (13.4%, =355) ad fear (11.5%, =304). 9 As Massachusetts is a latecomer to the atioal local aesthesia area ad after practicig for so log without the Permit L, a evaluatio of the perceived barriers ad motivatig factors surroudig obtaiig or ot obtaiig the Permit L will provide isight ito its impact. The purpose of this study was to gather data pertiet to Permit L practice amog detal hygieists i Massachusetts providig a overview of the characteristics of Permit L holders ad idicate self-perceived barriers to obtaiig the Permit L. This study assessed 2 research questios: 1. What are the characteristics of Permit L holders i Massachusetts? 2. What are the self-perceived barriers to pursuig the Permit L? 182 The Joural of Detal Hygiee Vol Jue 2016

3 Methods ad Materials Research Desig This cross-sectioal, oe poit i time, descriptive web-based survey research evaluated Permit L ad o-permit L holdig detal hygieists i Massachusetts. The survey was desiged to iclude oly those detal hygieists who were curretly practicig i Massachusetts ad residig i Massachusetts, Coecticut, New Hampshire or Rhode Islad, ad further idetified 3 idepedet variables: those with ad without the Permit L. Those who did have the Permit L were separated by type of Permit L traiig program they atteded; either cotiuig educatio-based or curriculum-based. The survey admiistered to o-permit L holders cosisted of 6 demographic questios ad 12 Permit L specific questios. Four of the 12 questios that requested opiios were rated usig a 5-poit Likert scale. After idetifyig which Permit L traiig program they atteded the Permit L holders were asked 20 questios related to the Permit L, 5 of which were rated usig a 5-poit Likert scale. Based upo the literature, 12,13 cotet validity idexes were obtaied from a pael of 6 experts to esure cotet validity of the survey istrumet. A S-CVI score of 0.87 was obtaied for o-permit L holder questios ad 0.8 was obtaied for the Permit L holder questios. The study received IRB approval with a exempt status from Huma Subject Committee of MCPHS Uiversity. Sample Iclusio/Exclusio Criteria All detal hygieists who were registered i Massachusetts ad residig i Massachusetts, Coecticut, New Hampshire or Rhode Islad at the time of the survey were ivited to participate (=6,167). The mailig addresses were obtaied from the Massachusetts Board of Registratio i Detistry via a publically available database. The iclusio criteria to participate were: curretly practicig hygieists i Massachusetts ad, if a curret Permit L holder, traiig at a accredited program i Massachusetts. The total umber of Permit L holders registered i Massachusetts ad residig i the aforemetioed states (=2,180) represeted 35% of the potetial sample of permit L holders. Data Aalyses Data were collected o-lie via SurveyMokey, dowloaded as Excel spreadsheets ad imported ito STATA versio 12 statistical aalysis software. Descriptive data summarized demographic characteristics ad Likert-scaled questios. Spearma s Rak correlatio testig was used to determie associatio betwee variables ad the level of sigificace for all data aalyses was set at <0.05. Results Demographics A overall respose rate of 10% (=615) was attaied with 245 o-permit L holders ad 370 Permit L holders. The o-permit L holdig respoders (=245) represeted 6.1% of the 3,987 o-permit L holders ad the Permit L holdig respoders (=370) represeted 16.9% of the 2,180 Permit L holders curretly licesed i Massachusetts ad residig i Massachusetts, Coecticut, New Hampshire or Rhode Islad. The majority i both categories were female (98%), the Permit L holders were geerally youger with 61% (=227) aged 45 or uder ad 87% (=212) of o-permit L holders were aged 41 or over. The umber of years