Page 87


Clinical Technical Performance and Performance Measures Using well-accepted criteria for selected clinical procedures, the therapists were directly

observed performing sealant placement, composite and amalgam preparations and placements, stainless steel crown placement, and oral health instruction. The sample sizes for each of these procedures were limited, ranging from 1 to 15 procedures. Nevertheless, the proportion of procedures with deficiencies was small, 8% overall. Prior restorations were assessed by a trained observer who was “blinded,� or unaware whether a therapist or dentist had been the provider, and rates and types of deficiencies were similar for these providers. Potential biases, as we have noted, include an observer effect and time elapsed since restoration, although we restricted this study component to restorations done in the previous 2 years. Finally, from the record audits, complications following restorative procedures were extremely infrequent, and no postextraction complications were noted. These data indicate that the therapists who were observed are technically competent to perform these procedures within their scope of practice. Previous studies of the care provided by therapists in other countries (Ambrose, Hord, & Simpson, 1977) as well as two previous smaller studies of the therapists in Alaska (Fiset, 2005) and (Bolin, 2008) found similar results. Performance measures indicate that risk assessment is well integrated into some but not all dental programs of tribal health organizations. Formal risk assessment is currently being promoted in dental schools, but has not yet become universally accepted in dental practices (Riley et al., 2010; Young et al., 2007). Regardless of risk assessment programs, virtually all children received appropriate caries preventive treatment, and two-thirds of children received oral hygiene instruction. Despite this attention to prevention, a majority of high-risk children experienced new disease in the course of a year. However, extraction of permanent teeth among children was relatively infrequent, which may be an early sign of generational improvement in oral health. A longitudinal assessment of the prevalence of lesions and restorations in adolescents and young adults will be necessary to determine if such improvement is taking place. The community examinations reported here represent the baseline for such analyses. Receipt of caries preventive treatment by adults was lower than for children. The provision of periodontal maintenance care to adults assessed as having periodontal disease was infrequent. Prophylaxes were also relatively infrequent, with less than half of adult and child patients receiving such treatments in the course of a year. It should be noted that, although this service is relatively common in U.S. dental practices, the caries preventive benefit of semiannual prophylaxis alone has not been demonstrated. Notation of gingival bleeding status was performed for less than one quarter of adults. However, this notation was apparently not part of