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Unlicensed dental assistants create a concern to patient safety: an evaluation study
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Unlicensed dental assistants create a concern to patient safety: an evaluation study
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Content
Running head: UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 1
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN TO PATIENT SAFETY:
AN EVALUATION STUDY
by
Denise Romero
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
December 2019
Copyright 2019 Denise Romero
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 2
TABLE OF CONTENTS
List of Tables 4
List of Figures 5
Dedication 6
Acknowledgements 7
Abstract 8
Chapter One: Introduction to the Problem of Practice 9
Background of the Problem 10
Importance of Addressing the Problem 11
Organizational Context and Mission 13
Description of Stakeholder Groups 14
Organizational Goal 15
Stakeholder Group of Focus 16
Purpose and Research Questions 17
Definitions 18
Organization of the Paper 19
Chapter Two: Literature Review 21
Patient Protection 22
Dentists Do Not Train to the Same Standards as Formal Education 23
Research Questions 25
Stakeholder Knowledge and Motivation Influences 26
Knowledge and Skills of Dental Assisting 26
Organizational Goal 32
Motivation 32
Organization 35
Chapter Three: Methods 38
Participating Stakeholders 38
Survey Sampling Criteria and Rationale 39
Survey Sampling (Recruitment) Strategy and Rationale 39
Explanation for Choices 40
Quantitative Data Collection 40
Surveys 40
Qualitative Data Collection 41
Interview Sampling Criterion and Rationale 41
Interview Group Sampling Strategy and Rationale 41
Validity and Reliability 42
Ethics 43
Limitations and Delimitations 44
Chapter Four: Results and Findings 45
Participating Stakeholders 46
Results and Findings 46
Surveyed Dentists 46
Interviewed Dentists 47
Research Question One 48
Licensing and Education 48
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 3
Motivation Results 52
Research Question Two 54
Procedural Knowledge 54
Conceptual Knowledge 55
Motivation Results 56
Organization Results 57
Research Question Three 58
Knowledge Results 58
Motivation Results 60
Organization Results 61
Research Question Four 62
Knowledge Results 63
Motivation Results 63
Organization 66
Synthesis of Findings 66
Knowledge 67
Motivation 67
Organization 68
Chapter Five: Recommendations 69
Purpose and Research Questions 69
Knowledge Recommendations 70
Increase Knowledge of Standards of Dental Assistant Education and Licensing 72
Increase Knowledge on Standards of CODA-Accredited Dental Assisting Programs 73
Increase Knowledge of Benefits of Board Exams 74
Motivational Recommendations 76
Require Dental Assistants to be Licensed 77
Organizational Recommendation 79
Implementation and Evaluation Framework 82
Organizational Purpose, Need, and Expectations 82
Level 4: Results and Leading Indicators 83
Level 3: Behavior 84
Level 2: Learning 87
Data Analysis and Reporting 92
Conclusion 93
References 95
Appendix A: Institutional Review Board Approval 101
Appendix B: Informed Consent Form 103
Appendix C: Survey Questions 105
Appendix D: Interview Questions 107
Appendix E: Sample Post-Training Items Measuring Kirkpatrick Levels 1 and 2 109
Appendix F: Sample Blended Evaluation Items Measuring Kirkpatrick Levels 1,2,3, and 4 111
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 4
LIST OF TABLES
Table 1: Organizational Mission, Global Goal and Knowledge Influences 31
Table 2: Motivational Influences and Motivational Influence Assessments 34
Table 3: Assumed Organizational Influences and Assessments for the Stakeholder Goals 37
Table 4: Dentist Sample for Qualitative Inquiry 48
Table 5: Dentist Requirements of Education and Licensing Sample for Qualitative Inquiry 52
Table 6: Summary of Knowledge Influences and Recommendations 71
Table 7: Summary of Motivation Influences and Recommendations 77
Table 8: Summary of Organization Influences and Recommendations 79
Table 9: Outcomes, Metrics, and Methods for External and Internal Outcomes 84
Table 10: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 85
Table 11: Required Drivers to Support Critical Behaviors 86
Table 12: Components of Learning for the Program. 91
Table 13: Components to Measure Reactions to the Program. 91
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 5
LIST OF FIGURES
Figure 1: The stakeholders’ knowledge, the organizational culture and the stakeholder’s goals 16
Figure 2: Dentists ownership of practice. 47
Figure 3: Dentists’ licensing requirements. 51
Figure 4: Allowable duties dentists have dental assistants perform. 55
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 6
DEDICATION
First and foremost, I would like to thank my family, my husband Joey and my daughters
Carlee and Kayla for your support and putting up with me for the last 2 ½ years. When I first
brought my crazy idea of going back to school to get my doctorate you all were supportive and
behind me 100% even though there would be sacrifices. Thank you for letting me lock myself
away to do my schoolwork while you all picked up the slack. Thanks mom for always
championing for me to continue my education when I was in doubt. For all my family the
Romero’s , Evan’s and extended family thanks for your support.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 7
ACKNOWLEDGEMENTS
Thank you to Dr. Barbara Freund and Pasadena City College for supporting my
education journey. You were instrumental in making my decision to complete my doctorate
degree. I am proud to be part of an organization that supports professional growth.
Thank you to the San Gabriel Dental Society, the Herman Ostrow School of Dentistry at
USC and the Dental Assisting National Board for supporting dental assisting. You were
instrumental in my data collection.
Thank you to my dissertation chair Dr. Pat Tobey. It has been a pleasure working with
you. Your calm and sweet nature always eased my nerves and gave me the confidence I needed
in the times of self-doubt.
Thank you to my dissertation committee member Dr. Yates for being there for me when I
really was struggling with my stakeholders. You took the time to work with me and I can’t
thank you enough.
Thank you and congratulations to everyone in Cohort 8 in the OCL program for your
feedback and encouragement. We did it, eight is great! Fight On!
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 8
ABSTRACT
Choosing a career in the dental field comes with great responsibility. When patients go to
the dentist, they trust their health team is providing them with a safe visit. Uneducated and
unlicensed dental assistants put both the patient’s and their own safety at risk. Deadly infectious
disease can easily be spread from patient to health team and health team to patient without proper
infection control techniques. It is a dental assistant’s daily responsibility to provide infection
control, set up treatment rooms using sterile techniques including dental unit waterline
maintenance, sterilization of instruments, decontamination of room and instruments like sharp
and contaminated needles and scalpels. Unlicensed and uneducated dental assistants have had no
formal education in microbiology, disease transmission and Centers for Disease Control
guidelines; thus, they can unknowingly spread infectious disease to the patients and themselves.
This is a national problem addressed in this study.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 9
CHAPTER ONE: INTRODUCTION TO THE PROBLEM OF PRACTICE
This study addressed the problem of patient safety during dental office procedures
conducted by unlicensed dental assistants in the United States. In California and most states, a
dental assistant is not required to have a license or dental assisting education to work on patients.
This problem is necessary to address because unlicensed and uneducated dental assistants can
unknowingly spread infectious diseases to patients. Although this problem is important to
address nationwide, for practical purposes, this analysis focuses on dentists in California.
The dental team responsible for patient care is composed of dentists, dental hygienists
and dental assistants and is regulated by the dental board of each state. The Dental Board of
California (DBC) defines a dental assistant as an individual who, without a license, may perform
basic supportive dental procedures under the supervision of a licensed dentist. Infectious diseases
like hepatitis B, hepatitis C, HIV and deadly bacteria can be spread and transferred to patients
during treatment and most are not reversible. In fact, the patient may have the disease for the rest
of their life, making them very sick or leading to death. The American Dental Association
(ADA) is a dentist member-run organization that works to advance the dental profession on the
national, state and local levels. The ADA describes one of the primary duties of a dental assistant
as serving as an infection control officer, developing infection control protocol, preparing, and
sterilizing instruments and equipment (ADA, 2017). Allowing unlicensed dental assistants
contradicts the board’s definition of completely reversible and unlikely to precipitate potentially
hazardous condition to the patient.
The dental boards develop regulations and statutes called dental practice acts that govern
dentists, hygienists and assistants (DBC, 2017). Depending on the regulations of each state’s
board, the members are primarily composed of citizen dentists and sometimes dental hygienists
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 10
and dental assistants. Some state boards allow for one position to be held by a dental hygienist
and a dental assistant. Dental assistants’ scope of practice, education requirements, and licensure
options vary significantly from state to state. Unlike dentists and hygienists, dental assisting does
not have education and licensing standardization, and, although the national accreditation for
dentistry and hygiene has a dental assisting component, it is not a requirement (DBC, 2017). This
study consisted of a gap analysis of dentistry in relation to dental assisting to communicate the
need to standardize education and licensing for dental assistants for patient safety. The focus of
this study was addressing the lack of standardization to effect change necessary for patient
protection.
Background of the Problem
The largest outbreak in dental history occurred in 2013 in an oral surgery office that
employed uneducated and unlicensed dental assistants who did not have training in infection
control. Over 6,000 patients were exposed to infectious diseases because the dental assistants did
not follow the Centers for Disease Control and Prevention (CDC) guidelines to properly sterilize
contaminated instruments and reused IV needles (Oklahoma State Department of Health, 2013).
The CDC is a governmental agency that is the nation’s health protection agency. The CDC
protects American citizens’ health and safety from chronic or acute, curable or incurable,
preventable human error or deliberate attack (CDC, 2019). Every dental office is required to
follow the CDC summary of infection prevention practices, which summarizes infection control
prevention and provides checklists for dental offices to follow (CDC, 2019). In this case, the
CDC confirmed the diagnosis of 96 patients with hepatitis C, six with hepatitis B and four with
HIV infections all contracted during dental procedures (Oklahoma State Department of Health,
2013).
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 11
In most states, there is no requirement for dental assistants to have to be licensed to work,
and a dentist can train them, this is referred to as on-the-job trained. Prioritizing patient
protection from infectious diseases can be accomplished by requiring standardized education and
licensing by the dental board. Although the California Dental Practice Act refers to the dental
assistant as able to perform duties that are “elementary characteristics, are completely reversible
and are unlikely to precipitate potentially hazardous conditions for the patient being treated,”
they can cause severe illness and harm to a patient or themselves by not performing proper
infection control techniques (DBC, 2019, p.7).
Importance of Addressing the Problem
Choosing to be a member of the dental health team holds a great responsibility to protect
patients under the practice’s care. This problem is important to address because innocent patients
are victims of negligent infection control practices that should have been prevented by proper
education and licensing. Unlicensed dental assistants are a national problem (Kracher et al.,
2014). Nationally, requiring dental assistants to graduate from a Commission on Dental
Accreditation (CODA) accredited program and pass a national certification exam would ensure
they have met a benchmark before working on patients. CODA is approved by the U.S.
Department of Education as the accreditation agency for dental assisting, dental hygiene and
dental program (ADA, 2019). Dental boards require CODA accreditation for dental and dental
hygiene programs; however it is optional for dental assisting programs, as it is used to monitor
the quality of these programs. CODA provides consumer protection to students and validates
programs by developing and implementing accreditation standards. CODA accreditation
standards require specific educational and licensing requirements for faculty to teach in dental
assisting programs. The certification also requires an annual renewal with required continuing
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 12
education units that include infection control and cardiopulmonary resuscitation as well as
requiring a background check before issuing a license.
California does have the registered dental assisting (RDA) license. To obtain the RDA
license, the applicant must apply, provide proof of education from a board-approved dental
assisting education provider and fingerprints and pass a background check to qualify to take the
board exam. The board exam must be passed with a score of 80% or higher to become licensed.
The RDA has the same responsibility as a dental assistant, but they can perform higher-level
procedures than a dental assistant. Currently, there is no state-required education or licensing for
dental assistants, as the RDA license is optional. As a result, unlicensed dental assistants have
not been fingerprinted and checked by the Department of Justice for a criminal background,
which makes patient protection a concern.
Moreover, dentistry is an evolving field, and continuing education of dental assistants
would ensure patient protection utilizing the most current scientific data on disease prevention.
This study focused on analyzing the needs that should be met to realize the industry goal of
mandatory state-required education and licensing for dental assistants.
In healthcare settings, infection control breaches continue to be a concern around the
world and should be priorities to both patients and healthcare professionals (OSAP, 2018).
LearnEthos conducted a needs assessment of education and training in dental infection control.
The assessment included educators, consultants, industry representatives and state dental board
administrators/ inspectors/ investigators and 1,700 dental team members. LearnEthos completed
a gap analysis and found a lack of standard education and training for all aspects of infection
control related to the OSHA Bloodborne Pathogens Standard and CDC Guidelines for Infection
Control in Dental Health Care Settings requirements. Content from the public domain varied in
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 13
quality, focus and relevance to appropriate infection control. The gap analysis found a need for
accessible practical education and training that fills gaps in knowledge, skills and abilities (Mills,
Shannon, Porteous, & Zawada, 2018).
Organizational Context and Mission
The state dental board is an agency created by legislation. Each board governs the
qualifications of the practice of dentistry. Each state’s legislation grants authority to the dental
board to establish qualifications for licensure, issue licenses to qualified individuals, establish
stands of practice and conduct develop disciplinary action and rules of the board and to perform
duties. State dental board members are composed of members of the profession and the public
(American Association of Oral and Maxillofacial Surgeons [AAOMS], 2019). Each board has a
mission to protect the public. This problem of practice is a national problem; however, this study
focused on dentists and the Dental Board of California (DBC). The DBC is the governing agency
that regulates the laws of dentistry in California. Its mission statement “is to protect and promote
the health and safety of consumers of the state of California.” The vision statement is that “the
Dental Board of California will be the leader in public protection, promotion of oral health, and
access to care.” (DBC, 2019, p. 1).
An unlicensed dental assistant with no formal education is considered to be an on-the-job
trainee. According to the California Dental Practice Act, a dental assistant without a license,
under the supervision of a licensed dentist, may perform basic supportive procedures, which
“have technically elementary characteristics, are completely reversible, and are unlikely to
precipitate potentially hazardous conditions for the patient being treated” (DBC, 2017, p. 7) The
ADA describes these duties as the “most comprehensive and varied in the dental office” (p.2).
One of the duties is serving as an infection control officer, developing infection control protocol
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 14
and preparing and sterilizing instruments and equipment (ADA, 2019). This problem is
important to address because unlicensed and uneducated dental assistants can unknowingly
spread infectious diseases to patients.
Description of Stakeholder Groups
Dentistry is a team approach to promoting continuity of care to patients. The members of
the dental team include dentists, dental hygienists, dental lab technicians and dental assistants
(ADA, 2019). Dentists are doctors who specialize in oral health care and are responsible for
leading the dental team (ADA, 2019). The dentists are the stakeholders and can insist the dental
boards change dental assisting regulations. Dentists have authority over dental assistants and
directly contribute to and benefit from the achievement of the organization’s licensing goal.
Dental assistants benefit from the organizational goal of licensing because it will elevate the
profession by having all team members formally trained in all aspects of dentistry, including
infection control and patient safety. Dentists will benefit because they are responsible and liable
for their assistants’ wrongdoing. The dentist should have comfort knowing that the dental
assistant completed a standardized formal education program. The dental assistant also would
have to prove minimum competency by passing a state board exam and a background check.
This would also benefit the patients. Patients would have comfort in knowing that each licensed
dental assistant has formal education, passed a state board exam, passed a background check and
must engage in continuing education hours in infection control to renew their license. This would
ensure each dental assistant is up to date in new education. A federal law requiring dental
assistants to have standardized education and licensing would benefit all stakeholders in the
dental field.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 15
Organizational Goal
According to the DBC, their mission is to “protect and promote the health and safety of
consumers” (DBC, 2019, p. 1). State dental boards are responsible for patient protection by
establishing qualifications for licensure and issuing licenses to qualified individuals. They have
the authority to make education from accredited programs and licensing mandatory. The boards
place the responsibility of the dental assistants on the dentist they work with. To accomplish the
DBC’s mission, the organizational performance goal should be for all dental assistants to have
education and licensing by 2025. Once education and licensing becomes mandatory, dentists will
be required to hire assistants with the required qualifications. These boards also require all
licensed dentists, dental hygienists and dental assistants to take continuing education courses
because dentistry changes and grows, so continuing education is important for the most current
information to stop the spread of disease. Unlicensed dental assistants are not required to take
continuing education courses, so mandating their licensing will ensure current infection control
standards are utilized. Figure 1 shows the stakeholders’ knowledge, the organizational culture
and the stakeholder’s goals.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 16
Figure 1. The stakeholders’ knowledge, the organizational culture and the stakeholder’s goals
The state’s dental board’s organizational goals for patient protection should mandate
education and licensing for all dental assistants by 2025. Following the law and required
guidelines for infection control procedures is primarily the responsibility of the dental assistant,
so education needs to be mandatory. Continuing education is necessary for all members of the
dental team to stop the spread of disease. If a dental assistant has not had education in infection
control, they will not know how to perform proper procedures.
Stakeholder Group of Focus
This study focused on dentists who have influence over the dental boards governing
dental assistants as the stakeholder group. Although a complete analysis would involve all
stakeholder groups, for practical purposes, this study focused on dentists. Dental assistants’
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 17
scope of practice, education requirements, and licensure options vary significantly from state to
state. Thus, a national model can provide structure and consistency. Dentists can provide a
structure to be directly implemented by each state. This will benefit the dentist, dental assistant
and the patient and can achieve the organization’s mission. Dental boards have authority over
dental assistants and can promote required education and licensing. The scope of duties a dental
assistant can perform also varies significantly from state to state. The goal is to have a national
educational and licensing model that all states can adopt. This will allow for enhanced career
opportunities and increase job satisfaction as well as public/patient protection.