i practice was fairly evely distributed except for those who had bee i practice for 1 to 5 years accoutig for 20% (=121) of the respodets of which 90% (=109) were Permit L holders. Thirty-seve percet (=135) of Permit L holders aticipated beig i practice loger tha 20 years compared to 15.7% (=39) o-permit L holders. Associate degree holders were more prevalet i the o-permit L holder category (70%) while Bachelor (38%) ad Master (14%) degrees were more prevalet i the Permit L holder category. Most (67%) worked i geeral practice, ad of those statig a academic work settig 93% (=41) were Permit L holders. practice types reported (=50) icluded multi-specialty, oral surgery, hospital/rehab, commuity health ceter, ad corporate settigs. Demographic data are reported i Table I. Opiios ad Descriptive Data of -Permit L Holders Data Collectio A postcard ivitatio to participate i the webbased survey was mailed to all detal hygieists (=6,167) i September Cocurretly, a ivitatio was posted o the Massachusetts Detal Hygieists Associatio (MDHA) website ad participats were recruited i-perso at the MDHA aual sessio. A blast was delivered by MDHA with a follow-up remider three weeks later. Table II shows the descriptive data for o-permit L holders. The vast majority (99.5%) of the o-permit L holders reported the Permit L was ot a coditio of employmet, ad 79% (=172) were ot plaig to become certified. The mai reasos for ot becomig certified were: ot eeded i type of practice (17.5%), ot plaig to stay i practice log eough to use (14.5%), fear of admiisterig local aesthetics (14%), cost (12.25%) ad o fiacial gai (13%). Employer resistace ad Vol Jue 2016 The Joural of Detal Hygiee 183

4 o value i practice raked lowest at 2.25% (=4) each. Domiat themes from the commets (=21) provided i relatio to ot becomig certified were related to the aforemetioed reasos. Of those plaig to take the certificatio course (=45), 53% (=25) cited stayig competitive i the job market, ad 40.5% (=19) cited self-improvemet as the reaso. The primary reaso for ot obtaiig the Permit L after takig a certificatio course was waitig beyod the 2 year deadlie (38%) ad other reasos (=6), such as ot watig the liability ad lettig the Permit L lapse. Whe asked if their employers would allow them to admiister local aesthetics if they obtaied the Permit L, 59.5% (=143) strogly agreed/ agreed. I regards to self-perceived ability 77% (=188) strogly agreed/ agreed with the statemet, I feel as though I would be able to complete the certificatio course, pass the NERB exam ad obtai the Permit L. Table III shows the Likert-scaled opiios of o-permit L holders. Opiios ad Descriptive Data of Permit L Holders Descriptive data for Permit L holders are show i Tables IV ad V. The Permit L as a coditio of employmet was reported by 22% (=80), ad 42% (=153) reported holdig the Permit L loger tha 5 years, of which 65% (=100) atteded a cotiuig educatio-based program. Although 72% (=263) were admiisterig local aesthetics, 28% (=104) Table I: Demographics of Detal Hygieists Practicig i Massachusetts Geder Age Female Male <21 21 to to to to to to to to to 65 >66 Years i practice <1 1 to 5 6 to to to to to to to 40 >40 -Permit L Holders (0) Permit L Holders (0) Total (Percet) (Percet) (Percet) 244 (99%) 1 (<1%) 13 (5%) 9 (3.5%) 11 (4.5%) 25 (10%) 46 (19%) 55 (22.5%) 53 (22%) 26 (10.5%) 7 (3%) 12 (5%) 21 (9%) 20 (8%) 18 (7.5%) 33 (14%) 28 (11.5%) 41 (17%) 47 (19%) 22 (9%) Aticipated umber of years remaiig i practice <1 1 to 5 6 to to to to to to to 40 >40 Highest level of educatio Associates Bachelors Masters PhD Type of practice Geeral Academic Periodotal Public health Pedodotic Prosthodotic PHDH 3 (1.25%) 49 (20%) 57 (23%) 63 (26%) 34 (14%) 23 (9.25%) 