Purpose and Research Questions
The purpose of this project was to evaluate the degree to which dentists and state dental
boards are meeting the organization’s goal of patient protection and the effect of not mandating
education and licensing for dental assistants. The analysis focused on knowledge, motivation and
organizational influences related to achieving the organizational goal. The project evaluated the
degree of the dentist’s knowledge and motivation to meet the organizational goal of dentists
mandating dental boards to require education and licensing for all dental assistants by the year
2025. The stakeholders this project focused on was dentists who utilize dental assistants. The
findings for this project are limited to the dentists who were willing to participate in this study.
Four research questions were used to direct this project. The four research questions
were addressed through both quantitative and qualitative inquiry. The evidence that was
collected through inquiry was used to make informed recommendations for the organization.
The questions that guided this project were the following:
1. What are the dentist’s knowledge and motivation related to requiring formal dental
assisting education and licensing for all dental assistants in California?
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 18
2. What is the dentist’s knowledge and motivation related to the organization of dentistry
culture and context associated with the dental assisting laws in the dental practice act?
3. What recommendations can be made to encourage or compel dentists to employ only
licensed dental assistants?
4. Does the flexibility in the dental assisting laws allowing unlicensed and uneducated
dental assistants affect the patient’s safety and the dental assisting profession?
Definitions
The terms and definitions used in this project will be provided in this section.
Accreditation: The Commission on Dental Accreditation (CODA) implements
accreditation standards are developed to serve the public and profession through promoting and
monitoring continuous quality and improvements of the dental education programs.
Accreditation is the ultimate source of protection for students (ADA, 2019).
Allowable duties: Are regulations and status specifically used to define the duties that
each category of auxiliary is allowed to perform, the level of supervision from the dentist and the
setting in which the duty may be performed. Performing illegal functions is a criminal offense
and is grounds for license discipline of both the person performing the illegal function and any
person who aids and abets illegal activity (DBC, 2019)
Certification: To become certified dental assistants have to pass an examination that
evaluates their knowledge. Certification assures the public that the dental assistant is
competently prepared to assist in providing dental care (ADA, 2019).
Dental assistant: The dental assistants are valuable members of the dental health team
who greatly increases the efficiency of the dentist to deliver quality oral health care. The dental
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 19
assistants duties are the most comprehensive and varied in the dental office, requiring both
interpersonal and technical skills (ADA, 2019).
Dental board: Each state has a dental board that acts as a regulatory agency that licenses
and regulates dentists, dental hygienists and dental assistants. The dental board is responsible for
setting the duties and functions of unlicensed dental assistants. The dental board’s highest
priority is patient protection during dental treatment. The dental board investigates complaints
against licenses and disciplines for violations of the Dental Practice Act (DBC, 2019).
Dentist: Licensed dentist can diagnose and treat by surgery or other method disease and
lesions, the correction of malposition of the human teeth, alveolar process, gums, jaws or
associated structures and all necessary related procedures as well as the use of drugs, anesthetic
agents and physical evaluation (DBC, 2019).
Infection control: The dental board regulations detail the minimum standards for
infection control that all dental health professions must follow (DBC, 2019).
Licensing: Certification and licenses demonstrate a level of skill and knowledge needed
to perform a specific job and need to be renewed periodically. Licenses are awarded from a
governmental agency based on predetermined criteria. The criterion typically includes a
combination of education certificate and state-administered exams. Licensing gives legal
authority to work in the occupation (BLS, 2019).
Organization of the Paper
This project is organized using five chapters. Discussed in Chapter One are the key
concepts and terminology related to unlicensed and uneducated dental assistants safety concerns
for patients. Also included in chapter one is the organization’s mission, goals, stakeholders and a
review of the evaluation framework that will be used for this project. In Chapter Two a review
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 20
of the literature will include literature surrounding the scope of the project using assumed factors
and influences of the stakeholder. The literature review will be used to frame the
underachievement of the stakeholder’s goal using a gap analysis. In Chapter Three will detail
the knowledge, motivation and organizational elements that were validated during data
collection. The chapter will also include the methodology used, the choice of participants, data
collection and analysis. In Chapter Four, the data and results will be analyzed and assessed.
Chapter Five will include solutions based on literature to close the performance gap. The
recommended solutions will also include an integrated implementation and evaluation plan.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 21
CHAPTER TWO: LITERATURE REVIEW
The California Dental Practice Act states a dental assistant can to perform “elementary
characteristics, are completely reversible and are unlikely to precipitate potentially hazardous
conditions for the patient being treated” (DBC, 2019, p. 7). However, they can cause serious
illness and harm to a patient or themselves through improper infection control techniques to
prevent the spread of infectious diseases to the patient as well as the dental health team (DBC,
2019). Most infectious diseases that can be spread and transferred to a patient during dental
treatment are not reversible. Virus and bacteria can be spread through mucosal exposure and
transmitted from contaminated dental equipment, instruments and surfaces. As Breen (2013)
explains, the role of the dental assistant has changed significantly over the years from the “Lady
in Attendance” (p. 4). In the late 1800s, a dentist hired the first female attendant. Her role was to
be present during procedures for female patients, so the husbands did not have to stay. As the
role of the dental assistant has changed to include a wide variety of sophisticated and invasive
clinical procedures, so should the requirements for entry into the field. Namely, they should
graduate from a formal education program and be licensed. The profession has a responsibility of
patient protection. Dental assistants should be required to meet a standard benchmark to provide
direct patient care (Breen, 2013). Not requiring this benchmark can result in infection outbreaks.
In 2013, the Oklahoma State Health Department was notified by the CDC of possible
dental healthcare-associated transmission of hepatitis C. The CDC was notified when a patient
who was a regular blood donor screened positive for HIV and HCV during a routine blood
donation. After further investigation, the health department confirmed the patient had received
dental care at an oral surgery practice and was exposed to hepatitis C, hepatitis B, and HIV. A
field investigation of the oral surgery office of Dr. Scott Harrington revealed breaches in
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 22
standard infection control procedures as well as in administration of controlled drugs. The final
report of the investigation revealed the need for heightened awareness regarding infection control
procedures and injection safety. Effective July 1, 2013, the Oklahoma Dental Practice Act added
requirements for dental assistants to pass a national certification exam (Oklahoma State
Department of Health, 2013).
Weaver (2014) expressed that only licensed health care professionals should perform
infection control protocols because of the significant risk associated with mistakes. Preventing
the spread of infectious diseases requires meticulous infection control protocols, as there is no
vaccine or cure at this time for hepatitis C or HIV. Weaver noted two events that changed
dentistry. The first was in 1980 when Dr. David Acer infected six patients with HIV in his
practice. The second event was the outbreak in 2013 at Dr. Scott Harrington’s practice in Tulsa,
Oklahoma (Weaver, 2014 ) .
Patient Protection
Following the law and required guidelines for infection control procedures is primarily
the responsibility of the dental assistant, so education needs to be mandatory (Eklund &
Marianos, 2013). When investigators questioned Dr. Harrington’s assistants about the many
infection control violations and performing procedures beyond their scope of practice, their
argument and claim were Dr. Harrington had them do it, and they did not know it was illegal.
When Dr. Harrington was questioned, he directed the questions to the dental assistants saying,
“They take care of that, and I do not.” (Hawley, 2013). Legally, it is the responsibility of the
dentist to know what is taking place in practice (DBC, 2019). During the investigation, the
Dental Board of Oklahoma found rusted instruments impossible to sterilize, needles being
reused, and that the autoclave had not been tested in years. Dentists rely on the dental assistant to
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 23
manage and maintain infection control procedures and assume they are being done according to
CDC guidelines. Hawley (2013) explains that, as dentistry changes and grows; continuing
education is necessary to stop the spread of disease. If a dental assistant has not had education in
infection control, they will not know how to perform the proper procedures, as was found in Dr.
Harrington’s office. Handley (2013) describes the criminal practices that happened, and Dr.
Harrington’s office reinforces the need for mandatory infection control practices and education.
Dr. Harrington never checked on whether staff were following proper procedures (Hawley,
2013).
Mustafa, Humam, and Al-Mosuli (2014) evaluated infection control knowledge levels of
dental assistants who attended education programs compared to those trained on the job. The
results showed appropriate education, training and work experience is needed to perform well.
However, the authors found that dental assistants with college-level qualifications who held
licenses had low errors in radiology asepsis (infection control), laboratory asepsis, disposal of
clinical waste and OSHA applications for microorganism transmission. The study concluded the
uneducated unlicensed dental assistant needed to be closely supervised to maintain proper
infection control standards (Mustafa et al., 2014).
Dentists Do Not Train to the Same Standards as Formal Education
Dental assisting programs require an extensive number of hours on curriculum and
passing tests of clinical competencies to graduate. Hartshorne (2010) explains it is a professional
obligation to provide infection control and safe dental care. Standard of care implies healthcare
workers are knowledgeable in the guidelines required to prevent disease transmission. Dentists
who do not properly train their staff are providing substandard patient treatment (Hartshorne,
2010). Dental health professionals have an ethical responsibility and a moral obligation to have
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 24
the most current training for infection control practices to prevent the spread of disease
(Hartshorne, 2010).
The investigator from the Oklahoma Board of Dentistry, Susan Rogers, was interviewed
to discuss the infectious disease outbreak that occurred at Dr. Scott Harrington. Rogers stated
this dentist was allowing his dental assistants to start IV sedation and put patients under
anesthesia. The assistant would guess how much drug dosage to give depending on how heavy
patients were. A dental assistant cannot legally insert needles into patients and cannot administer
drugs. Instruments were rusted, peeling and still had debris on them. The instruments were being
wrapped in a baby diaper rather than an FDA approved sterilization bag or paper. The two
assistants who were interviewed were ignorant of the law and stated they had always done things
that way. Dental assistants should get permits before they can be in the operatory (Hawley,
2013).
In a separate incident, five people became infected with a hepatitis B outbreak that
occurred in a portable dental clinic in West Virginia. This breach that caused the outbreak was
from direct failures of following infection control practices and policies (Radcliffe et al., 2013).
During an interview with the health department, the patient stated the dentist picked up
contaminated instruments from a previous patient’s bracket table and used them on a different
patient. Dental handpieces were wiped down with a paper towel and not sterilized (Radcliffe et
al., 2013).
Health care providers have a legal and ethical responsibility to follow CDC guidelines as
well as federal, state and local regulations. These regulations are primarily complaint-driven and
result in lack of monitoring for compliance. Requiring mandatory education for all dental health
professionals and inspections of their offices would be an effective solution to provide safe care
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 25
to patients (Eklund & Marianos, 2013). It cannot be assumed all dentists follow infection control
guidelines and have had bloodborne pathogens training (Radcliffe et al., 2013).
Occupational infectious risk in dentistry awareness and protection was the focus of a
study using dental students in their fourth, fifth and sixth year and dental practitioners (Balcheva,
Panov, Madjova, & Balcheva, 2015). The study of the occupational infectious risks in dentistry
and the risk of transmission of bloodborne and other occupational microbial pathogens was
performed to evaluate the risk of infectious disease transmission. The study was to determine the
extent to which the dentist evaluated the risk of infectious disease to protect themselves and their
patients by adhering to infection control guidelines. The study found the dentists and students
were not following standard safety measures. For example, they rarely used goggles and never
put on a face shield. The study found that 79.8% of participants treated their patients even if they
had an infectious disease or viral shedding. The results of the study showed that, although they
had the knowledge of infectious diseases and understood standard precaution, they neglected to
follow the correct infection control protocol (Balcheva et al., 2015).
Research Questions
1. What are the dentist’s knowledge and motivation related to requiring formal dental
assisting education and licensing for all dental assistants in California?
2. What is the dentist’s knowledge and motivation related to the organization of dentistry
culture and context associated with the dental assisting laws in the dental practice act?
3. What recommendations can be made to encourage or compel dentists to employ only
licensed dental assistants?
4. Does the flexibility in the dental assisting laws allowing unlicensed and uneducated
dental assistants affect the patient’s safety and the dental assisting profession?
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 26
Stakeholder Knowledge and Motivation Influences
Knowledge and Skills of Dental Assisting
This literature review addresses the knowledge-related influences on the dental board’s
goals for health and safety for patients and the dental assistant’s role in providing safe dental
visits. The literature review also addresses the lack of national consistency and standards
regarding education and licensing. Knowledge addresses whether people know how, what or
when to do something and is derived from education (Rueda, 2018). Foundational knowledge is
produced in the didactic, laboratory and clinical setting through instruction. Biomedical, dental
behavioral and clinical science instruction establishes the educational foundation for students to
synthesize and analyze the implementation of treatment procedures, preparation for supportive
services for patient care and patient education (Monroe Community College, 2011).
Learning is a science and is not a straightforward one-way process. It involves three
essential elements: learning, instruction, and assessment (Mayer, 2011). Learning is incomplete
if there is not a way to assess what was learned. Descriptions of desired learning outcomes are
essential for evaluating instructional effectiveness (Mayer, 2011). Dental assistants’ complex job
duties require conceptual knowledge to perform daily tasks. In dental assisting education,
competencies are a measure of acceptable, measurable and defined level of specialized skills and
knowledge. Competency is a defined level of special skill and knowledge derived from education
(Monroe Community College, 2011). To be competent in their duties, dental assistants must
perform at or above the defined acceptable minimum competency standards.
The performance objective of a dental assistant’s job requirements requires multiple
knowledge dimensions to perform all tasks successfully. Defining achievement goals can be
done by knowledge dimensions allowing for concrete teaching and learning (Rueda, 2011).
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 27
Factual knowledge is basic elements a student must know for a discipline. Knowledge of
terminology is discrete, isolated contents and specific elements (Lampinen & Arnal, 2009).
Conceptual knowledge is complex organized forms of knowledge that include basic elements
within a larger structure that enable them to function together (Lampinen & Arnal, 2009).
Procedural knowledge is how to do something using methods, criteria for using skills and
techniques (Lampinen & Arnal, 2009). Metacognitive knowledge is awareness and knowledge
about one’s own cognition or awareness of knowledge (Lampinen & Arnal, 2009).
Dental assistants need knowledge in all four dimensions to meet the performance goals of
the minimum clinical competency required. An example is to follow state law, and a higher level
of knowledge is required to follow guidelines for infection control procedures. There is a risk of
occupational exposure to bloodborne pathogens every day to dental practitioners (Balcheva et al.,
2015). Infection control it is not merely a checklist. It requires education at a conceptual
knowledge level on why specific procedures are performed. Thus, it requires factual and
conceptual knowledge of microbiology and disease transmission to understand and perform
disinfection and sterilization procedures correctly. Procedural knowledge is then used to set up
the clinical operatory correctly and to decontaminate the treatment room. Following step-by-step
guidelines to disinfect and sterilize instruments ensures patient safety.
Education allows people to acquire conceptual, theoretical and strategic knowledge and
skills needed for unexpected challenges (Clark & Estes, 2008). Unexpected challenges happen
daily in the dental field. For example, if a dental assistant does not have the proper education,
they can injure themselves with dirty instruments. Although on-the-job training or job aids are
more cost-effective, these are not suitable for jobs that require guided practice to achieve
complex performance goals (Clark & Estes, 2008). Clark and Estes (2008) explain the types of
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 28
knowledge and skill enhancements; when people do not know how to accomplish performance
goal, then information, job aids or training are needed. When challenges require problem-
solving, there is a need for continuing and advanced education (Clark & Estes, 2008).
Awareness of the problem. Awareness of the problem of uneducated dental assistants is
critical to address because they can unknowingly spread infectious diseases or overexpose
patients to radiation (Breen, 2013). Training that is effective can increase productivity,
motivation, and commitment, improve morale and teamwork and reduce errors (Grossman &
Salas, 2011). There is a danger from only learning the “what and how” and not learning the “why
or when” in regards to learning and can lead to trial and error (Rueda, 2011). Dental assistants,
under state law are the responsibility of the licensed dentist. Therefore, it is the dentists’
responsibility to delegate necessary infection control procedures through proper training and
check-up to confirm procedures are carried out correctly. Neglecting this responsibility can
detrimental effects. Chronic disease can be spread to patients and can cause death. Legal and
criminal charges can be filed against the dentist and dental assistants (Hawley, 2013). Reports
indicate injuries can be extremely costly, as $180.0 billion is spent on injuries and death from
insufficient training each year (Grossman & Salas, 2011). Although California’s Dental Practice
Act allows for uneducated unlicensed dental assistants who are trained on the job, they can cause
severe illness and harm to a patient or themselves by not performing proper infection control
techniques. On-the-job training is learning how-to knowledge for recurring knowledge tasks but
does not address unexpected, novel or non-recurring problems (Clark & Estes, 2008). Although
organizations emphasize training, the bulk of the training does not transfer to the job. The
employee may gain some new knowledge and skill, but it is not sufficient to be considered
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 29
adequate (Grossman & Salas, 2011). On-the-job training in the field of dentistry is inadequate
because the job is always unexpected and changing.
As an example, Mustafa et al. (2014) found the success of a dental practice depends on
the dental assistant who is the primary link from the patient to the dentist. The dental assistant is
responsible for most of the practical procedures to avoid contamination during procedures. The
authors found a need for appropriate education, training and work experience. Based on recent
evidence, some dental assistants underperform in infection control procedures. Mustafa et al.
found that dental assistants with college-level qualifications and licenses had lower rates of
errors. The authors concluded uneducated unlicensed dental assistant need to be carefully
supervised to maintain proper infection control standards (Mustafa et al., 2014).