7 (3%) 4 (1.5%) 4 (1.5%) 171 (70%) 58 (23.5%) 14 (6%) 173 (70.5%) 3 (1%) 12 (5%) 6 (2.5%) 13 (5.5%) 5 (2%) 7 (3%) 26 (10.5%) 361 (97.5%) 9 (2.5%) 1 (0.25%) 36 (9.75%) 47 (12.5%) 52 (14%) 40 (11%) 51 (13.75%) 50 (13.5%) 47 (12.75%) 26 (7%) 11 (3%) 9 (2.5%) 21 (6%) 109 (29%) 69 (19%) 34 (9%) 22 (6%) 31 (8%) 28 (7.5%) 26 (7%) 20 (5.5%) 10 (3%) 3 (1%) 36 (10%) 63 (17%) 61 (16%) 70 (19%) 32 (9%) 44 (12%) 29 (8%) 20 (5%) 10 (3%) 177 (48%) 139 (38%) 52 (14%) 236 (64%) 41 (11%) 26 (7%) 18 (5%) 12 (3.25%) 7 (2%) 5 (1.25%) 24 (6.5%) 605 (98%) 10 (2%) 1 (0.25%) 36 (6%) 60 (9.75%) 61 (10%) 51 (8%) 76 (12%) 96 (15.5%) 102 (16.5%) 79 (13%) 37 (6%) 16 (3%) 21 (3.5%) 121 (20%) 90 (15%) 54 (9%) 40 (6%) 64 (10.5%) 56 (9%) 67 (11%) 67 (11%) 32 (5%) 6 (1%) 85 (14%) 120 (19.5%) 124 (20%) 104 (17%) 55 (9%) 51 (8%) 33 (5.5%) 24 (4%) 11 (2%) 348 (57%) 197 (32%) 66 (10.75%) 1 (0.25%) 409 (67%) 44 (7%) 38 (6%) 24 (4%) 25 (4%) 12 (2%) 12 (2%) 50 (8%) 184 The Joural of Detal Hygiee Vol Jue 2016

5 were ot admiisterig local aesthetics with 37% (=38) of those reportig admiistratio was ot eeded i the type of practice where they were employed. reasos for ot admiisterig (=29) icluded: ot practicig uder direct supervisio, workig i a academic settig, lack of opportuity ad practice policy. Delegatio of local aesthesia by the supervisig detist was reported at 85% (=305) for detal hygiee procedures ad 42% (=150) for operative or surgical procedures. The types of ijectios admiistered were geerally distributed evely except for the greater palatie, asopalatie, ad ifraorbital. ijectio types (=18) icluded aterior middle superior alveolar erve block, Gow-Gates ad papillary. A successful ijectio was defied as oe that achieves the desired level of aesthesia o the first attempt with 68.5% (=197) reportig success rates of 95 to 100%. local or systemic patiet complicatios were reported by 81% (=241) with tachycardia the most frequetly reported complicatio at 6% (=18). complicatios (=13) icluded patiet axiety, trismus, ausea, trauma or hematoma localized to the ijectio site, ad umbess of the madible after a posterior superior alveolar ijectio. Frequecy of aspiratio prior to depositio of local aesthetics was reported to be 100% by 79% (=229). Safe eedle recappig usig a sigle had techique or recappig device was used by 94% (=282), ad icidece of percutaeous eedle sticks was zero for 87% (=260). Needle breakage was experieced by 1% (=4) ad formal complaits to the Board of Registratio i Detistry were reported by 2.5% (=9). The self-perceived opiios of the Permit L holders are show i Table VI with similar results reported betwee the 2 educatioal forums. Amog the Permit L holders, 84% (=310) strogly agreed/agreed the Permit L was valuable whe seekig employmet, ad 88% (=322) strogly agreed/agreed the Permit L was valuable i practice. Local aesthesia as ecessary for o-surgical periodotal therapy (NSPT) was strogly agreed/agreed to by 97% (=356), ad 81% (=290) strogly agreed/agreed they felt competet i their local aesthesia admiistratio. The type of educatioal program atteded for traiig adequately prepared most with 89% (=322) strogly agreeig or agreeig. Correlatios Spearma s Rho correlatios used to assess relatioships betwee demographics, practices, ad opiios are show i Tables VII to IX. Sigificat Table II: Descriptive Statistics of -Permit L Holders Was the Permit L a coditio of employmet? (Percet) Vol Jue 2016 The Joural of Detal Hygiee 185 Have you take the Permit L course? What type of course did you take? Curriculum based Cotiuig educatio based Both Have you take the NERB exam? 242 (99.5%) 26 (11%) 219 (89%) 14 (54%) 10 (38%) 2 (8%) 8 (34%) 16 (67%) If you have take the certificatio course ad do ot have the Permit L, what is your primary reaso? Waited too log I applicatio process Failed NERB exam Employer resistace Did ot eed Are you plaig to take the certificatio course? 