Conceptual knowledge influence. Conceptual knowledge in dental assisting builds from
the essential elements previously learned from factual knowledge. For example, fundamentals of
bones of the skull and tooth morphology are used to build on and learn conceptual knowledge of
dental radiography. Conceptual knowledge from the bones of the skull is necessary to learn
landmarks of the skull in dental radiographs aids in reading dental radiographs and identifying
anatomical features of the teeth from previous knowledge of learning tooth morphology.
Conceptual knowledge obtained from learning microbiology allows for the understanding of
disease transmission. Value needs to be placed on knowledge influences and sequences of
information to master the information required for patient safety. A standardized benchmark that
includes competencies and a measurement of knowledge should be required before a dental
assistant can be allowed to participate in patient treatment.
Procedural knowledge influence. Procedural knowledge is how to do something using
very specific skills and techniques and particular methodologies to accomplish a task (Rueda,
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 30
2011). Dental Assisting relies very heavily on procedural knowledge to accomplish clinical
procedures. The Bureau of Labor Statistics (2019) estimates there are 337,160 dental assistants
nationally and 50,100 in California. According to statistics, employment in this area is expected
to grow 18% between 2014 and 2024 (Kracher et al., 2014). As Breen (2013) explains, the
profession has responsibility for patient protection. Dental assistants should be required to meet a
standard benchmark before providing direct patient care (Breen, 2013).
The focus of the American Dental Assistants Association (ADAA) is to advance the
careers of dental assistants through education, legislation and credentialing (ADAA, 2018).
Licensing or certifications are tests used to provide a benchmark to ensure the protection of
public health, safety, and welfare. The test content is based on knowledge, skills, and abilities
directly related to the candidate’s qualification to work in the industry (Shimberg, 1981).
Licensure is
A process by which an agency of government grants permission to an individual to
engage in a given occupation upon finding the applicant has attained the minimum degree
of competency required to ensure that the public health, safety, and welfare will be
reasonably protected. (Shimberg, 1981, p. 1138)
Licensing laws are referred to as “practice acts” because they contain the scope of practice. It is
against the law for an unlicensed person to perform any activities defined in the scope of practice
(Shimberg, 1981). Table 1 Identifies the organizational mission, global goal and knowledge
influences discussed in the literature review.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 31
Table 1
Organizational Mission, Global Goal and Knowledge Influences
Organizational Mission
The mission is to protect and promote the health and safety of consumers/patients nationally.
Organizational Goal
Dentists in each state dental board are regulated by the dental board. Dentists and the dental board have
a goal to protect patients during dental treatment. This study will focus on dentists who employee
dental assistants. The Dental Board of California’s mission is to protect and promote the health and
safety of consumers of the state of California. To fulfill the mission of the dental board, for patient
protection, state-required education and licensing should be mandatory for dental assistants working in
the dental health care field by 2025.
Stakeholder Goal
Dentist’s goal is to protect and promote the health and safety of patients during dental treatment under
their supervision. Dentists rely on the dental board for making laws and regulations that determine the
education and licensing of dental assistants. Dentists can encourage the dental board to require all
dental assistants be “registered” to have formal dental assisting education and licensing to protect and
promote the health and safety of patients.
Knowledge Influence Knowledge Type (i.e.,
declarative (factual or
conceptual),
procedural, or
metacognitive)
Knowledge Influence Assessment
Dentists know the licensing criteria. Factual Surveys
Dentists know that requiring dental
assistants to be educated and licensed
promotes patient protection.
Conceptual Surveys
Dentists know the education and
requirements for dental assistants
licensing criteria.
Factual Surveys
Knowledge Influence Knowledge Type (i.e.,
declarative (factual or
conceptual),
procedural, or
metacognitive)
Knowledge Influence Assessment
Dentists promote the Dental Boards
establishing required dental assisting
licensing.
Procedural Surveys
Dentists know how to reflect on their
purpose of providing safe dental visits
for patients and progress toward
promoting the Dental Board to
achieving licensing for all dental
assistants.
Metacognitive Surveys
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 32
Organizational Goal
For patient protection, state dental boards should require education and licensing for
dental assistants by 2025. Dentists rely on dental assistant to manage and maintain the infection
control procedures in the office and assume they are being done according to CDC guidelines.
Continuing education is a necessity for all members of the team to prevent the spread of disease.
If a dental assistant has not had education in infection control, they will not know how to
perform proper procedures.
Motivation
Motivation addresses the influences on people’s choice, effort, and persistence to do
something. Knowing how to do something does mean one will or wants to do it (Rueda, 2011).
Four critical components to motivation are that it is personal or internal, that it is activating and
instigates behavior, that it is energizing which fosters intensity and persistence, and that it is
directed at accomplishing a goal (Rueda, 2011). Active choice is defined as making a choice and
actively pursuing a goal. After choosing to join the healthcare field, dental assistants need to
have self-efficacy to complete the performance goals of providing the highest level of patient
care. Using Clark and Estes’ (2008) active choice as an example, the uneducated dental assistant
might not intentionally mean to give a patient HIV, but, by choosing to not be persistent and
pursue dental assisting education, they do not place value on the patient’s safety (Clark & Estes,
2008). The value of the patient’s safety needs to be a priority and considered when determining
the state’s dental assisting minimum requirements. Dentistry as an organization should value the
patient’s safety and actively follow industry standards and require dental assisting education and
licensing. Changing these standards will ensure the highest level of patient safety.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 33
Expectancy-value theory finds that learning and motivation are enhanced when the
learner values the task (Eccles, 2006). Activities and materials need to be relevant and useful to
the learner to connect real world tasks (Pintrick, 2003). Expectancy-theory can be used to
recognize the need of education and licensing of dental assistants. Clark and Estes (2008)
identified that many organizations use wrong or outdated information or incomplete strategies
for their motivational systems. Allowing for uneducated and unlicensed dental assistants can be
viewed inherently cultural motivation in dentistry. Rueda (2011) described cultural model as a
shared mental schema or normative understandings of how things work or ought to work and
expressed through cultural practices and behaviors. The belief that a dentist can train a dental
assistant to the same competencies and standards as an accredited program is seen in the social
context of dentists. Rueda (2011) defines motivational value as the importance one attaches to a
task. The DBA’s vision and mission statements offer evidence that patient protection in the form
of education and licensing of dental assistants does not have a value to the dental board.
Value motivational theory. Motivation gets us going and determines how much time
and effort to spend on tasks (Clark & Estes, 2008). Dental assistants have a responsibility to
protect patients. There is a belief that dental assistants do not need education competencies
because of negative interpretations in the dental industry. Clark and Estes (2008) explained,
right or wrong, beliefs can be as strong as taking a placebo; the patient believes the medication is
working, but it is just a sugar pill. The dental industry has strong beliefs that dentists can train
dental assistants as well as an education program while paying them far less. Utility value asks
people to focus on the benefits of finishing a task (Clark & Estes, 2008). Research shows that, if
an individual feels personally responsible for their behavior and goals, they will fully engage in
learning. The individual’s value of the task is characterized by the anticipated cost (Window,
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 34
Window, & Eccles, 2006). When an individual understands having no education causes potential
risks to patients and themselves, they can envision the sense of self-worth after graduating. Then
the individual gains value task motivation (Window et al., 2006).
Goal orientation theory. Goal orientation theory examines the reasons why people
engage in academic work and can be used to examine other domains (Anderson, 2005). Goals
motivate and direct individuals and encourage personal and social responsibility (Pintrich, 2003).
It is essential for a dental assistant to have mastery and performance goals to develop the skills to
provide the highest level of patient care and protection. They are required in dental assisting
programs to have proven minimum competency in both performance and mastery goals set by
accreditation standards. Table 2 identifies the motivational influences and assessments for the
stakeholder goals.
Table 2
Motivational Influences and Motivational Influence Assessments
Organizational Mission
The mission is to protect and promote the health and safety of consumers/patients nationally.
Organizational Goal
Dentists in each state dental board are regulated by the dental board. Dentists and the dental
board has a goal to protect patients during dental treatment. This study will focus on dentists
who employee dental assistants. The Dental Board of California’s mission is to protect and
promote the health and safety of consumers of the state of California. To fulfill the mission of
the dental board, for patient protection, state-required education and licensing should be
mandatory for dental assistants working in the dental health care field by 2025.
Stakeholder Goal
Dentist’s goal is to protect and promote the health and safety of patients during dental
treatment under their supervision. Dentists rely on the dental board for making laws and
regulations that determine the education and licensing of dental assistants. Dentists can
encourage the dental board to require all dental assistants be “registered” to have formal dental
assisting education and licensing to protect and promote the health and safety of patients.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 35
Table 2, continued
Assumed Motivation Influences
Motivational Influence Assessment
The dentist values having licensed dental
assistants. (Value).
Survey
The dentist is confident they can influence the
dental board to establish licensing criteria. (self-
efficacy)
Survey
The dentist attributes their success or failure to
establish licensing criteria to their own efforts.
the dental assistants and promotes establishing
licensing criteria to their own efforts (attribution)
Survey
The dentist feels positive about licensing criteria
(affect)
Survey
Organization
General theory. The organizational culture in dentistry requires a regulating board to
determine statues and regulations called dental practice acts. Dentistry is primarily governed by
each state, but the federal government controls some portions of dental practice (Troolin, 1997).
Regulatory boards are responsible for regulating the profession and are the responsibility of each
state. One-quarter of the U.S. job market requires a state license. Manicurists, shampooers,
florists, and auctioneers require licensing. Boards are intended to protect the health, safety, and
welfare of the public (Troolin, 1997). Dental boards have been historically regulated by their
members who are practitioners in the field. Regulatory boards define and enforce practices of a
profession by creating a cultural model. Regulatory boards like the dental board, distinguish the
dental assistant’s responsibilities including the need for required education and licensing.
Regulatory boards are controlled by the members of the profession they govern, and,
therefore, there is a risk that these boards can make anticipative decisions that serve the private
interests of their members and not in the interest of protecting the public (Rivers, 2016). The
state board of dentistry regulates the majority of the practice of dentistry including qualifications
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 36
to practice (Troolin, 1997). The board has executive, legislative and judicial powers over
dentistry. Most boards have a full-time government employee or commissioner to oversee it and
its members are private citizens (Troolin, 1997). Each state’s board establishes qualifications for
licensure and specifies qualifications, including education requirements (Troolin, 1997).
The dental practice act of each state regulates the legal duties of dentists, dental
hygienists, and dental assistants as well as their required education and licensing. Although every
state has different regulations for duties a dental assistant can perform, there is a minimum
“allowable duties” the Dental Practice Act allows them to perform. Although the duties vary
from state to state, these minimum duties will be referenced as the cultural setting addressed in
this paper as defined by the ADA. The ADA defines a dental assistant as increasing the
efficiency of the dentist in the delivery of quality oral care. The duties of a dental assistant are
“among the most comprehensive and varied in the dental office” (ADA, 2019). The job duties
include assisting the dentist during a various treatments, exposing and developing dental
radiographs, taking and recording vital signs and medical history, serving as infection control
officer, developing infection control protocol, sterilizing instruments and equipment, comforting
patients before and after treatment, providing patients with post-operative instructions and
consent before treatment, providing patients with oral hygiene instructions and nutritional
counseling, taking impressions of teeth for study cases, performing office management and
helping with direct patient care (ADA, 2019). These duties are complex and require formal
education for adequate training.
Stakeholder-specific factors. The cultural setting for dental assistants causes
considerable confusion in the industry. There are many interpretations of regulations, and, most
often, dentists decide for themselves what they will allow their dental assistants to do despite
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 37
what the laws state. In 2014, there were an estimated 318,800 dental assistants employed in the
United States. The average dentist in private full-time solo practice employs a minimum of 1.5
dental assistants. Dental assistants with formal education have a higher salary than those trained
on the job (Kracher et al., 2014). They are critical members of the team and should be formally
educated in all aspects of clinical patient treatment (Kracher et al., 2014).
Table 3 identifies the assumed organizational influences and assessments for the stakeholder
goals.
Table 3
Assumed Organizational Influences and Assessments for the Stakeholder Goals
Assumed Organizational Influences
Organizational
Influence
Assessment
The dentists support the culture in the CA dental domain that supports
the Board to establish licensing criteria. (model)
Survey
The public culture supports the dentists to provide patient safety. (Model) Survey
The culture within the dentistry is to support patient safety (Model) Survey
Dentists meetings and day to day activities support the effort to protect
and promote the health and safety of consumers. (setting)
Survey
Licensing dental assistants in California is motivation for the dentists. Survey
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 38
CHAPTER THREE: METHODS
The purpose of this project was to address the problem of patient safety during
procedures conducted by unlicensed and uneducated dental assistants. In California and most
other states, a dental assistant is not required to have a license or dental assisting education to
work on patients, although dentistry requires extensive knowledge to provide patient treatment
and infection control procedures. This project addressed unlicensed and uneducated dental
assistants unknowingly spreading infectious diseases to patients. The DBC defines a dental
assistant as an individual who, without a license, may perform basic supportive dental
procedures under the supervision of a licensed dentist (DBC, 2019). The ADA describes one of
the primary duties of a dental assistant as serving as an infection control officer, developing
infection control protocol, preparing, and sterilizing instruments and equipment (ADA, 2017).
This contradicts the dental board’s definition of “completely reversible and unlikely to
precipitate potentially hazardous conditions to the patient” (DBC, 2019, p. 7).
Dentists rely on dental assistant to manage and maintain infection control procedures in
the office and assume they are being done according to CDC guidelines. Dentists are legally
responsible for hiring, providing training and supervision of dental assistants as well as ensuring
patient safety. Many dentists feel they can train a dental assistant adequately; however, a
dentist’s education does not focus on the same training as that of an accredited dental assisting
educational program, which creates a discrepancy in training. Therefore, education for all dental
assistants should be required by law.
Participating Stakeholders
Dentists were the stakeholders for this study, as they are directly responsible for dental
assistants and delegate allowable duties under their supervision. Dentists are also primarily the
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 39
ones who make the decision to hire assistants. They determine whether candidates will be
required to have a formal education and be licensed or be trained on the job. Using dentists for
the survey provides valuable information to the dental board regarding the procedures dentists
are relying on the dental assistant to perform. This information allows for a gap analysis to be
performed on whether on-the-job training is sufficient for the tasks dental assistants perform.
Survey Sampling Criteria and Rationale
Criterion 1. Dentists in the United States were the focus of this study. They provided
information on the culture of dentistry, knowledge, and motivation of dental assisting education
and licensing from a national perspective.
Criterion 2. Dentists who employ dental assistants were the focus of this study.
Survey Sampling (Recruitment) Strategy and Rationale
Quota sampling and non-random strategy were used for this study using dentists from a
phone list. According to the ADA (2019), in 2017, there were 198,517 working dentists in the
United States. The study sought sampling from 100 dentists in the United States using an
internet-based survey emailed to potential respondents (Creswell, 2014). Using online surveys
allows for a larger sample of dentists. The study sought a large enough sample to provide enough
opinions on education versus no education and licensing versus no licensing. The study sought to
understand the value of dentists place on dental assisting education and licensing compared to
the role of the dental assistant performs in the office. The survey was the start of data collection.
The survey included a statement on the purpose of the study and was cross-sectional with the
data being collected over one point in time (Creswell, 2014).
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 40
Explanation for Choices
The method of data collection was a survey so that a larger sample could be convened.
Dentists from all over the United States were asked to take the survey. The data required to
address the research questions needed to be numerically based to provide dental boards a
numerical impression to accurately describe the relationship of the problem of unlicensed and
uneducated dental assistants providing patient care.
Quantitative Data Collection
This study utilized surveys for data collection from dentists who employ dental assistants.
Surveys provide a numeric description of the opinions and attitudes of populations by studying a
sample population (Creswell, 2014). This method was selected to reveal a large sample of rich
and accurate data from dentists regarding the dental assistants they employ and their
responsibilities within their practices. The survey asked multiple questions to identify the
dentist’s expectations of the dental assistant’s knowledge and motivation as well as the dental
assistant’s responsibilities in the practice and the variations of dental assistants: trained on the
job, formal education, licensed or unlicensed.
Surveys
The purpose of a survey for research is to provide a sample of characteristics, attitudes,
and behavior of a population (Creswell, 2014). This survey sampled a population of dentists on
the characteristics, attitudes, and behaviors of dental assistants they employ. Random samples of
dentists were emailed surveys using a local dental society and dental assisting program contacts.
The survey consisted of 20 multiple-choice questions organized in two sections. The questions in
the first section asked about education and licensing. The second section included the dental
assistant’s responsibilities alongside a list of typical duties. The literature review justified
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 41
addressing the problem and established the importance of this study (Creswell, 2014). Previous
studies have not addressed the problem of unlicensed and uneducated dental assistants providing
dental care. Topics might not be found in literature because the voices of underrepresented
groups of people have not been published (Creswell, 2014). The questions chosen specifically
address the conceptual framework regarding dentist’s knowledge and motivation regarding
uneducated and unlicensed dental assistants providing dental treatment and patient care.
Surveys were administered online using Qualtrics. An email directed participants to the
survey link. The email contained an explanation and purpose of the study. The instructions stated
that the participant could withdraw from the study at any time. Using online surveys allowed for
a larger sample size. The survey was administered to dentists rather than to the dental assistants
and the dental board. The rationale for having dentists fill out the survey was that they are the
ones who hold positions on the dental board and are the ones who hire dental assistants. Dentists
are also responsible for the duties that a dental assistant performs under their supervision, and,
therefore, can provide insight on these duties as they vary by dental practice.