10 (38%) 6 (23%) 2 (8%) 1 (4%) 1 (4%) 6 (23%) 45 (21%) 172 (79%) If you are plaig to take the certificatio course, what is your primary reaso? Stay competitive i the job market Self improvemet Curret employmet requiremet 25 (53%) 19 (40.5%) 1 (2%) 2 (4.5%) If you are ot plaig to take the certificatio course, what is your primary reaso? t eeded i type of practice t plaig to stay i practice log eough Fear of admiisterig local aesthetics fiacial gai Cost Icreased liability Too log out of school Employer resistace value i practice 30 (17.5%) 25 (14.5%) 24 (14%) 23 (13%) 21 (12.25%) 12 (7%) 8 (5%) 4 (2.25%) 4 (2.25%) 21 (12.25%) relatioships were foud betwee demographics ad opiios of o-permit L holders ad Permit L holders. The Permit L holders are likely to be: youger (p<0.01), have bee i practice for fewer years (p<0.01) ad have more years remaiig i practice (p<0.01). They are also more likely to agree tha disagree that local aesthesia is ecessary for some detal hygiee procedures (p<0.01)

6 Table III: Opiios of -Permit L Holders SA A U D SD (Percet) (Percet) (Percet) (Percet) (Percet) The Permit L is valuable i practice (17%) 98 (40%) 65 (26.5%) 33 (13.5%) 7 (3%) Local aesthesia is ecessary for some procedures such as NSPT 245 My supervisig detist would allow me to admiister local aesthetics if I obtaied the Permit L I feel as though I would be able to complete the certificatio course, pass the NERB exam ad obtai the Permit L 104 (42.5%) 107 (43.5%) 14 (6%) 14 (6%) 6 (2%) (26.5%) 79 (33%) 53 (22%) 30 (12.5%) 15 (6%) (36%) 101 (41%) 38 (16%) 15 (6%) 3 (1%) Likert Scale used: 1=Strogly Agree (SA), 2=Agree (A), 3=Udecided (U), 4=Disagree (D), 5=Strogly Disagree (SD) Table IV: Descriptive Statistics of Curriculum(1) ad Cotiuig Educatio (2) Based Permit L Holders How log have you held the Permit L? <1 year 1 to 3 years 4 to 5 years >5 years Was the Permit L a coditio of employmet? CU Based CE Based Total (Percet) (Percet) (Percet) 18 (10%) 74 (41.5%) 33 (18.5%) 53 (30%) 39 (22%) 138 (78%) O average, how ofte are you admiisterig local aesthetics? At least oce a day 1 to 3 times a week 4 to 6 times a moth t admiisterig 23 (13%) 42 (24%) 54 (30%) 59 (33%) If you are ot curretly admiisterig, what is your primary reaso? t eeded i type of practice Do ot feel cofidet Employer resistace 25 (43%) 8 (14%) 13 (22%) 12 (21%) 9 (5%) 42 (22%) 39 (20.5%) 100 (52.5%) 41 (22%) 149 (78%) 20 (10.5%) 63 (33%) 61 (32.5%) 45 (24%) 13 (28%) 6 (13%) 10 (22%) 17 (37%) Does your supervisig detist delegate local aesthesia for detal hygiee procedures? 143 (82%) 31 (18%) 162 (87.5%) 23 (12.5%) Does your supervisig detist delegate local aesthesia for operative or surgical procedures? 68 (39%) 105 (61%) 82 (45%) 101 (55%) Have there bee ay formal complaits filed i relatio to your admiistratio of local aesthetics? 6 (3.5%) 169 (96.5%) 3 (1.5%) 179 (98.5%) 27 (7%) 116 (31.5%) 72 (19.5%) 153 (42%) 80 (22%) 287 (78%) 43 (12%) 105 (29%) 115 (31%) 104 (28%) 38 (37%) 14 (13%) 23 (22%) 29 (28%) 305 (85%) 54 (15%) 150 (42%) 206 (58%) 9 (2.5%) 348 (97.5%) How soo after obtaiig the Permit L did you feel cofidet i your ability to safely ad effectively admiister local aesthetics? Immediately Withi 3 moths 4 to 12 moths Over oe year 89 (51%) 33 (19%) 24 (14%) 28 (16%) 75 (41%) 60 (33%) 30 (16%) 18 (10%) 164 (46%) 93 (26%) 54 (15%) 46 (13%) 186 The Joural of Detal Hygiee Vol Jue 2016