Qualitative Data Collection
Interview Sampling Criterion and Rationale
Criterion 1. Dentists in the United States were the focus of this study. This population
provided data on cultural of dentistry, knowledge, and motivation of dental assisting education
and licensing from a national perspective.
Criterion 2. Dentists who employ dental assistants were the focus of this study.
Interview Group Sampling Strategy and Rationale
Purposeful sampling of the stakeholder group was used to conduct the interviews. The
samples for the interviews were dentists from the survey that indicated they would like to
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 42
participate in a follow-up interview questions and provided an email address. The dentists
interviewed were in private practice or government run clinics and were directly responsible for
hiring dental assistants. The interviews began by explaining the purpose of the study was to
address concerns in dental assisting. All the information gathered from the interviews was
confidential. The information was only used for the purpose of this study and participants could
withdraw at any time. The dentists could choose not to answer questions they did not feel
comfortable answering. The majority of the interviews were conducted over the phone and a
couple elected to answer the questions via email.
Validity and Reliability
Validity in quantitative research can come from content validity, predictive or concurrent
validity and construct validity (Creswell, 2014). In this study, content validity and construct
validity were used to establish the validity of the survey. Content validity ensures a sample truly
reflects items in a specific topic (Salkind, 2016). Construct validity ensures a measure has some
underlying psychological construct (Salkind, 2016). Field or pilot testing a survey is essential to
establish the content validity of an instrument and to improve questions, format, and scales
(Creswell, 2014). A pilot survey was field tested with 10 participants to establish content
validity. Knowing the respondents and making the questions understandable can improve the
response rate (Fink, 2013).
The survey was reviewed by stakeholders in the dental assisting community for content.
Using a pilot survey provided the feedback to make changes to the questions before the final
survey was sent to dentists. The results of the survey were anonymous, and no identifiable
information about the dentist or dental office was collected. This should enhance the validity of
the study so that dentists can answer honestly without the fear of repercussions from the dental
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 43
board for having dental assistants practice outside the scope of the dental practice act. There is an
increase in response rate by telling respondents how you plan to use the data collected (Fink,
2013). The hope was to have a 90% response rate. The dentists had 30 days to complete the
survey. A reminder email was sent out at ten, five and one day before the survey deadline.
Ethics
My role and interest in this study are due to my being a dental assistant for 23 years and
transitioning career-wise to education. I am a program director and instructor for a state and
nationally accredited dental assisting program at Pasadena City College.
There are many layers to the profession of dental assisting addressing education,
licensing and the national shortage of dental assistants. There could be a relationship between the
two problems, and this study could distinguish it. The participants were dentists who have
employed unlicensed dental assistants. It was important not to attempt to educate or debate
during the interview (Rubin, Rubin, & Sage, 2012). It was my responsibility to keep the
information confidential because it was likely that the dentists had dental assistants perform tasks
and procedures outside of their scope of practice and against the law. The dentist and dental
assistants could face charges from the dental board for breaking the law. It was important during
the interview to not pretend to share the same beliefs as the person being interviewed (Rubin et
al., 2012). I use an informed consent form that stated participation is voluntary. Their
participation and the data were kept confidential. I obtained permission to record the interviews.
I stored data in a secure location. There was no relationship between research and interviewees
that would compromise the study. Assumptions and biases I had going into the field was that
dentists employed unlicensed dental assistants and had them perform duties and tasks that are not
part of their allowable duties according to the dental practice act. The foreseeable risks to the
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 44
participants was that they were not honest because they were breaking the law by having dental
assistants perform tasks they were not licensed to perform. I minimized that risk by stating the
study was confidential and the information would not be shared.
Limitations and Delimitations
Some of the limitations to this study are the dentists answering the questions with an
honest response. Some of the survey questions included items that would be outside the scope of
practice for dental assistants, which would mean the dentists is having the dental assistant
perform duties beyond there scope, which is illegal and can have legal consequences for the
dentist. Although the survey was anonymous, a dentist could still feel that answering truthfully
could jeopardize their license.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 45
CHAPTER FOUR: RESULTS AND FINDINGS
The purpose of this project was to conduct a gap analysis (Clark & Estes, 2008) using
qualitative data to examine the knowledge, motivation and organizational elements that influence
dentists’ decision to hire unlicensed dental assistants. Chapter One discusses the problem of
unlicensed dental assistants creating a concern for patient safety. Chapter Two provides a review
of the literature and research as well as assumed knowledge, motivation, and organizational
influences in dentistry that affect dental assistants. Chapter Three outlines the methodology used
to study the assumed influences within the organization of dentistry in regards to dental assisting.
The purpose of Chapter Four is to present the results of this study in terms of answering the
following research questions:
1. What are the dentist’s knowledge and motivation related to requiring formal dental
assisting education and licensing for all dental assistants in California?
2. What is the dentist’s knowledge and motivation related to the organization of dentistry
culture and context associated with the dental assisting laws in the dental practice act?
3. What recommendations can be made to encourage or compel dentists to employ only
licensed dental assistants?
4. Does the flexibility in the dental assisting laws allowing unlicensed and uneducated
dental assistants affect the patient’s safety and the dental assisting profession?
The analysis began by generating a list of assumed interfering elements that influence
dentists’ hiring of unlicensed dental assistants and validating the influencing using surveys and
interviews. The survey and interview questions were constructed according to the methodology
proposed in Chapter Three.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 46
Participating Stakeholders
Participants were licensed dentists working with dental assistants. A survey was
distributed via email to licensed dentists. No identifiers were collected during this study to
protect the identity of the participants. To answer the research questions, a 20-question online
survey was conducted. A follow-up interview was conducted with those who wished to
participate. The data collection for this study took place over twelve weeks. The survey was
offered online and was available from April 1 to June 14 in 2019. The survey took
approximately 10 minutes to complete. The final sample consisted of 64 dentists, which
represented a 12% response rate. Follow-up interviews were conducted with 10 dentists from
the survey participants who submitted an email address indicating their interest in being
interviewed. The interviews consisted of 12 questions to expand on the survey questions in
regards to knowledge, motivation, and organizational influences in dentists’ requirements of
dental assistants.
Results and Findings
Results from the survey and interviews are presented in this chapter as well as the
findings and recurring themes. This chapter is organized to present the results as related to
knowledge, motivation, and organizational influences.
Surveyed Dentists
The survey for this study consisted of 20 survey items. Six of these items were
knowledge questions, nine were motivation questions, and seven were about the organization.
Demographic information related to age, race, or gender was not collected. The questions
included both open-ended and Likert-scale items. The dentists who responded to the survey
directly work with dental assistants in a private office, dental school, or government facility.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 47
Item 1 on the survey stated, “How would you describe the ownership of your practice?” The
four possible answers were (a) owned by a single dentist, (b) owned by a group of two or more
dentists, (c) owned by a dental management organization, (d) dental school or government. The
results were that 52 dentists worked at a facility owned by a single dentist, 6 at one owned by a
group of two or more dentists, none at one owned by a dental management organization, and 6
dentists at a dental school or government facility. The mean was 1.38, and the standard
deviation was 0.89.
Figure 2. Dentists ownership of practice.
Interviewed Dentists
Ten dentists from a variety of settings were interviewed. The dentists are identified using
a pseudonym. Six dentists were interviewed over the phone, and four requested to be
interviewed via email. Seven of the dentists interviewed worked in private practice, and two
worked for government-run clinics. The analysis included systematic line-by-line coding to
identify topics, similar words, and/or phrases. Pseudonyms were used in place of participants’
names. Table 4 provides a visual representation of the interviewees.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 48
Table 4
Dentist Sample for Qualitative Inquiry
Dentist (Pseudonym) Interview Method Private Practice Type of Practice
Dr. Molar Telephone Yes General Dentistry
Dr. Bicuspid Telephone Yes General Dentistry
Dr. Premolar Telephone Yes Prosthodontics
Dr. Incisor Email Yes General Dentistry
Dr. Canine Telephone No Government Clinic
Dr. Central Telephone No Government Clinic
Dr. Cuspid Email Yes General Dentistry
Dr. Teeth Email Yes General Dentistry
Dr. Braces Email Yes Orthodontic
Dr. Tooth Telephone Yes General Dentistry
Research Question One
What are the dentist’s knowledge and motivation related to requiring formal dental
assisting education and licensing for all dental assistants in California? The first research
question was designed to understand the dentists’ knowledge and motivation related to requiring
formal dental assisting education and licensing. Both the survey and interview results showed
similarities and variations in regards to education requirements, licensing, and the various duties
dentists have dental assistant perform. Participants varied significantly in their views of
licensing and education. The following sections describe what education and licensing
requirements participants required as well as the different duties the dental assistants were
responsible for performing.
Licensing and Education
Factual knowledge. Three of the interview questions and two of the survey questions
were proposed to determine the dentists’ understanding of the different dental assisting pathways
and licensing. This information aids in understanding the dentist’s knowledge of requirements
when hiring dental assistants. Analysis of interview data revealed respondents knew and
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 49
understood the differences between on-the-job training, formal education accredited by CODA,
and for-profit programs. However, most of the dentists did not really know the differences
among CODA-accredited programs, ROP and for-profits. Two of the dentists stated they did not
know all the details regarding whether the for-profit schools qualified students to take the
licensing exam. They did not realize the DBC does not accredit some of the for-profit schools;
therefore, students in those schools would not qualify to take the licensing exam. They also did
not know there was an on-the-job pathway.
Although not directly part of the question, a common theme throughout the interviews
was the reference to the cost of the dental assisting programs as problematic, and participants did
not understand the cost difference between for-profit schools and community colleges. For
example, Dr. Tooth was asked, “What is your knowledge of the different pathways to becoming
a dental assistant?” He replied, “I am aware of that, yes.” As a follow-up, he was asked, “Are
you comfortable with the variations of programs like community college versus ROP?” He
stated, “ Do both of those mentioned lead to a registered dental assistant?” After being told they
do, he replied, “So, then, probably have not. Most people I have hired in the past all have been
through community college.” Dr. Canine was asked the same question, and he replied,
You know what, as far as the requirements, I know some have changed recently. I
probably used to know it more maybe. Yeah, not as much. So honestly, I sometimes ask
the dental assistant, did you learn this in school? Are you trained to perform this
procedure? So that is really how I kind of keep updated in a way on what is part of their
training and what is not.
The interview questions addressed knowledge and understanding of allowable duties for
a dental assistant, registered dental assistant, registered dental assistant in expanded functions
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 50
and an orthodontic assistant. As mentioned in the literature review, the state’s dental practice act
refers to unlicensed dental assistants (DA), licensed dental assistants as (RDA), registered dental
assistants in expanded functions (RDAEF), and a licensed orthodontic assistant as an (OA). This
question addresses literature on allowing dental assistants to perform duties they are not licensed
to perform. The data revealed a majority of the dentist did not require their dental assistants to
be licensed.
All interviewees understood the different types of dental assistants and the allowable
duties. Some of the dentists stated they did not agree with the differentiation, but they
understood it. The following sections describe and identify the multiple ways a dentist can hire a
dental assistant. The analysis of the data found variations in their understanding of the allowable
duties. Dr. Canine stated,
As far as what I require them, I do keep an eye on what the dental board says under
general supervision because it depends. Some offices allow their dental assistants to do
more, depending on how comfortable they feel, and it’s the same with us. Sometimes we
do have assistants that do things that may not necessarily be a part of their so-called
training.
Item 6 on the survey stated, “Which of the following licensing do you require when
hiring a dental assistant? Please mark all that apply.” Respondents could choose from three
responses: require dental assistants to have RDA license (Registered Dental Assistant) or CDA
(Certified Dental Assistant) state-specific, Require x-ray certification only, and require no
licensing. Ten dentists selected two choices. Thirty-eight did not require licensing, 24 require an
x-ray certificate, 26 required an RDA or CDA license, and some who did not require an RDA or
CDA required the x-ray certificate. Of the 10 dentists who selected two or more choices, 4 chose
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 51
required RDA or CDA plus the x-ray certificate, 2 required x-ray and certificate and no
licensing, 2 selected all three choices and 2 chose RDA or CDA and require no license. Figure 3
presents the results.
Figure 3. Dentists’ licensing requirements.
The interviewees were asked what they require for education and licensing when hiring
dental assistants. Dr. Central works for the government and stated they do not employ RDAs
because of the higher salary requirements, so, to their knowledge, everyone they hire is a DA.
Dr. Canine works for a government-run community health center. They do not hire anyone
unlicensed, and all hired must have a certificate from a dental assisting school. Dr. Braces only
hires RDAs and recently had all of their registered dental assistants complete the advanced
orthodontic assistant training program, and they are all now RDAs and OAs. Dr. Premolar only
hires RDAs and RDAEF, and believes it’s the way to go. Three of the interviewees indicated
they would hire a DA or an RDA. Dr. Molar stated a preference for an RDA and someone with
dental assisting education over a DA, but a shortage of dental assistants would determine who is
hired. If necessary, Dr. Molar said, they would be willing to train the right person without dental
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 52
assisting education or an RDA license, but they prefer formal education and licensing. Dr.
Bicuspid stated giving preference to a candidate with dental assisting education and a license.
Dr. Cuspid said they employ both a DA and an RDA. A common theme from all interviewees
was all gave preference to someone with an education and license, but all were willing to
compromise if necessary. In survey and the interview responses, there was no consensus on the
requirements for licensing. The data revealed the participants did not have adequate factual
knowledge for education and licensing or conceptual knowledge for the dental board to promote
licensing which indicates the need of influences. Table 5 is a visual representation of the data.
Table 5
Dentist Requirements of Education and Licensing Sample for Qualitative Inquiry
Participant Education
Licensing
Private Practice Type of Practice
Dr. Molar DA or RDA Yes General Dentistry
Dr. Bicuspid DA or RDA Yes General Dentistry
Dr. Premolar RDA & RDAEF Yes Prosthodontics
Dr. Incisor RDA Yes General Dentistry
Dr. Canine RDA No Government Clinic
Dr. Central DA No Government Clinic
Dr. Cuspid DA or RDA Yes General Dentistry
Dr. Teeth RDA Yes General Dentistry
Dr. Braces RDA or OA Yes Orthodontic
Dr. Tooth RDA Yes General Dentistry
Motivation Results
The motivational questions using expectancy value theory and goal-orientation
motivation were used in this research project was designed to gain an understanding of the
respondents’ philosophy on dental assisting education and licensing despite what the law allows.
The data reflect significant variations in what the participants prefer. Some only hire licensed
dental assistants with formal education and prefer CODA programs. Some are fine with on-the-
job training and no licensing. There was no correlation to type of practice.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 53
One of the survey questions was designed to determine the participants’ motivations for
hiring dental assistants who have had formal education. Item 5 on the survey stated, “Which of
the following education do you require when hiring a dental assistant? Mark all that apply.”
Respondents could choose from four responses: graduation from only a CODA-accredited dental
assisting program, graduation from any dental assisting program (ROP, private for-profit),
require x-ray certificate only, and no formal education is required (on the job trained). Out the 64
respondents, 44 require graduation from any dental assisting program (ROP, private for-profit),
19 require graduation from only a CODA-accredited dental assisting program and 16 require no
formal education as they train on the job. The question indicated to “mark all that apply.”
Fifteen of the respondents marked two or more responses. The responses indicated four of them
would require either graduation from any dental assisting program (ROP, private for-profit) or
graduation from only a CODA-accredited program.
One of the interview questions sought more data about survey item 5 on the primary
reason respondents would not require a dental assistant to have dental assisting education and
licensing. There was a variety of answers. Six of the interviewees stated they only hire licensed
registered dental assistants or RDAEF. Dr. Tooth explained they only hire registered dental
assistants who graduated from a community college because they seek to distinguish their offices
as “high service” and feel their patients would value it. Dr. Premolar stated they have two
RDAEF, as “it’s the only way to go. I could hardly work without an EF anymore.” Two
participants stated they prefer to hire licensed and formally educated dental assistants, but they
would consider hiring someone who is not licensed if there were a shortage of dental assistants.
Two dentists worked for government clinics. Of those two, one stated they only hire
someone who has a certificate from a school and is registered, and the other said they used to
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 54
employ registered dental assistants, but their salaries were too high, so now they only hire
unlicensed applicants. The data indicates differences even in government-run facilities. Two of
the dentists stated they would hire either. Dr. Tooth only hires licensed dental assistants who
have graduated from a community college CODA program. In reference to hiring unlicensed and
uneducated dental assistants, Dr. Tooth stated, “So that’s not for me. I don’t pinch pennies when
it comes to my team members. I value what people bring to the table.” The data validated the
assumed influences of the participants’ motivation to hire unlicensed dental assistants was
primarily a financial decision.
Research Question Two
What is the dentist’s knowledge and motivation related to the organization of dentistry
culture and context associated with the dental assisting laws in the dental practice act? The
second research question was designed to determine the participants’ perceptions of dental
assisting laws and the culture associated with the qualifications required for hiring dental
assistants. The majority of the questions were developed to uncover the influences behind the
participants’ knowledge and motivation in terms of their preference in regards to education and
licensing requirements. The surveys and interviews uncovered varied opinions on these topics
and validated the assumed influences mentioned in Chapter Two. Two items on the survey and
were about knowledge and motivation related to the organizational culture of dentistry in regards
to dental assisting laws.
Procedural Knowledge
Item 4 on the survey was used to determine how the dentist utilized their dental assistant.
All survey respondents answered this question. This information gives an understanding of the
variation in responsibilities a dentist can delegate and the type of knowledge necessary to
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 55
perform the duty. The data reflect the significant variation in duties. The list of duties included
fundamental dental assisting duties up to duties considered advanced. The highest-ranking
procedures dentists had dental assistants perform were in the areas of infection control. All
respondents required their dental assistants to perform sterilization and disinfection procedures
for infection control. Figure 4 provides a visual presentation of the survey results.
Figure 4. Allowable duties dentists have dental assistants perform.
Although the data reflect significant variations in the more complex functions dentists
have the dental assistant perform, they reflect the literature on the importance of dentists place on
assistants to ensure all instruments and supplies are sterilized and prepared. The data
demonstrate the information collected in the literature review confirming the assistants are
primarily responsible for these duties.
Conceptual Knowledge
The conceptual knowledge questions were to determine what duties dental assistants
perform daily. All interviewees had their assistants perform all of the infection control,
including sterilization, set-up, tear-down/decontamination of the operatory, and chairside
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 56
assisting. The two interviewees who worked for the government had a lead registered dental
assistant who would delegate the duties to the other assistants and would determine what
procedures they would perform. The rest of the interviewees’ responses varied depending on the
type of office. Some had the dental assistants performing the more advanced duties like
temporary crowns and coronal polishing. One had three registered dental assistants who were
also licensed orthodontic assistants, and they performed advanced duties like bonding bracket,
bracket removal, and scans using a CAD/CAM.
Motivation Results
The literature review revealed that unlicensed dental assistants have no continuing
education requirements. Item 18 on the survey was designed to determine whether the
respondents believed a DA or RDA should be required to take continuing education units,
including on infection control and the dental practice act requirements. The data reflect a
majority of respondents felt it is essential for dental assistants, whether licensed or unlicensed, to
take continuing education courses. The results indicated 58 of the dentists agree that a DA
should have mandatory continuing education courses, four neither agreed or disagreed, and one
disagreed. The mean was 2.14, and the standard deviation is 1.04.
Item 10 on the survey stated, “Continuing education is critical to maintaining dental
assistants skills.” All 64 respondents answered this item. Sixty agreed or strongly agreed while
four neither agreed nor disagreed. The mean was 1.67, and the standard deviation was 0.92.
These questions both reflect the respondents’ knowledge that continuing education courses are
essential for dental assistants to ensure they use current standards for patient safety.
Intrinsic value. An additional survey question was used to determine the respondents’
motivation for dental assistants to take specific yearly continuing education courses that have to
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 57
do with patient and staff safety. Survey item 7 stated, “Please indicate which continuing
education courses you require your dental assistant to take yearly. Mark all that apply.” Possible
responses were (a) infection control, (b) dental practice act, (c) OSHA, (d) CDC guidelines, (e)
do not require specific course and any continuing education is accepted, and (f) do not require
my assistant to take continuing education courses. There were 64 responses. Of those, 51 require
a yearly infection control continuing education course, 34 require a California Dental Practice
Act continuing education course, 46 require an OSHA continuing education course, 33 require a
CDC guidelines continuing education course, 8 don’t require specific continuing education and
accept any courses, 6 do not require continuing education courses. As indicated in the previous
survey responses, the dental assistants in all 64 offices are responsible for some kind infection
control. A gap was indicated in dental assistants’ performing duties they are not trained for, as
stated in regulations.
Organization Results
The organizational expectations of a dental assistant are primarily infection control. Item
24 on the survey stated, “The dental assistant in my office is the primary person in my office to
maintain infection control in the office including but not limited to decontamination, disinfection
of treatment rooms, instruments and anything used during patient treatment. Preparing treatment
rooms and instruments, including barriers and treatment of the waterline.” The seven response
options ranged from “strongly agree” to “strongly disagree.” Of the 64 respondents, 62 selected
“agree” and 2 selected “somewhat disagree.” The mean was 1.58, and the standard deviation was
0.84. Item 12 on the survey stated, “In your dental office, who is primarily responsible for
disinfection and sterilization?” There were four possible responses: dentist assistant, dentist,
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 58
dental hygienist, and front desk assistant.” All respondents answered dental assistant. The mean
is 1.00, and the standard deviation is 0.00.
Research Question Three
What recommendations can be made to encourage or compel dentists to employ only
licensed dental assistants? The third research question was designed to determine what factors
help or hinder respondents from employing licensed dental assistants. This question was meant
to identify specific elements in the framework of the dentists’ knowledge, motivations, or
organizational context that influence their hiring preferences. The survey and interview
responses were used to uncover these influencers
Knowledge Results
Two items on the survey and one of the questions in the interviews were about
knowledge and understanding of mandatory office compliance duties that would typically be
delegated to a dental assistant. This information comes from education training courses. These
items are intended to address the third research question with declarative (factual) knowledge.
These data reflected a significant variation of whom respondents utilize for these duties.
Declarative (factual) knowledge. Item 16 on the survey asked, “How comfortable are
you applying the CDC guidelines bloodborne pathogens standard act in your dental office?” The
four possible answers were, (a) very comfortable, (b) comfortable, (c) rely on the dental
assistant, or (d) none of the above. The 64 responses indicated that 44 dentists were very
comfortable, 17 were comfortable, 2 rely on the dental assistant and 1 was slightly comfortable.
Item 17 on the survey asked, “How comfortable are you applying the OSHA standards in your
dental office?” The four possible answers were “very comfortable,” “comfortable,” “rely on the
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 59
dental assistant,” or “none of the above.” The 64 responses indicated that 45 dentists were very
comfortable, 17 were comfortable, and one relies on the dental assistant.
To get a better understanding of the data from survey items 15, 16, and 17, a follow-up
question was asked during the interview: “Can you describe in your office who in your office is
responsible in your office completes the yearly training and written compliance manual, and how
do they get the training to complete it?” Two of the dentists work for a government-run clinic,
and a manager is responsible for compliance. Four of the dentists have their office manager
responsible for it, one makes their office manager and back office manager responsible, and two
do it themselves. Dr. Cuspid stated, “I do. It is not good.” Four of the dentists have their RDA
be responsible for it. It is unclear how the office managers get their training, as their experience
was outside the scope of this study.
When asked whether the different types of dental assisting allowable duties covered in
the dental practice act are clear and easy to understand, only four of the dentists said yes.
Dr. Canine noted,
It’s a little wordy. It’s like a law book, so it could be more simplistic. I usually don’t read
it. I go online to the list. It’s more bullet points and makes it much easier than actually
reading it. If you actually read it, you’re like, Oh, my God, so you read it twice. I’m
like, let me make sure I understand this. Sometimes you’re like what do they really
mean? Let me read it again.
Dr. Braces indicated,
the laws for the RDA and OA duties don’t correspond. I have to pay for both an OA and
RDA renewal for each of my clinical staff, and this is unfair to the employee or employer
that has to pay for it. One license should be enough.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 60
Dr. Bicuspid stated that it leaves too much room for interpretation. Dr. Tooth noted that he relies
on his RDAs to tell him what they are allowed to do; however, he does a majority of the work
unless they happen to get busy.
Motivation Results
The items on the survey were designed to determine the dentists’ motivation to licensing
dental assistants and what would compel them to hire licensed dental assistants over someone
unlicensed. The interview questions were meant to discover dentists’ motivation regarding the
third research question. In the context of motivation, questions were designed to uncover
whether a dentist has concerns about being legally responsible for a dental assistant’s
wrongdoing. The data revealed respondents do find value in having dental assistants pass a
criminal background check. The data showed varying opinions on how the participants ensure
their dental assistant has had education in infection control.
Attainment value. Survey item 3 stated, “RDA’s are required to have background
checks and pass a board exam to a minimum standard. Do you feel this is important for patient
safety?” The four possible responses ranged from “strongly agree” to “strongly disagree.” The
survey had 64 respondents, with 50 choosing one of the “agreed” categories while nine
respondents neither agreed or disagreed and one respondent somewhat disagreed. The highest
response rate was that of 21 respondents who strongly agreed. Twenty respondents agreed, and
nine respondents somewhat agreed. The mean was 2.41, and the standard deviation was 1.47.
The interviewees were asked about where their dental assistants receive training in light
of the fact that they, as supervisors, are responsible for ensuring their subordinates have the
proper education for infection control. The interviewees all had their dental assistants complete
some training for infection control in various ways. Two require graduates from dental assisting
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 61
programs, so they get their training from school. Two hire an outside company for yearly
training for their staff. Four of the dentists use continuing education courses online or live, and
two work for the government and have training provided by the facility.
Organization Results
Two items on the survey pertained to the organizational structure and the relationship to
the patient assessment. Interviewed dentists were also asked several questions to ascertain if
there were influences in their organization that determined how they utilized their dental
assistants. In the context of these organizational factors, two interviewees who worked for a
government facility described these influences as mainly determined by management. Of the
two dentists who worked for a government facility, one did not have any impact on what the
dental assistants were allowed to do, as that was determined by a supervisor. The other eight
interviewees established the way they utilized their dental assistants. The influences were
determined by the individual office or facility based on the practice. Some of the interviewees
had smaller dental practices and preferred to do more themselves.
Cultural model of dentists organizations. Item 11 on the survey stated, “ In your
dental office, who is primarily responsible for taking the patient’s health history?” There were
four possible responses: dentist assistant, dentist, dental hygienist, and front desk assistant. The
64 responses indicated a considerable variation: 12 use dental assistants, 24 use themselves, 6
use hygienists, and 22 use the front desk assistant. The mean is 2.59, and the standard deviation
is 1.14.
Item 13 on the survey stated, “In your dental office, who is primarily responsible for
reviewing patients’ consent before a procedure?” There were four possible responses: dentist
assistant, dentist, dental hygienist, front desk assistant. The 64 responses indicated a
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 62
considerable variation: 22 use dental assistants, 26 use themselves, and 16 use the front desk
assistant. The mean is 2.16, and the standard deviation is 1.15.
Item 14 on the survey stated, “In your dental office, who is primarily responsible for
taking vital signs and reviewing medical history before the start of the dental treatment?” There
were four possible responses: dentist assistant, dentist, dental hygienist, front desk assistant. The
64 responses indicated significant variation: 40 use assistants, 20 use themselves, 2 use the
hygienist, and 2 use the front desk assistant. The mean is 1.47, and the standard deviation is
0.71.
During the interview, Dr. Tooth explained his office was very small. He requires his
dental assistants to be licensed and graduated from a community college dental assisting
program. He explained,
This is a cash office for the most part, and so the patients in practice, I probably have a
mix of about 50% insurance, 50% not insurance. Both groups of pay to come to this
office where they could possibly go somewhere else for cheaper. So, my patients, I’m
aware that they have a choice of trying to find someone cheaper. So, I try to distinguish
our office as being one that’s kind of high service. And, so, I tend to do a lot of auxiliary
procedures myself, either rightly or wrongly because I feel like the patient is kind of paid
more and maybe they do, maybe they don’t appreciate that I’m more hands-on with that.
But there are times in the practice where we get busy, and I like to know that the
assistants can do what they’re allowed to do well.
Research Question Four
Does the flexibility in the dental assisting laws allowing unlicensed and uneducated
dental assistants affect the patient’s safety and the dental assisting profession? Survey items
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 63
were used to address research question 4 regarding the dentist’s influences on the utilization of
the dental assistant’s role and responsibilities with declarative (factual) and procedural
knowledge necessary to provide infection control duties safely.
Knowledge Results
Item 9 on the survey stated, “A dental assistant should ensure all instruments and supplies
are sterilized and ready in case the dentist needs them during a procedure?” The seven response
options ranged from “strongly agree” to “strongly disagree.” The responses indicate 61 strongly
agreed, and 3 agreed. The mean was 1.05, and the standard deviation was 0.21.
Item 23 on the survey stated, “I feel confident I can train a dental assistant to my needs of
my office without them passing a board exam.” The seven response options ranged from
“strongly agree” to “strongly disagree.” The 64 responses indicated 3 strongly agreed, 12
agreed, 10 somewhat agreed, 18 neither agree nor disagree, 10 somewhat disagree, 8 disagree,
and 3 strongly disagree. The mean was 2.68, and the standard deviation was 1.48
The interviewees were asked, “What steps would you recommend the dental board take
to ensure uneducated and unlicensed dental assistants are providing all infection control protocol
required by the dental practice act for patient’s safety during patient treatment in regards to
infection control during dental treatment?” Eight stated they should require continuing education
courses for unlicensed dental assistants. Dr. Braces said, “I think dental assistants should be
licensed but understand there may be circumstances where on-the-job training might be
acceptable.” Dr. Tooth stated, “to require formal education.”
Motivation Results
Value. Four items on the survey were designed to determine the respondents’ motivation
regarding unlicensed dental assistants who lack continuing education requirements, and if there
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 64
should be one type of dental assistant. Two important themes emerged from the survey and the
interviews. The results indicated a high response rate regarding the importance of continuing
education courses for unlicensed dental assistants and a majority agreed they should be required
to have fingerprints and a background check before working in the field. A majority of the
dentists also agreed it would be easier to have one type of dental assistant.
Item 18 on the survey stated, “Do you believe all dental assistants whether a DA or RDA
should be required to take the same continuing education units and mandatory (IC and DPA)
requirements?” The four possible responses ranged “strongly agree” to “strongly disagree.” The
responses indicated that 63 dentists answered the question, and 58 were agreed or strongly
agreed. There were four dentists who neither agree nor disagree, and one disagreed. The mean
was 2.14, and the standard deviation was 1.02.
The interviewees were asked their thoughts on unlicensed dental assistants not being
required to take continuing education and what they would recommend to ensure they know the
most current standards. Eight of the interviewees thought unlicensed dental assistants should be
required to take the same continuing education courses as registered dental assistants. Dr.
Premolar stated, “So I’m going to say that’s really important to me, but it’s going to be a
deterrent to some people because they’re not going to like have to have there.” Dr. Cuspid
stated, “give the dental assistant class in my office.” Dr. Teeth said, “monitor their work and
teach them on the job to maintain patients and their safety.”
Item 19 on the survey stated, “All members of the dental health team have to get
fingerprinted and background checked before being licensed except unlicensed dental assistants.
Do you believe dental assistants should be required to do the same for patient protection?” The
four possible responses ranged “strongly agree” to “strongly disagree.” All 64 respondents
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 65
answered the question, and 49 agreed. Ten neither agreed nor disagreed, two somewhat
disagreed, and 3 disagreed. The mean was 2.45, and the standard deviation was 1.38.
Item 20 on the survey asked if respondents believed the law should require all dental
assistants be registered. The four possible responses ranged “strongly agree” to “strongly
disagree.” The responses indicated that 64 dentists answered the question, and 49 agreed. Ten
dentists neither agreed nor disagreed, two somewhat disagreed, and 3 disagree. The mean was
2.45, and the standard deviation was 1.38.
Dentists were asked, “in regards to the allowable duties do you believe it would be easier
to have one type of dental assistant (RDA) versus multiple levels?” Seven interviewees agreed
that it would be easier and “ideal.” The other three felt it was fine as it is. The three who stated it
was fine the way it is determined the reason would be financial concerns. The smaller offices
might not be able to afford an RDA. The other concerns were whether the dental assistant would
be able to afford the licensing exams and education. Those three dentists all have hired RDA’s
but voiced financial concerns for the dental assistant. Dr. Tooth stated,
I wouldn’t have any problem with having dental assistants as long as the dentists treat
them as dental assistants and not registered dental assistants. And I can tell you where
having worked at other places that there are plenty of untrained people that are doing
procedures that they shouldn’t be doing. That’s not good, and it’s the dentist’s fault for
those things. So, in a perfect world, I would say yes. Again, it just the financial impact
that it would have on younger people that are trying to become dental assistants by
requiring them to get their RDA. That’s my only stumbling block in just saying yes to
the question.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 66
Organization
Two items on the survey pertained to the dentists’ practice organizational structure for
hiring unlicensed dental assistants who have not had background checks. Interviewed dentists
were also asked several questions to determine the influences in their dental practice in regards
to background checks and patient safety.
Item 22 on the survey stated, “I feel confident during the interview process I can screen a
dental assistant without needing fingerprints and a background check.” The seven response
options ranged from “strongly agree” to “strongly disagree.” The 64 responses indicated 3 of
the dentists strongly agreed, 12 agreed, 10 somewhat agreed, 18 neither agree nor disagree, 10
somewhat disagree, 8 disagree, 3 strongly disagree. The mean was 3.88, and the standard
deviation was 1.55.
The interviewees were asked about fingerprints and background checks for unlicensed
dental assistants. All interviewees stated unlicensed dental assistants should be fingerprinted and
pass a background check. Dr. Brace’s recommended requiring fingerprinting, continuing
education, and a lower fee license. Dr. Cuspid said it would be ideal but costly for small
practices and difficult to enforce.
Synthesis of Findings
The following section highlights the results from in the context of knowledge,
motivation, and organization. The assumptions developed from the literature review were either
validated or partially validated as a need. There were no additional unexpected themes. To close
the performance gap between uneducated and unlicensed dental assistants creating concerns for
patient’s safety all dentists need to require graduation from accredited programs and licensing
before hiring a dental assistant.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 67
Knowledge
All respondents displayed factual knowledge of the dental assisting educational pathways
as well as licensing. Interview data revealed a lack of understanding about dental assisting
programs and pathways to licensure, which ultimately impacted the way they use their dental
assistants. The data also showed that most of the dentists were not as familiar with dental
assisting duties as they should be. The more critical issue to address regarding knowledge is the
lack of conceptual knowledge regarding education and licensing with concerns to patient safety.
All participants had limited understanding of the correlation between education and patient
safety.