7 Table V: Local Aesthesia Practice Statistics of Curriculum (1) ad Cotiuig Educatio (2) Based Permit L Holders CU Based CE Based Total O average, what is the success rate of your local aesthesia admiistratio? 95 to 100% 85 to 94% 75 to 84% 51 to 74% <50% (Percet) (Percet) (Percet) 89 (68%) 28 (21%) 10 (8%) 4 (3%) 108 (69%) 35 (22%) 9 (6%) 5 (3%) 197 (68.5%) 63 (22%) 19 (6.5%) 9 (3%) What patiet complicatios, local or systemic, have you ecoutered as a result of your local aesthesia admiistratio? e Tachycardia Extesive IA or PSA hematoma Sycope Temporary paresthesia Allergic reactio Local aesthetic overdose Vasocostrictor overdose Permaet paresthesia Facial paralysis What types of ijectios do you admiister? Ifiltratio MSA IA ASA PSA Log buccal Metal/icisive GP NP IO t admiisterig 110 (81%) 6 (4%) 5 (3.5%) 1 (<0.5%) 8 (7%) 125 (70%) 123 (69%) 119 (67%) 116 (65%) 109 (61%) 101 (57%) 93 (52%) 38 (21%) 37 (21%) 36 (20%) 42 (23%) 5 (3%) How frequetly do you aspirate prior to depositio of local aesthetics? 100% 95 to 99% 85 to 94% 75 to 84% 51 to 74% >50% Never 103 (77%) 17 (13%) 6 (5%) 2 (1%) 4 (3%) 131 (81%) 12 (7.5%) 7 (4%) 4 (2.5%) 5 (3%) 148 (78%) 134 (70.5%) 127 (67%) 127 (67%) 118 (62%) 119 (63%) 113 (59%) 65 (34%) 57 (30%) 49 (25%) 25 (13%) 13 (7%) 126 (82%) 11 (7%) 5 (3%) 7 (4%) Do you practice safe eedle recappig usig a oe-haded techique or recappig device? 130 (92%) 11 (8%) 152 (95%) 8 (5%) How may times have you received a percutaeous eedle stick while admiisterig local aesthetics? Never (84%) 18 (13%) 2 (1%) 143 (90%) 15 (9%) 2 (1%) How may times have you experieced eedle breakage durig depositio of local aesthetics? Never (98%) 2 (1.5%) 159 (99.5%) 241 (81%) 18 (6%) 10 (3%) 8 (2.5%) 7 (2.5%) 1 (<0.5%) 13 (4.5%) 273 (74%) 257 (70%) 246 (67%) 243 (66%) 227 (62%) 220 (60%) 206 (56%) 103 (28%) 94 (25%) 85 (23%) 67 (18%) 18 (5%) 229 (79%) 28 (10%) 9 (3%) 6 (2%) 2 (0.5%) 11 (1.5%) 4 (1.5%) 282 (94%) 19 (6%) 260 (87%) 33 (11%) 3 (1%) 2 (0.5%) 2 (0.5%) 296 (99%) 2 (0.5%) 2 (0.5%) Vol Jue 2016 The Joural of Detal Hygiee 187

8 Table VI: Opiios of Permit L Holders The permit L is valuable whe seekig employmet Curriculum Based SA A U D SD (Percet) (Percet) (Percet) (Percet) (Percet) (52%) 56 (31.5%) 19 (11%) 9 (5%) The Permit L is valuable i practice (57%) 51 (28%) 14 (8%) 12 (7%) Local aesthesia is ecessary for some procedures such as NSPT I feel competet i my admiistratio of local aesthetics The type of traiig program I atteded adequately prepared me to admiister local aesthetics The permit L is valuable whe seekig employmet The Permit L is valuable i practice 188 Local aesthesia is ecessary for some procedures such as NSPT I feel competet i my admiistratio of local aesthetics The type of traiig program I atteded adequately prepared me to admiister local aesthetics (70%) 47 (26%) (45%) 57 (33%) 22 (12%) 10 (6%) 7 (4%) (59%) 50 (29%) 18 (10%) 4 (2%) Cotiuig Educatio Based SA A U D SD (Percet) (Percet) (Percet) (Percet) (Percet) (53%) 110 (58.5%) 61 (32.25%) 25 (13.25%) 2 (1%) 60 (32%) 12 (6.5%) 4 (2%) 2 (1%) (71%) 50 (26%) 2 (1%) 2 (1%) 1 (<1%) (41%) 79 (43.5%) 11 (6%) 14 (8%) 3 (1.5%) (58%) 61 (33%) 7 (4%) 6 (3%) 3 (1%) Likert Scale used: 1=Strogly Agree (SA), 2=Agree (A), 3=Udecided (U), 4=Disagree (D), 5=Strogly Disagree (SD) ad the Permit L is valuable i practice (p<0.01). Amog o-permit L holders, those who are more likely to agree tha disagree that their supervisig detist would allow them to admiister local aesthetics are youger (p<0.05), have bee i practice for fewer years (p<0.05) ad have more years remaiig i practice (p<0.05). The o-permit L holders who are older (p<0.01), have more years i practice (p<0.01), ad fewer years remaiig i practice (p<0.01) are more likely to disagree tha agree with a positive self-perceived ability to obtai the Permit L. The Permit L holders demostrated o sigificat differeces betwee the curriculum ad