Motivation
The assumed influence in motivation was task value. Intrinsic and attainment value were
reviewed to understand the participants’ motivation for hiring dental assistants who have
graduated from an accredited program and been licensed. A large number of participants were
content with hiring dental assistants who did not have formal education or licensing. The survey
respondents reported they were comfortable training dental assistants in the required infection
control protocols. A limiting factor is that a majority of the dentists do not seem to understand
the complexity and benefits of the infection control requirements, educational programs, and
licensing.
Although the survey data revealed that many participants would hire a dental assistant
without formal education or license, almost all find it important to require continuing education
courses. Additionally, a majority also felt it was important for unlicensed dental assistants to
pass a background check.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 68
Organization
This study sought to discover impediments in the complexity of the dental assisting field.
The participants make up the cultural model of the organization of dentistry. The assumed
barriers in knowledge, motivation and organization from the literature review were found to be
the same in this study. The organization of dentistry has many influences that guide the dental
assisting profession; however, dentists, for the most part, drive the cultural model of the dental
assisting profession. All of the interviewees agreed the dental board needs to make significant
changes to dental assisting laws. The survey results also indicated a majority of the respondents
believed there were aspects of the dental assisting statutes that need to be improved for patient
safety.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 69
CHAPTER FIVE: RECOMMENDATIONS
Chapter Four presented results and findings from qualitative and quantitative data to
answer the Research Questions One and Two. Surveys were used to determine what was
happening with the stakeholders in this project, and interviews helped determine why it was
happening. In this chapter, the research questions are answered. The chapter also presents the
recommendations proposed for closing the performance gap to help meet the organizational goal
of all dental assistants graduating from an accredited dental assisting program and passing a
licensing exam by 2025. Results are presented using Clark and Estes’ (2008) framework of
knowledge, motivation, and organizational influences. Key findings are synthesized, and
implications are stated. This chapter is organized using Clark and Estes’ framework to address
context-specific recommendations for knowledge, motivation, and organization solutions. Also
presented is an integrated implementation and evaluation plan using the New World Kirkpatrick
model (Kirkpatrick & Kirkpatrick, 2016). Chapter Five closes with recommendations to reduce
the number of unlicensed dental assistants.
Purpose and Research Questions
The purpose of this project was to evaluate the degree to which dentists and state dental
boards are meeting the organization’s goal of patient protection and the effect of not mandating
education and licensing for dental assistants. The analysis focused on knowledge, motivation
and organizational influences related to achieving the organizational goal. The project evaluated
the degree of the dentist’s knowledge and motivation to meet the organizational goal of dentists
mandating dental boards require education and licensing for all dental assistants by the year
2025. The stakeholder’s this project focused on are dentists who utilize dental assistants to
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 70
practice dentistry. The findings for this project are limited to the dentists who were willing to
participate in this study.
Four research questions were used to direct this project. The four research questions
were addressed through both quantitative and qualitative inquiry. The evidence collected
through inquiry was used to make informed recommendations for the organization. The
questions that guided this project were the following:
1. What are the dentist’s knowledge and motivation related to requiring formal dental
assisting education and licensing for all dental assistants in California?
2. What is the dentist’s knowledge and motivation related to the organization of dentistry
culture and context associated with the dental assisting laws in the dental practice act?
3. What recommendations can be made to encourage or compel dentists to employ only
licensed dental assistants?
4. Does the flexibility in the dental assisting laws allowing unlicensed and uneducated
dental assistants affect the patient’s safety and the dental assisting profession?
Knowledge Recommendations
The assumed knowledge influence pertained to knowledge and skill gaps for job training,
job aids, and education. Using a research test approach closes performance gaps caused by the
lack of knowledge (Clark & Estes, 2008). Factual and procedural knowledge types were used to
identify and validate the gap in dentists’ knowledge of dental assisting education and licensing.
Table 6 presents the list of assumed knowledge influence and validation based on the most
frequently mentioned responses.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 71
Table 6
Summary of Knowledge Influences and Recommendations
Assumed
Knowledge
Influence
Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Dentists must be
knowledgeable of
the standards of
education and
licensing for
Dental Assistants
as established by
the Dental Board
to protect patient
health. (D)
V Y “When we tell people
something about their job
they need to know to
succeed on their own, we are
giving them information. If
people do not need help
practicing in order to apply
the information successfully,
then information is all that is
necessary to reduce their
uncertainty about how to
achieve a performance
goal.” (Clark & Estes, p. 58)
Provide Dentists with
information on the
benefits to the dentists
and patient of hiring
dental assistants that
have formal education
and are licensed.
Dentists must
understand the
benefits of hiring
highly qualified
dental assistants
that graduate from
a CODA-
accredited dental
assisting program.
Provide the
dentists with
CODA standards
and expectations
for desired
outcomes of dental
assistants that
graduate from a
CODA-accredited
dental assisting
program. (D)
V Y “The only way to equip
people to handle the novel
and unexpected is with
education. A good education
provides people with solid
but general conceptual and
analytical knowledge. This
knowledge is often in the
form of new (descriptions of
how things work), and
current (new terms or
variables), vital processes
(descriptions of how things
work), and current theories
or principles (research-based
theories about cause and
effect) The best-advanced
degree or certificate
programs also offer ways to
understand how to use the
knowledge gained in
education to solve novel
programs.” (Clark & Estes,
p. 62)
Provide dentists
information on the
benefits of a dental
assisting program that
has been accredited by
CODA.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 72
Table 6, continued
Assumed
Knowledge
Influence
Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Providing dentists
with the benefits
of requiring dental
assistants to take
and pass either a
state or national
board exam like
the national dental
assisting National
Board (DANB)
exam provides a
measurement of
Competency for
dental assistants
through an exam
with a minimum
benchmark. (P)
V Y Education is any situation in
which people acquire
“conceptual, theoretical, and
strategic” knowledge and
skills that might help them
handle novel and unexpected
future challenges and
problems” (Clark & Estes, p.
59).
Provide Dentists the
steps for identifying
dental assistant that
have passed a state or
national board exam.
Increase Knowledge of Standards of Dental Assistant Education and Licensing
Results indicated 90% of the dentists need more in-depth procedural knowledge about the
kinds of dental assisting educational programs. The recommendation for closing this procedural
knowledge gap is rooted in information processing theory. Training is often required when
learning a higher level of knowledge and skills (Clark & Estes, 2008). Training can be proven,
and instructors can observe and give corrective feedback to trainees while they are practicing a
new skill (Clark & Estes 2008). Providing dentists with information will ensure they are
knowledgeable of the standards of education and licensing for dental assistants established by the
dental board to protect patient health. To ensure dental assistants have had adequate training
dentists should only hire dental assistants who have graduated from an accredited program.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 73
The goal for all dental assistants to have graduated from an accredited program will
ensure patient safety. DePaola and Slavkin (2004) express that reform is needed in the oral health
care education system. Education has not kept up with the shifting patient population, health
systems, and emerging technologies and fall short in dental education needs (DePaola, 2014).
The recommendation is to provide dentists with knowledge of the benefits of hiring dental
assistants who graduated from accredited programs.
Increase Knowledge on Standards of CODA-Accredited Dental Assisting Programs
The results showed 90% of the dentists need more in-depth declarative knowledge about
the benefits of hiring highly qualified dental assistants who graduated from CODA-accredited
programs compared. The recommendation to close this declarative knowledge gap is rooted in
information processing system theory. Clark and Estes (2008) suggest the only way to equip
people to handle the novel and unexpected is with education. A good education provides solid
but general conceptual and analytical knowledge. This knowledge is often in the form of new
(descriptions of how things work), and current (new terms or variables), vital processes
(descriptions of how things work), and current theories or principles (research-based theories
about cause and effect). Requiring dental assistants to graduate from an accredited program will
ensure they have the training to work on patients and face unexpected challenges that may occur
during treatment. The recommendation is to provide dentists with CODA dental assisting
program standards and expectations for desired outcomes of dental assistants.
The increase in infectious outbreaks can be directly related to education (Haden et al.,
2003). Educating people can generate new conceptual knowledge for solving problems and
handling job challenges (Clark & Estes, 2008). CODA standards follow the same concept as
Clark and Estes (2008) in performance goals. Clark and Estes describe three causes of
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 74
performance gaps: people’s knowledge, skills, and motivation to achieve the goal. Factual,
conceptual, procedural, strategy, and belief-based knowledge are needed for academic success
(Mayer, 2011). CODA standards utilize these knowledge types and require students have
comprehensive didactic understanding of each topic before practicing preclinical skills and pass
a pre-clinical competency exam before transitioning to clinical skills. Lastly, students must pass
a clinical competency exam. Hence, the recommendation is to provide dentists with knowledge
of the benefits of CODA-accredited dental assisting programs.
Increase Knowledge of Benefits of Board Exams
Results showed 80% of the participants do not know the benefits of hiring dental
assistants who hold a state or national license. To close this procedural knowledge gap, the
recommendation is rooted in information processing theory. Informing dentists of the benefits of
requiring dental assistants to take and pass a state or national board exam provides a
measurement of procedural knowledge and a minimum measurement of competency for dental
assistants. Clark and Estes (2008) stated education is any situation in which people acquire
“conceptual, theoretical, and strategic” knowledge and skills that might help them handle novel
and unexpected future challenges and problems” (p. 59). Requiring a minimum benchmark from
an exam would ensure the knowledge to provide safe patient care. The recommendation is for
dentists to require all dental assistants pass either a state or national licensing exam.
Information processing theory provides information on effective strategy use, including
“how” and “when” to use particular strategies (Schraw & McCrudden, 2006). This information
can be transferred to ensure the dental assistant has an understanding of complex information
required in the profession. The scientific approach to learning, instruction, and assessment is
whether a theory is testable (Mayer, 2006). Having a testable measurement to determine
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 75
understanding of various dental assisting procedures is essential to public health. Shimberg
(1981) defines tests as part of the licensing and certification process for the protection of the
public health safety and welfare. Test content is usually based on skills, ability, and knowledge
related to the area of qualification. Licensure is defined as a process by which a government
agency allows an individual to engage in an occupation after the applicant attained a minimal
degree of competency required to ensure public health, safety and welfare.
Factual knowledge. The results of the survey and interviews revealed that, although the
dentists thought they had knowledge about dental assisting educational programs and licensing, a
majority did not have the correct information. A lack of factual knowledge creates
misunderstanding of education and licensing and creates a danger to patient safety. Factual
knowledge is also necessary for dental assistants to understand the infection control process.
Rueda (2011) defines factual knowledge as facts about things like terminology, details, or
elements that one must be familiar with to understand and function effectively and to problem
solve in a specific area. Helping individuals identify and understand important points is the key
to learning, and providing information is useful when individuals need to know how to do their
job (Clark & Estes, 2008). The literature review indicated the dental assisting profession is
expected to grow by 18% by 2014. While the number of CODA-accredited program graduates
has decreased, the rate of dental assisting employment increased (Kracher et al. 2014).
Procedural knowledge solutions. Procedural knowledge pertains to how to do
something (Aguinis & Kraiger, 2009). Rueda (2011) defined procedural knowledge as knowing
how to do something using very specific skills, techniques, very specific skills, and particular
methodologies required to complete a specific task. Training is central to importing how-to
knowledge (Clark & Estes, 2008). The tasks of a dental assistant require procedural knowledge.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 76
The data showed a gap in participants’ understanding of the procedural knowledge provided in a
dental assisting program. Dentists felt they could train the assistants on the job without
understanding the complexity of learning strategies. Effective training yields improved work
quality, increased motivation and commitment, higher productivity, higher morale and
teamwork, and fewer errors, whereas poorly trained workforce leads to errors, injuries and even
legal issues Grossman & Salas (2011).
Motivational Recommendations
Motivational influences were validated. Motivation is an internal state that initiates and
maintains goal-directed behaviors needed for meaningful learning (Mayer, 2011). Knowing how
to do something does not mean one will do it (Rueda, 2015). Dentists might train a dental
assistant; however, if they do not provide the critical components needed to generate new
learning and knowledge, they could make mistakes. Three components of motivation are active
choice, persistence, and mental effort (Rueda, 2015). Motivational indicators can be utilized to
identify learning engagement (Window & Window, 2006). Intrinsic value can be described as
the enjoyment one expects to feel when doing a task, and attainment value can be described as
the value of the task (Window & Window, 2006). Table 7 lists the participants’ assumed
influences.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 77
Table 7
Summary of Motivation Influences and Recommendations
Assumed
Motivation
Influence
Validated
as a Gap
Yes, High
Probability
, No
(V, HP, N)
Priori
ty
Yes,
No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
The dentist
encourages the
dental assistant’s
goals of licensing
dental assistants as
hiring requirement.
(Goal-orientation
theory).
V Y “Focusing on mastery,
individual
improvement,
learning, and progress
promotes positive
motivation” (Yough &
Anderman, 2006).
Provide dentists
rationales for having
licensed dental
assistants.
The dentist values
CODA accredited
dental assisting
programs.
(Expectancy Value
Theory).
V Y “Learning and
motivation are
enhanced if the learner
values the task”
(Eccles, 2006).
Provide dentists
rationales of the benefits
of accreditation
standards of CODA
accredited dental
assisting programs
Require Dental Assistants to be Licensed
Results of this study were that only 35% of the dentists surveyed valued having licensed
dental assistants. The recommendation is to close this gap that is rooted in goal orientation
theory. “Focusing on mastery, individual improvement, learning and progress promotes positive
motivation” (Yough & Anderman, 2006). Providing dentists rationale for licensed dental
assistants will inform them of the value of licensure.
Goal-orientation theory is a social-cognitive theory that examines academic motivation
and the reasons why students engage in their academic work (Anderman, 2015). Goal orientation
theory describes the link between tasks and individual identities as well as the preferences an
individual develops, which includes needs, interests, and value (Window, Window, & Eccles,
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 78
2006). Education and vocational achievement-related choices are mostly related to either the
individual’s expectation for success or the importance of value the individual attached to the
various options (Wigfield & Eccles, 2000). The value of a task depends on beliefs determined
by the cost, which is influenced by factors such as anticipated anxiety, fear of social
consequences (Window, Window, & Eccles, 2006). Clark and Estes (2008) define beliefs as
interpretations of past experiences which are not always accurate. The dentists have not found
value in hiring licensed dental assistants. From a theoretical perspective, because the dentists did
not see the value, increasing the task values would change their beliefs. Table 8 lists the
participants’ assumed influences.
The dental board needs to change the requirements for dental assisting licensing.
Results of this study were that all interviewees felt the dental board should make some changes
in licensing requirements for dental assisting. The recommendation to close this gap is rooted in
attribution theory and is to provide feedback on the process of learning, including the importance
of effort, strategies, and potential self-control of learning (Anderman & Anderman, 2009). This
would suggest dentists are motivated to make changes to dental assisting requirements to close
the gap.
Expectancy value theory suggests learning and motivation are enhanced if the learner
finds value in the task (Eccles, 2006). Expectancy value can also influence the learners
performance, effort and persistence of a task (Wigfield & Eccles, 2000). When students engage
in a task, they have tied motivational beliefs and their interest in the content, efficacy and values
toward the content (Pintrich, 2003). Having higher expectations for success can positively
influence learning and motivation (Eccles, 2006). Expectancy theory has important implications
for motivating employees in the health care setting and includes cognitive factors such as
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 79
training and education (Simone, 2015). Demonstrating expectancy value requires dentists to
promote patient protection through requesting dental assistants learning by requesting the dental
board to change the dental assisting requirements for education and licensing. Using rationales
that include the importance of the value of work and learning will help develop positive values
(Pintrich, 2003).
Organizational Recommendation
Organizational influences were validated. There are factors which can impede the
organization from obtaining goals (Rueda, 2011). The organization of dentistry follows the
dental board’s recommendation. A cause of performance gaps can be caused from the lack of
efficient and effective processes and even those with exceptional knowledge and motivation
missing or inadequate processes and material can prevent the organization from achieving their
performance goals (Clark & Estes, 2008). Table 8 lists the participates’ assumed organizational
influences.
Table 8
Summary of Organization Influences and Recommendations
Assumed
Organization
Influence
Validated
as a Gap
Yes, High
Probabilit
y, No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation
Context-Specific
Recommendation
Cultural Models
The dentists need
to support the
Dental Board to
establish licensing
criteria.
V
Y
Effective change
begins by addressing
motivation influencers;
it ensures the group
knows why it needs to
change. It then
addresses
organizational barriers,
and then knowledge
and skills needs (Clark
and Estes, 2008).
Dentists to change the
cultural model of
dentistry by requesting
the dental board to
require all dental
assistants to pass a
licensing exam.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 80
Table 8, continued
Assumed
Organization
Influence
Validated
as a Gap
Yes, High
Probabilit
y, No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation
Context-Specific
Recommendation
Cultural Models
Dentist's support
the Dental
Practice Act
requiring dental
assisting
programs to be
accredited by
CODA for
standardization.
V Y Effective organizations
ensure that
organizational
messages, rewards,
policies, and
procedures that govern
the work of the
organization are
aligned with or are
supportive of
organizational goals
and values (Clark and
Estes, 2008)
Dentists to change the
cultural model of
dentistry by requesting
the dental board to
incorporate
accreditation standards
(CODA) in dental
assisting education
laws and require all
dental assistants to
graduate from an
accredited dental
assisting program.
Increasing the dentist’s confidence in dental assisting licensing. The results of this
study indicated that only 75% of interviewees support the dental boards establish licensing
criteria. A principle rooted in organizational cultural models is recommended to close this
resource gap. Effective change begins by addressing motivation influencers to ensure a group
knows why it needs to change and to address organizational barriers as well as knowledge and
skills needs (Clark & Estes, 2008). Incorporating dentists’ support of licensing criteria would
lead to organizational change. The recommendation is for dentists to change the cultural model
of dentistry by requesting the board to require all dental assistants pass a licensing exam.
Rueda (2011) states organizational features include the policies and practices that define
the organization and how people interact with each other within the setting. Learning and
adapting to challenges and changes in the environment are part of organizational learning
(Rueda, 2011). Planned change models in organizations are purposeful and adaptive, and change
occurs because leaders, change agents, and others see it as necessary to make a change (Kezar,
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 81
2001). The change processes are primarily bargaining, persuasion, consciousness-raising, social
movements, and influence and power (Bolman & Deal, 1991). Cultural models can be described
as tools for the mind that have evolved and shared ways of perceiving, thinking, and storing
responses to challenges and changing conditions (Gallimore & Goldenberg, 2001). Cultural
models define the way things are and should be, including taken-for-granted assumptions and are
developed gradually from collectively transmitted information (Shore, 1996). The dentists
supporting changing cultural models will support the dental board changing licensing
requirements.
Increasing the dentist’s support of accredited dental assisting programs. The results
indicate that only 25% of participants require accredited dental assisting programs. To close this
resource gap, a principle rooted in the organizational cultural model was selected. Effective
organizations ensure that organizational messages, rewards, policies, and procedures that govern
the work of the organization are aligned with or are supportive of organizational goals and values
(Clark & Estes, 2008). The recommendation is for dentists to change the cultural model of
dentistry by requesting the dental board incorporate CODA accreditation standards in dental
assisting education laws and require all dental assistants to graduate from an accredited program.
Changing organizational culture by making legislative changes will prove the
organization's value for patient safety and support the DBC’s mission and vision statement: “to
protect and promote the health and safety of consumers of the State of California” and “the
Dental Board of California will be the leader in public protection, promotion of oral health, and
access to care” (DBC, 2019, p. 1). The culture of an organization present the conscious and
unconscious understanding of who we are, what we value, and how we do what we do as an
organization (Clark & Estes, 2008). The cultural models incorporate shared environments and
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 82
interpretations of what is valued and ideal, what setting should be avoided, who should
participate, and the purpose and rules of the interactions (Gallimore & Goldenberg, 2001).
Change is a natural part of organizational development and entails alterations of values, beliefs,
myths, and rituals (Kezar, 2001). Data indicates that, within many organizations, stakeholders
withhold their opinions and concerns about organizational problems (Shore, 1996). Utilizing
these principles, the organization of dentistry will change cultural models to legally require
dental assistants graduate from an accredited program.
Implementation and Evaluation Framework
The New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) will be
implemented and evaluated based on the Kirkpatrick Four-Level Model of Evaluation
(Kirkpatrick & Kirkpatrick, 2006). Using the original model entails working backward for best
results. In Level 4, the results are the targeted outcomes for the organization and the highest
level of results. In Level 3, behavior is the most important step, but the one that is most often
left out of the planning process. This level is where participants are to apply what they learned
during training to their job. During Level 2, learning refers to participants’ degree of acquiring
training in knowledge, skills, attitude, confidence, and commitment. Lastly, in Level 1, the
reaction is the degree to which the participant finds the training engaging, relevant to their jobs,
and favorable. The New World Kirkpatrick Model can add new elements to help effectively
operationalize business, government, military, and not-for-profit organizations.
Organizational Purpose, Need, and Expectations
The organization of dentistry is overseen by the state dental board to ensure patient
protection. The problem is that unlicensed dental assistants create a concern for patient safety.
To close this gap, there needs to be a standardization and mandatory licensing. The goal
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 83
selection is based on the danger to patient safety. The desired outcome is that all dental
assistants will graduate from a CODA-accredited as well as pass a licensing exam. The licensing
exam will ensure the licensees can pass a minimum metric, and retaining the license will require
yearly continuing education courses in infection control, the Dental Practice Act, CPR and other
areas. The licensee will also have to pass a criminal background check through fingerprinting
and will be continually monitored. These expectations will ensure patient safety.
Level 4: Results and Leading Indicators
Increasing the number of licensed dental assistants will be reflected in dental board data,
provided for each accredited-school, that is released quarterly on the number applicants and
those who passed or failed the exam. Also released are data on accredited programs as well as
accreditation status. The board can make the transition to the new requirements and give a one-
or two-year warning of pending changes. An additional option is to have a tiered
implementation process to give applicants time to take the exam by creating a lower-tiered
license that still requires an application, pass a criminal background check and continuing
education with a three-year window to complete the rest of the requirements. The continuing
education can be monitored periodically. The board monitors continuing education courses at the
time of license renewal. A certificate of completion with a board approval number is issued to
the participant from the course provider.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 84
Table 9
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
1.Increase the number of
licensed dental assistants.
Decrease number of reports of
dentist errors, public
perceptions, and other
healthcare outcomes.
Increase the number of
licensed dental assistants and
will be measured by the
Dental Board of California
1.b Dental patients with receive
care from dental assistants
that have been fingerprinted
and passed a background
check through the
Department of Justice.
As part of the licensing exam
fingerprints and a background
check through the Department
of Justice must be cleared
before the applicant can
qualify to take the exam.
2. Increased number of
dental assistants that
graduate from a CODA-
accredited dental assisting
program.
The number of Dental patients
who receive care from a
dental assistant that has
graduated from an
accredited dental assisting
program.
Utilized the American Dental
Association's Commission on
Dental Accreditation (CODA)
to accredited existing dental
assisting programs.
Internal Outcomes
1. Dentists ensure safety
by ensuring that dental
assistants have a license.
The number of Dental assistants
that have graduated from
accredited dental assisting
programs has passed
competencies with a minimum
standard to ensure their safety
when working with hazards.
Through CODA accreditation,
a standardized curriculum
includes infection control.
OSHA standards, CDC
bloodborne pathogens,
chemical waste management.
Level 3: Behavior
Critical behaviors. The stakeholders of focus are dentists who utilize dental assistants
for whom they are legally responsible. The first critical behavior is to hire assistants who have
passed a minimum competency or metric before working with patients. The second critical
behavior to hire those who have had formal education. The third critical behavior is that
licensees have passed a background check to ensure they do not have a criminal background.
The fourth critical behavior is to require a continuing education course on infection control or
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 85
disease transmission to remain current on standards for patient safety. The specific metrics,
methods, and timing for each of these outcome behaviors appear in Table 10.
Table 10
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. Dentists will only hire
licensed dental
assistants to work in
dental facilities.
The number of
licensed dental
assistants
working for
dentists
The dentists will verify
dental assisting licensing
utilizing the dental
board's website and keep
copies of the license in
employee files
every other year
during the license
renewal period
2. The dentists will
advocate the dental
board to make changes
to the dental practice act
to require graduation
from a CODA-
accredited dental
assisting program.
The number of
dental assistants
with certificates
from an
accredited dental
assisting
program.
The dentist will only hire
dental assistants that
have a dental assisting
certificate from a dental
assisting program and
will keep a copy in the
employee file.
Once upon being
hired
3. The dentists advocate
for the dental board to
make changes to the
dental practice act to
require fingerprinting
and criminal
background checks.
The number of
licensed dental
assistants.
Dental assistants will
pass a criminal
background from the
Department of Justice
through fingerprinting.
Once at the time of
application. If a
person does
anything illegal, it
will be reported to
the dental board.
4. The dentists will
advocate to the dental
board to make changes
to the dental practice act
to require all dental
assistants to take
continuing education
courses in infection
control, OSHA, CDC
bloodborne pathogens,
CPR, dental office
compliance and dental
practice act.
The number of
dental assistants.
Dental assistants will
complete mandatory
continuing education
courses every year. The
dentist will keep records
of course in the
employee file, and the
dental board monitors
with each license
renewal every other year.
every other year
during the license
renewal period
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 86
Table 11
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing (K solutions)
Provide Dentists with
information on the benefits to
the dentists and patient of hiring
dental assistants that have formal
education and are licensed.
yearly 1,3
Provide dentists information on
the benefits of formal dental
assisting programs accredited by
the Commission on Dental
Accreditation (CODA )
once
Provide Dentists the steps for
identifying dental assistant that
have passed a state or national
board exam.
once 2
Encouraging (M solutions)
Provide dentists rationales for
having licensed dental assistants.
once 1,3
Provide dentists attributional
retraining in providing feedback
that stresses the nature of
learning and improved
outcomes.
quarterly at dental board
meetings
2,3
Rewarding (M solutions)
The dentist's values, having
licensed dental assistants for
patient safety.
Once after passing the licensing
exam then yearly per evaluations.
1,2
Monitoring (O Accountability)
Dentists require dental assistants
to be educated and licensed to
promote patient protection.
Once after passing the licensing
exam. Every other year with
licensing expiration.
1,3,4
Dentists know licensing criteria Every year as part of the dental
practice act.
2
Dentists know the education and
requirements for dental
assistants licensing criteria.
Every year as part of the dental
practice act.
1,2,3,4
Dentists require the dental board
to incorporate accreditation
standards ( CODA) in dental
assisting education laws and
require all dental assistants to
graduate from an accredited
dental assisting program
quarterly at dental board
meetings
1,3
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 87
Organizational Support. The critical behaviors and required drivers mentioned above
assume the recommendations at the organizational level will be implemented and monitored. For
the dentist to achieve their organizational goal, the dental board can avoid the need for additional
resources by utilizing organizations that already exist. The dental board will utilize CODA as the
accreditation agency. CODA will work directly with the programs for standardization and
compliance. Program reports will be sent from CODA to the board. Utilizing an outside agency
relieves the dental board from using its resources to accredit and monitor programs. The board
will save money by utilizing CODA for accreditation by reducing the staff, training, and travel
expenses. Similarly, the board will use DANB to offer state-specific licensing exams. The
board will outsource to DANB who will monitor and proctor the exams and provide reports.
Outsourcing the licensing exam will save the board money as reduce the amount time-
intensive paperwork required, training, and the need for subject matter experts for exam writing,
and fees to exam proctoring agencies. These will all be provided from DANB. Empirical
studies are needed to compare the outcomes of formal education compared to on the job training.
There needs to be standardization of regulations of education and licensing to advance the
profession (Fried, 2017).
Level 2: Learning
Learning goals. Using Kirkpatrick and Kirkpatrick (2016) evaluations at Levels 1 and 2,
reactions and learning are introduced to dentists to educate them on CODA-accredited dental
assisting program and licensing. Following the completion of the recommended solutions will
help dentists identify the benefits of hiring those who graduated from CODA-accredited
programs and have passed a licensing exam. The program will also ensure the dentists are
educated on the most current regulations and standards. The dentist will be able to:
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 88
1. Demonstrate knowledge of the standards of education and licensing for Dental Assistants
as established by the Dental Board to protect patient health. (P)
2. Execute the requirement of all dental assistants hired in the dentist’s practice to pass a
state or national board exam.
3. Differentiate the benefits of hiring highly qualified dental assistants that graduate from a
CODA standards and expectations for desired outcomes of dental assistants that graduate
from a CODA-accredited dental assisting program compared to on the job trained with no
licensing.
4. Identify the government regulatory agencies concerned with the dental practice and
integrate the necessary documentation for a dental office to be in compliance with OSHA
regulations. (Value)
Program. The above listed learning goals will be achieved by dentists completing a
workshop to understand the value of dental assistants’ duties and of their completing a CODA
accredited dental assisting program and pass a licensing exam. The dentists will patriciate in a
workshop that will educate them on the advantages of dental assisting program curriculum that
has been accredited by CODA and value of hiring licensed dental assistants.
An awareness campaign will be created utilizing social media, webinars and workshops.
The program will be designed using an approach that will promote awareness for the dentist,
dental board and patients. The title of the campaign will be “How to protect your practice and
patients using educated and licensed dental assistants.” The program will be launched during the
national dental infection control awareness month. The first workshop will be held at the annual
dental conference. The workshop will include the following learning outcomes:
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 89
1. Dentists utilizing a licensed dental assistant can help to protect your practice a patient's
through education and licensing.
a. Hiring the most qualified dental assistant shows the dentists commitment for the
patients safety.
b. Licensed dental assistants offer tremendous benefits to the employer (dentist) by
providing assurance that the dental assistant has met rigorous requirements to pass a
licensing exam, including a criminal background check.
c. Graduation from an accredited dental assisting program ensures the program has met
a stringent governance, administrative and measurement standards set by the
accreditation agency.
d. Graduation from an accredited dental assisting program includes standardized
education and training protocols for all aspects of infection control in the dental
setting using the OSHA Bloodborne Pathogens Standard and CDC Guidelines for
Infection Control in Dental Health Care Settings requirements.
e. Dental Assisting programs provide practical education and training that fills gaps in
knowledge, skills and abilities to perform all aspects of dental assisting duties in a
safe environment without jeopardizing patient safety as can be seen in on the job
training.
f. Graduation from an accredited dental assisting program ensures the dental assistant
has met the expected learning outcomes that have been identified as what the dental
assistant is expected to know and understand upon successful completion of the
program.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 90
g. Graduation from an accredited dental assisting program ensure the dental assistant is
trained in all aspects of the mandatory dental office compliance and can be utilized as
the compliance officer in the dental facility.
h. Confidence that the licensed dental assistant will maintain a current level of dental
education by required continuing education courses from the dental board which
includes infection control, dental practice act and CPR.
2. Utilizing a licensed dental assistants allows for the dentist to have the dental assistant
perform “allowable duties” that frees up the dentist and allows them to work on another
patient which has financial benefits by increasing practice production.
Components of learning. At the conclusion of the workshop, a brief survey will be
completed to validate the learning objectives have been met. There will be an option to provide
additional feedback. The survey and feedback will be evaluated to provide the campaign with an
additional information that could be provided in the social media blasts that will be issued
quarterly. The overall objective of the program is to increase the dentist’s knowledge and
understanding of the value of hiring dental assistants that have graduated from a CODA
accredited program and have passed a licensing exam
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 91
Table 12
Components of Learning for the Program.
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks using evaluation survey. After workshop
Procedural Skills “I can do it right now.”
Evaluation using a survey to evaluate if the
dentist will hire dental assistants that have
graduated from a CODA accredited program
and passed a licensing exam.
After workshop
Attitude “I believe this is worthwhile.”
Has the dentist’s attitude toward education and
licensing changed to appreciate the importance
of CODA accreditation and licensing.
After workshop
Confidence “I think I can do it on the job.”
The dentist has an understanding of the
complexity of dental assisting duties and the
correlation to patient safety.
After workshop
Commitment “I will do it on the job.”
The dentists always put the safety and quality
of the patient’s as their priority and as a
commitment to the patients that come under
their care.
After workshop
Level 1: Reaction
Table 13 will list the methods used to determine the participant’s reactions.
Table 13
Components to Measure Reactions to the Program.
Method(s) or Tool(s) Timing
Engagement
Participation During workshop
Relevance
Evaluation sent via email Six weeks after workshop
Customer Satisfaction
Evaluation sent via email Twelve weeks after workshop
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 92
Evaluation Tools
Immediately following the program implementation. Evaluations at Levels 1 and 2
are necessary to provide feedback about the quality of the workshop. A follow up surveys will
be emailed to those who completed the workshop. The first survey will be six weeks after the
workshop, and the second one will be twelve weeks after the workshop . The survey will be
emailed using a link to a survey. A 6 point Likert scales with responses from strongly agree to
strongly disagree. The survey will also include some open ended questions that will be utilized
for some of the responses. The survey will identify the effectiveness of the workshop and
provide information to make any adjustments.
Delayed for a period after the program implementation. Workshop participants will
be evaluated after training to identify if the workshop had an impact on their motivation to hire
graduates of CODA programs and require licensing. About 12 weeks after workshop, a second
survey will be sent to the participants to access their perspective and relevance of the training
(Level 1), confidence and value of applying the training to their hiring practices of dental
assistants (Level 2), application of the training to their hiring practices of dental assistants (Level
3), and the extent to which the training will be integrated into their dental practice (Level 3).
Data Analysis and Reporting
The Level 4 goal of the implementation plan is to reduce the safety risks to patients. The
reduction will come when dentists require graduation from a CODA accredited program and
passing a licensing exam to be hired. The dentist can work closely with the dental board to
implement a plan to increase the number of educated and licensed dental assistants in the
industry.
Summary
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 93
Kirkpatrick and Kirkpatrick’s New World Model (2016) was the framework used to
create and implement an integrated plan geared towards the goal of all dental assistants
graduating from an accredited program and being licensed by 2025. Using Kirkpatrick and
Kirkpatrick’s (2016) four levels allows the implementation of reaction (Level 1), learning (Level
2) and how the training occurs. Using these levels highlights the complexity of learning.
However, before an integrated plan can be developed, research needs to be conducted to
determine where the gap exists. The implementation of Level 3 is the most important and can be
evaluated by participants’ motivation to hire assistants who graduated from CODA accredited
programs and have passed a licensing exam. Using this model allows for close monitoring of the
education curriculum. Participants can apply Levels 1 and 2 in hiring. Level 4 will be evaluated
at program completion.
Kirkpatrick and Kirkpatrick's (2016)framework is presented so that the evaluation begins
at Level 4 and works backward to formulate the training and evaluation. The expectation of
using this integrated plan is the dentists can see value in education and appreciate the complexity
of the dental assisting education compared to training on the job. Using an integrated plan
allows dentists to have input into levels 1 through 4 to optimize the performance of the dental
assistant to meet the dentist’s needs while providing patients with a safe visit.