cotiuig educatio-based traiig programs i regards to practice ad opiio items. Sigificat correlatios were foud amog the demographic data showig those traied i a curriculum program are likely to be youger (p<0.01), have fewer years i practice (p<0.01), have more years remaiig i practice (p<0.01), have held the Permit L for loger (p<0.01) ad report the Permit L was a coditio of employmet tha those traied i a cotiuig educatio program. The legth of time the Permit L has bee held yielded sigificat correlatios i several areas. Those who have held the Permit L for loger are more likely to be older (p<0.01), have more years i practice (p<0.01), have fewer years remaiig i practice (p<0.01), hold a Bachelors or Masters degree, ad less likely to report the Permit L as a coditio of employmet (p<0.05). They also report higher admiistratio success rates (p<0.05) ad higher delegatio rates for operative ad surgical procedures (p<0.05). Those who have held the Permit L for loger are more likely to agree tha disagree that local aesthesia is ecessary for some detal hygiee procedures (p<0.05) ad are more likely to agree tha disagree with a positive self-perceived competecy i admiisterig local aesthetics (p<0.05). Discussio The demographic characteristics of respodets i this survey were similar to the 2011 Massachusetts Departmet of Public Health profile of detal hygieists i regards to geder, age, years i practice ad level of educatio. 14 At the time of this survey there were 2,345 Permit L holders represetig 35.4% of all curretly licesed detal hygieists i Massachusetts (=6,616), which is similar to the 188 The Joural of Detal Hygiee Vol Jue 2016

9 regioal results of Boyes et al who reported 32.1% of detal hygieists admiisterig i the rtheaster states. 6 Demographic ad practice items such as geder, age ad years i practice were similar to those reported by Aderso, 5 DeAgelis ad Goral, 4 ad Cross-Polie et al. 3 Practice types i this study differed from most i that 64% (=236) worked i geeral practice whereas Aderso reported 89.6%, 5 Boyes et al 76.1%, 7 DeAgelis ad Goral 92%, 4 ad Cross-Polie et al 76%. 3 However, the greater variety of practice settigs that have emerged may accout for this differece. The levels of educatio i this study show sigificace amog those who have held the Permit L for loger (p<0.01) which may be affected by the certificatio of faculty iitially eeded to teach the skill. Table VII: Selected Correlatio Tred Tests Betwee Demographics ad Opiios of -Permit L Holders ad Permit L Holders Spearma s Rak Correlatio Coefficiet (p) Age -0.4** Years I Practice -0.45** Years remaiig i practice 0.28** Local aesthesia is ecessary for some detal hygiee procedures such as NSPT The Permit L is valuable i practice -0.3** -0.45** This study, whe compared to the 2007 Massachusetts Departmet of Public Health survey, 11 reveals 79% (=172) are ot plaig o becomig certified as compared to 64.4% (=1,936) ad fids similarity i the reasos for ot becomig certified such as fear, cost ad o moetary compesatio. This survey also foud fewer who cited icreased liability (7% vs. 28.2%), with the mai reasos for ot becomig certified beig ot eeded i type of practice (17.5%) ad ot plaig to stay i practice log eough to use (14.5%). Employer resistace at 2.25% (=4) raks lowest alog with o value i practice as reasos for ot becomig certified. This study ad DeAgelis ad Goral 4 foud sigificat differeces i opiio regardig the ecessity of local aesthesia betwee certified ad ot certified. The primary reaso for ot admiisterig reported by 28% (=104) of the Permit L holders was ot eeded i type of practice (37%) ad employer resistace (22%). Cross-Polie et al reported 12% of those certified were ot admiisterig due to employer or patiet resistace, practice type, ad patiets ot eedig aesthesia. 3 Aderso also reported similar reasos for ot admiisterig. 5 Delegatio of local aesthesia for detal hygiee (85%) ad detal (42%) procedures are below those reported by Aderso (95%, 65%) 5 ad DeAgelis ad Goral (94%, 68%), 4 but above the regioal results of Boyes et al (32.1%, 30.4%) 7 that icluded states where detal hygieist admiistered local aesthesia was ot legal. A sigificat relatioship betwee delegatio for detal procedures ad legth of time the Permit L has bee held (p<0.01) was foud by this study. Success achievig aesthesia o the first attempt 95 to 100% of the time was reported by 68.5% of the Permit L holders which is below the 92% overall first attempt success rate reported by Lobee 2 while Aderso 5 reported a success rate of 76%, 90 to 100% of the time. This study foud a sigificat relatioship betwee level of successful ijectios ad legth of *p<0.05 for tred **p<0.01 for tred Table VIII: Selected Correlatio Tred Tests Betwee Demographics ad Opiio Variables of -Permit L Holders Local aesthesia is ecessary for some detal hygiee procedures such as NSPT The Permit L is valuable i practice My supervisig detist would allow me to admiister local aesthetics if I obtaied the Permit L I feel as though I would be able to complete the certificatio course, pass the NERB exam ad obtai the Permit L Spearma s Rak Correlatio Coefficiet (p) Vol Jue 2016 The Joural of Detal Hygiee 189 Age Years i practice Years remaiig i practice * 0.14* -0.14* 0.24** 0.29** -0.3** *p<0.05 for tred **p<0.01 for tred time the Permit L has bee held (p<0.01) but o relatioship betwee success ad educatioal level or years i practice which correlates with the fidigs of Aderso. 5 Aspiratio rates of 100% were reported by 79% of Permit L holders whereas Aderso foud 86% were aspiratig all the time. This lower rate of aspiratio may be the determiig factor for tachycardia beig reported as the most frequet complicatio. The mai differeces betwee Permit L holders ad o-permit L holders lie withi demographics of

10 Table IX: Selected Correlatio Tred Tests Betwee Demographic, Practice, ad Opiio Variables of Permit L Holders Spearma s Rak Correlatio Coefficiet (p) Curriculum (1) ad Cotiuig Educatio (2) Based Program Years Permit L Held (<1 year, 1 to 3 years, 4 to 5 years, >5 years) Age 0.61** 0.41** Years i practice 0.78** 0.49** Years remaiig i practice -0.37** -0.22** Years Permit L held 0.27** - Level of educatio ** Value of Permit L whe seekig employmet Permit L a coditio of employmet 0.2** -0.13* Frequecy of admiistratio Delegatio for DH procedures Delegatio for operative or surgical procedures * Admiistratio success rate * Frequecy of aspiratio Safe eedle recappig Frequecy of eedle stick Local aesthesia is ecessary for some detal hygiee procedures such as NSPT * The Permit L is valuable i practice Self-perceived competece i admiistratio * Self-perceived efficacy of traiig program Time to feel cofidet i admiistratio *p<0.05 for tred **p<0.01 for tred age, years i practice ad years remaiig i practice, ad differeces i opiio regardig the value of the Permit L i practice ad the eed for local aesthesia durig some detal hygiee procedures. The barriers to obtaiig the Permit L also lie withi demographics ad opiios of value, but may be combiatios of may factors as suggested by commets provided by o-permit L holders. The limitatios of this study iclude the low respose rate (10%) which may be primarily due to the sigle postcard ivitatio ad the limitatios of the MDHA list. The accuracy of self-reported data with its potetial for bias remais a issue throughout survey-based research ad most likely also cotributed to the limitatios of this study. The