Conclusion
The main takeaway from this project is that the problem associated with unlicensed
dental assistants is a national problem for patient safety. The project found a lack of
standardized regulation of education and licensing across all the states. Empirical studies are
needed to compare the performance of formally educated dental assistants compared to those
trained on the job. Address the harm to patient safety will require a collaborative, multi-faceted
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 94
approach. Specifically, dentists, dental boards, and patients need to be educated about the risks
of unlicensed and untrained dental assistants providing patient care. Additionally, partnerships
between dentists, state dental boards, CODA, and DANB will be crucial to obtain the goal of all
dental assistants’ having formal education and licensing by 2025.
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 95
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Window, C., Window, P., & Eccles, J. (2006). Asking “Can I Do the Task ?” Asking “ Do I
Want To Do the Task ?” Retrieved from http://www.Education.com/reference/article/
expectancy-value-motivational-theory?
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 101
APPENDIX A
INSTITUTIONAL REVIEW BOARD APPROVAL
University of Southern California Institutional Review Board
1640 Marengo Street, Suite 700
Los Angeles, California 90033-9269
Telephone: (323) 442-0114
Fax: (323) 224-8389
Email: irb@usc.edu
Date: Mar 28, 2019, 07:40am
Action Taken: Approve
Principal
Investigator:
Denise Romero, CDA, COA, RDA, OA, MA
ROSSIER SCHOOL OF EDUCATION
Faculty Advisor: Patricia Tobey
OFFICE OF THE PROVOST
Co-
Investigator(s):
Project Title: Unlicensed dental assistants create a concern
Study ID: UP-19-00116
Funding:
The University of Southern California Institutional Review Board (IRB) designee determined that your project
meets the requirements outlined in 45 CFR 46.104(d) category (2) and qualifies for exemption from IRB review.
This study was approved on 03/28/2019and is not subject to further IRB review.
Consent and recruitment documents are not required to be uploaded for exempt studies; however,
researchers are reminded that USC follows the principles of the Belmont Report, which requires all potential
participants to be informed of the research study, their rights as a participant, confidentiality of their data, etc.
It is recommended that you utilize the Information Sheet For Exempt Research and revise the template to be
specific to your study. This document will not be reviewed by the IRB. It is the responsibility of the researcher
to make sure the document is consistent with the study procedures listed in the application.
**Per USC Policy, someone may not collect data about people he or she oversees in a professional capacity.
Please ensure that someone on the study (represented in 2.1, with the required human subjects certification) is
able to serve as an independent data collector. Further, data must be stripped of any identifying information
before being provided to people who have the supervisory relationship in order to protect the confidentiality of
the participant responses.**
**Note: Data stored on a cloud service must comply with USC policy
You are responsible for ensuring that your project complies with all federal, state, local and institutional
standards. Please check with all participating sites to make sure you have their permission (including IRB/ethics
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 102
board approval, if applicable) to conduct research prior to beginning your study.
All submissions, including new applications, contingency responses, amendments and continuing reviews are
reviewed in the order received.
Funding source(s): N/A – no funding source listed
Attachments:
Information Sheet for Exempt or Flex-Exempt Studies, dated 03-29-2013.doc
Recruitment Tool Instructions.doc
Social-behavioral health-related interventions or health-outcome studies must register
with clinicaltrials.gov or other International Community of Medical Journal Editors
(ICMJE) approved registries in order to be published in an ICJME journal. The ICMJE will not
accept studies for publication unless the studies are registered prior to enrollment, despite the
fact that these studies are not applicable “clinical trials” as defined by the Food and Drug
Administration (FDA). For support with registration, go to www.clinicaltrials.gov or contact
Jean Chan ( jeanbcha@usc.edu, 323-442-2825).
Approved Documents: view
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 103
APPENDIX B
INFORMED CONSENT FORM
University of Southern California
Rossier School of Education
3470 Trousdale Pkwy
Los Angeles, CA 90089
UNLICENSED AND UNEDUCATED DENTAL ASSISTANTS CREATE A
CONCERN TO PATIENT SAFETY
You are invited to participate in a research study. Research studies include only people who
voluntarily choose to take part. This document explains information about this study. You should
ask questions about anything that is unclear to you.
PURPOSE OF THE STUDY
This research study aims to understand the dentist’s perspective of hiring unlicensed and
uneducated dental assistants compared to licensed and educated dental assistants. Being a dental
assistant comes with great responsibility and dentists rely on the dental assistant to manage and
maintain the infection control procedures in the office and assume they are being done according
to Centers for Disease Control (CDC) guidelines among many other tasks. Dentists are legally
responsible for hiring, providing training and supervision of dental assistants as well as ensuring
patient safety. This study will take an in depth look at the dental assisting profession and provide
data to enable to profession to understand the gap which will provide ways to address concerns.
Secondary it is hopefully the data will provide some answers to address the storage/lack of dental
assistants which is a national problem.
PARTICIPANT INVOLVEMENT
If you agree to take part in this study, you will be asked to complete an online survey which is
anticipated to take about 10 minutes. You do not have to answer any questions you don’t want
to, click “next” or “N/A” in the survey to move to the next question.
If you agree to take part in the second part of the study, you will be asked to participate in a 20
minute audio-taped interview. You do not have to answer any questions you don’t want to; if you
don’t want to be taped, please indicate so written notes can be taken.
PAYMENT/COMPENSATION FOR PARTICIPATION
You will not be compensated for your participation.
CONFIDENTIALITY
All information and data will be kept confidential. The data may be kept
indefinitely. Any identifiable information obtained in connection with this study will remain
confidential. Your responses will be coded with a false name (pseudonym) and maintained
separately. The audio-tapes will be destroyed once they have been transcribed. The data will be
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 104
stored on a password protected computer in the researcher’s office for ten years after the study
has been completed and then destroyed.
Required language:
The members of the research team, the funding agency and the University of Southern
California’s Human Subjects Protection Program (HSPP) may access the data. The HSPP
reviews and monitors research studies to protect the rights and welfare of research subjects.
INVESTIGATOR CONTACT INFORMATION
Principal Investigator Denise Romero via email at dmromero@usc.edu at (562) 305-8645 or
Faculty Advisor Dr. Pat Tobey via email at tobey@usc.edu.
IRB CONTACT INFORMATION
University Park Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los
Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 105
APPENDIX C
SURVEY QUESTIONS
Research Question/
Data Type
Survey Item (question and response)
1. Which of the following education do you require
when hiring a dental assistant? Please mark all that
apply.
a. Graduation from only a CODA (commission on
dental accreditation) accredited dental assisting
program.
b. Graduation from any dental assisting program
(ROP, private for-profit)
c. No formal education is required (on the job
trained)
2. Which of the following licensing do you require
when hiring a dental assistant? Please mark all that
apply.
a. Require dental assistant to have RDA license
(Registered dental assistant) or CDA (Certified
Dental Assistant). State specific
b. Require x-ray certificate only
c. Require no licensing
3. Please indicate which CE courses you require your
dental assistants to take yearly. Mark all that apply.
a. Infection control
b. Dental practice act
c. OSHA
d. CDC guidelines
e. Don’t require specific course any CE accepted
f. Don’t require my assistant to take CE
4. Which of the following duties do you have your
dental assistant perform? Mark all that apply.
a. Perform sterilization and disinfection procedures
(Infection control)
b. Office compliance manual
c. Take Impressions
d. Prepare procedural trays/ set-up
e. Fabricate and cement temporary crowns
f. Place temporary fillings
g. Expose, process, mount/label dental x- rays
h. Coronal polishing
i. Topical fluoride
j. Place pit and fissure sealants
k. Assist with dental treatment by transferring dental
instruments and maintaining field using suctions,
retraction, etc.
l. Assist with restorative procedures
m. Assist with oral surgery
n. Assist with endodontic procedures
o. Provide pre and post op instructions
p. Fabricate custom trays for bleaching, night guards,
and mouth guards including taking impressions.
q. Place and remove matrices
r. Take and record vital signs
s. Intra and extra oral exam
t. Chart existing restorations
u. Intra oral and extra oral photography
v. Place, bure and finish composite restorations
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 106
5. In your dental office, how critical is patient safety
during dental treatment?
a. Absolutely critical
b. Important
c. Nice to have
d. Not important
6. In your dental office, how critical is it that your
dental assistant has a strong understanding of the
most current infection control standards including
CDC guidelines?
A. Absolutely critical
b. Important
c. Nice to have
d. Not important
7. In your dental office, how critical, is it that your
dental assistant performs all disinfection and
sterilization procedures exactly to CDC guidelines?
a. Absolutely critical
b. Important
c. Nice to have
d. Not important
8. In your dental office, who is primarily responsible
for disinfection and sterilization?
a. Dental assistant
b. Dentist
c. Dental Hygienist
d. Front desk assistant
9. In your dental office, who is primarily responsible
for reviewing patient’s consent before a procedure.
a. Dental assistant
b. Dentist
c. Dental Hygienist
d. Front desk assistant
10. In your dental office, who is primarily responsible
for taking vital signs and reviewing medical history
before the start of dental treatment?
a. Dental assistant
b. Dentist
c. Dental Hygienist
d. Front desk assistant
11. In your dental office, who is primarily responsible
for maintaining the mandatory office compliance
manual that includes (OSHA, bloodborne pathogens,
hazardous waste, chemical management, etc.) and
the training to employees?
a. Dental assistant
b. Dentist
c. Dental Hygienist
d. Front desk assistant
12. In your dental office, how important is it for the
dental assistants to be effective to allow for you (the
dentist) to move from patient to patient?
a. Absolutely critical
b. Important
c. Nice to have
d. Not important
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 107
APPENDIX D
INTERVIEW QUESTIONS
1. What is your knowledge of the different pathways to becoming a dental assistant? For
example on the job trained versus education from a dental assisting program. If answer no
requirements.
2. What would be your primary reason for not requiring a dental assistant to have dental
assisting education and licensing?
3. Currently the DBC does not require a formal education for dental assistants. As the dentist
you are responsible to ensure that they have the proper education for infection control. How
or where do you have the dental assistant get that training?
4. What is your understanding of the different types of dental assistants and their allowable
duties (from the dental practice act)? For example, the difference between a dental assistant
registered dental assistant, registered dental assisting expanded function and orthodontic
assistant.
5. What duties do you rely on your dental assistants to perform on a routine/ daily basis?
6. What steps would you recommend the dental board take to ensure uneducated and
unlicensed dental assistant are providing all infection control protocol required by the dental
practice act for patient’s safety during patient treatment in regards to infection control during
dental treatment?
7. Please explain your position related to requiring education and licensing for the dental
assistants working in a dental office? (Do you require RDA?)
8. Can you describe who in your office is responsible in your office completes the yearly
training and written compliance manual and how do they get the training to complete it?
Ex. Illness and injury, office fire and safety, exposure control plan, hazard communication, radiation
safety, BBP, CDC Infection control, Medical waste, records, water, ergonomics
9. All licensed members of the dental health team have to take mandatory continuing education
units. Every other year 25-50 including infection control and the California Dental Practice
Act. This ensures the DHT has the most current up to date knowledge for patient safety.
Unlicensed dental assistants do not have this same requirement. They do not have to take
any CE. What are your thoughts about them not being required to take CE? What would you
recommend or do in your office to ensure your DA has the most current standards?
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 108
10. Do you find the DPA (dental practice act) for the different type of dental assisting allowable
duties to be clear and easy to understand?
11. In regards to the allowable duties do you believe it would be easier to have one type of
dental assistant (RDA) versus multiple levels.
12. Dental assistants that apply for the RDA are required to get fingerprints and pass a
background check before qualifying for the exam. This is for patient protection. The current
laws do not require dental assistants to get fingerprinted. Unlicensed dental assistants can’t
be tracked like an RDA. What your option on this law?
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 109
APPENDIX E
SAMPLE POST-TRAINING ITEMS MEASURING KIRKPATRICK LEVELS 1 AND 2
1. The courses held my interest. (Level 1 Engagement)
Strongly Disagree, Disagree, Agree, Strongly Agree
2. The course content was relevant to dental assisting. (Level 1 Relevance)
Strongly Disagree, Disagree, Agree, Strongly Agree
3. I am satisfied with the dental assisting courses. (Level 1 Student Satisfaction)
Strongly Disagree, Disagree, Agree, Strongly Agree
4. Do you feel satisfied that the dental assisting course prepared you to anticipate equipment
and instruments necessary for various procedures and to plan ahead to ensure readiness
for procedures? (Level 2 Procedural Knowledge)
Strongly Disagree, Disagree, Agree, Strongly Agree
5. Do you feel satisfied that the dental assisting course prepared you to prepare the patient
treatment rooms and disassemble the treatment room using CDC guidelines? (Level 2
Procedural)
Strongly Disagree, Disagree, Agree, Strongly Agree
6. Did the dental assisting course prepare you to take, develop, and mount quality
radiographs to assure the highest degree of diagnostic quality with the least amount of
exposure following State and Federal guidelines? (Level 2 Factual Knowledge)
Strongly Disagree, Disagree, Agree, Strongly Agree
7. Did the dental assisting course prepare you to anticipate the dentist's needs, pass
instruments and supplies in a timely manner? (Level 2 Procedural Knowledge)
Strongly Disagree, Disagree, Agree, Strongly Agree
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 110
5. Did the dental assisting program prepares you for all the duties you are legally allowed to
perform as a registered dental assisting: coronal polishing, sealants, impressions,
temporary crowns, ultrasonic scaling, etc. (Level 2 Procedural Knowledge)
Strongly Disagree, Disagree, Agree, Strongly Agree
6. Are you confident in training for providing verbal pre and post-treatment instructions to
the patients as indicated by the dentist? (Level 2 Factual Procedural)
Strongly Disagree, Disagree, Agree, Strongly Agree
7. I am satisfied with the training I received in all the dental assisting courses. (Level 1
Student Satisfaction)
Strongly Disagree, Disagree, Agree, Strongly Agree
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 111
APPENDIX F
SAMPLE BLENDED EVALUATION ITEMS MEASURING KIRKPATRICK LEVELS 1,2,3,
AND 4
Dental Assisting Graduates Exit survey
1. Are you currently working in the dental field? (Level 1 Relevance)
a. private practice b. group practice c. Government or education d. Not working in
dentistry.
2. Did you take the RDA or CDA exam? (Level 1 Relevance)
a. Yes, and passed b. Yes, did not pass c. No, I have not but will d. no, will not take the
exam
3. I feel the dental assisting program has prepared me in all areas of dental assisting I need to be
successful in my office. (Level 3 Transfer)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
1b. If answered c or d, please indicate areas what areas need to be improved.
4. I feel confident in my ability to provide a safe visit for patients under my care. Using all of
the knowledge from the dental assisting program (Infection control and all DA duties). (Level 3
Transfer)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
5. I feel confident after graduation from the dental assisting program I have been prepared and
have the knowledge to pass the registered dental assisting the licensing exam. (Level 4 Results)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 112
6. I am confident I can demonstrate and integrate entry-level infection control skills and
technical abilities to successfully perform dental assisting procedures and minimum standards as
outlined by the DPA. (Level 3 Transfer)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
7. I am confident I can execute technical skills and abilities, safety, and infection control
procedures as outlined by the California Dental Practice Act in all dental assisting courses.
(Level 3 Transfer)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
8. I am confident in my ability to integrate entry-level infection control skills and technical
abilities to successfully identify and perform dental assisting procedures and minimum standards
as outlined by the governing bodies. (Level 3 Transfer)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
9. After graduation, I can differentiate between various disease-producing microorganisms and
their relationship to infection control. (Level 4 Results)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
10. I feel the dental assisting program gave me the skills to exhibit professional growth,
behavior, knowledge and development, foster empathy and concern, and work toward a
commitment of excellence at all times in my dental office. (Level 4 Results)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
UNLICENSED DENTAL ASSISTANTS CREATE A CONCERN 113
11. The dental assisting program gave me the skills I need to exhibit communication and
conflict skills and strategies that are effective with individuals and groups who are
diverse in age, gender, or culture in my dental office. (Level 4 Results)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
12. I am confident I can identify the government regulatory agencies concerned with a dental
practice and integrate the necessary documentation for a dental office to be in compliance
with OSHA regulations and apply it in my dental office. (Level 2 Confidence)
a. Strongly agree b. Agree c. Disagree d. strongly disagree
13. What information was missing from your training? (Level 2)
Abstract (if available)
Abstract
Choosing a career in the dental field comes with great responsibility. When patients go to the dentist, they trust their health team is providing them with a safe visit. Uneducated and unlicensed dental assistants put both the patient’s and their own safety at risk. Deadly infectious disease can easily be spread from patient to health team and health team to patient without proper infection control techniques. It is a dental assistant’s daily responsibility to provide infection control, set up treatment rooms using sterile techniques including dental unit waterline maintenance, sterilization of instruments, decontamination of room and instruments like sharp and contaminated needles and scalpels. Unlicensed and uneducated dental assistants have had no formal education in microbiology, disease transmission and Centers for Disease Control guidelines
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Asset Metadata
Creator
Romero, Denise Marie
(author)
Core Title
Unlicensed dental assistants create a concern to patient safety: an evaluation study
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Publication Date
10/23/2019
Defense Date
08/07/2019
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
dental assistant,dental assisting,dental team,infection control,OAI-PMH Harvest
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Tobey, Patricia Elaine (
committee chair
), Freund, Barbara Marie (
committee member
), Yates, Kenneth Anthony (
committee member
)
Creator Email
denisemromero@gmail.com,dmromero@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-227211
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Tags
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