use of social media for accessig the populatio of iterest may improve the respose rate i future studies ad the use of social media i research studies may prove a iterestig area of ivestigatio. Areas for future research iclude surveyig the detists i Massachusetts to gather ad evaluate opiios ad practices i relatio to the Permit L, its use, value, ad factors ifluecig its low prevalece. Geeratig iterest i local aesthesia admiistratio with cotiuig educatio courses that directly address the reasos for ot becomig certified or admiisterig may icrease the prevalece ad use of the Permit L. Coclusio This curret study of Massachusetts detal hygieists raises cocer over prevalece ad use of the Permit L as demostrated by lower umbers of detal hygieists admiisterig local aesthetics ad lower delegatio rates. Sigificat differeces i opiios exist betwee o-permit L holders ad Permit L holders as to the value of the Permit L ad the eed for local aesthesia durig some detal hygiee procedures. Katherie A. Soal, CDA, RDH, MSDH, is a associate professor, Departmet of Detal Hygiee, Quisigamod Commuity College. Lida Boyd, RDH, RD, EdD, is a professor. Susa Jekis, RDH, MS, CAGS is a associate professor. Debra vember-rider, RDH, MSDH, is a adjuct assistat professor. Adrew Rothma, MS, EIT, is a adjuct faculty. All are at the Forsyth School of Detal Hygiee, MCPHS Uiversity. 190 The Joural of Detal Hygiee Vol Jue 2016

11 Refereces 1. Nash D, Friedma J. A review of the global literature o detal therapists i the cotext of the movemet to add detal therapists to the oral health workforce i the Uited States. W.K. Kellogg Foudatio Lobee RR, evaluatio of results. I: The Forsyth Experimet. Cambridge, MA: Harvard uiversity press p. 3. Cross-Polie GN, Passo JC, Tilliss TS, Stach DJ. Effectiveess of a cotiuig educatio course i local aesthesia for detal hygieists. J Det Hyg. 1992;66(3): DeAgelis S, Goral V. Utilizatio of local aesthesia by Arkasas detal hygieists, ad detists delegatio/satisfactio relative to this fuctio. J Det Hyg. 2000;74(3): Aderso JM. Use of local aesthesia by detal hygieists who completed a Miesota CE course. J Det Hyg. 2002;76(1): Scofield JC, Gutma ME, DeWald JP, Campbell PR. Discipliary actios associated with the admiistratio of local aesthetics agaist detists ad detal hygieists. J Det Hyg. 2005;79(1):8. 7. Boyes SG, Zovko J, Basti MR, Grillo MA, Shigledecker BD. Detal hygieists evaluatio of local aesthesia educatio ad admiistratio i the Uited States. J Det Hyg. 2011;85(1): Sisty-LePeau N, Boyer EM, Lutje D. Detal hygiee licesure specificatios o pai cotrol procedures. J Det Hyg. 1990;64(4): Local aesthesia admiistratio by detal hygieists state chart. America Detal Hygieists Associatio [Iteret] [cited 2015 April 13]. Available from: State.pdf 10. Admiistratio of aesthesia ad sedatio. Board of registratio i detistry. Massachusetts Departmet of Public Health [Iteret] [cited 2015 April 13]. Available from: courts/docs/lawlib/ cmr/234cmr6.pdf 11. A report o the commowealth s detal hygiee workforce. Massachusetts Departmet of Public Health. [Iteret] 2008 [cited 2015 April 13]. Available from: docs/dph/com-health/detal-hygiee-workforce. pdf 12. Polit DF, Beck CT. The cotet validity idex: Are you sure you kow what s beig reported? critique ad recommedatios. Res Nurs Health. 2006;29(5): Polit DF, Beck CT, Owe SV. Is the CVI a acceptable idicator of cotet validity? appraisal ad recommedatios. Res Nurs Health. 2007;30(4): Health professios data series detal hygieists Executive office of health ad huma services Massachusetts Departmet of Public Health. [Iteret] [cited 2014 March 5]. Available from: com-health/primary-care/2011-detalhygieefactsheet.pdf Vol Jue 2016 The Joural of Detal Hygiee 191