DENTAL ASSISTANTS IN THE TEAMWORK

Purpose: The aim of the study was to establish the socio-demographic and professional characteristics of the sample of dental assistants and their contributions to the efficiency of dental teamwork. Material and methods: An anonymous inquiry was conducted among 108 dental assistants working in dental offices in 4 Bulgarian cities. The questionnaire consisted of 18 questions about socio-demographic and professional characteristics of the sample and their opinion about obligations, positives and negatives in the workplace, and efficiency of teamwork. The methods used in the survey were sociological (poll) and statistical (alternative analysis). Results: The socio-demographic and professional characteristics of the surveyed dental assistants were established, such as: gender and age distribution, work in active working age/pension, types of working places, location of practices, types of education and number of dentists working with over the period of their work experience. All respondents reported that they assisted the physicians in the treatment process and the majority of them (70.3785.19%) cleaned, disinfected and sterilized the instruments, the workplace and the premises of the practice. Only 4.6% dealt financial relations with the patients and worked directly in their mouths. The opinion of the respondents for building a well-functioning dental team was that both the personal and professional qualities of the team members were essential. Conclusions: Dental assistants were convinced of the benefits of their assistance; between 79.6% and 58.3% of them believed that they had contributed for quicker and better job of the doctor and to patient’s comfort.


INTRODUCTION
In a historical aspect, the individual practice of dentists has been increasingly transformed into teamwork. Team work and co-operation between healthcare professionals influence the outcomes of higher quality care and work satisfaction.
For the first time in the history of dentistry, the American dentist Dr Edmund Kells operated with support staff in 1885. The practice of Dr Ed. Kells has thrived so much that he needed to hire an assistant -"Lady in Attendance" -Malvina Querria. She is considered the first dental assistant in the modern history of dentistry. [1] In 1960, the term "4-Handed Dentistry" was introduced during the Conference "Training of dentists for using an assistant to the chair" in order to reduce the stress and the fatigue of the operator. [2] In 1968 Glen Robinson summed up the concept of "Four Handed Dentistry". It includes a coordinated work of the dentist and the dental assistant as a team. [2] The names of the auxiliary staff in the dental practice have varied over the years, and in 1977 the WHO adopted a classification for auxiliary staff: [3] 1. Auxiliary staff not directly working with patients: -Dental Chairside Assistant (Nurse), Dental technician, Oral Health Educator.
The teamwork in dental practice improves the quality of the service, increases the working capacity of the dental practitioner, reduces the duration of the manipulations, and improves the organization of the workplace. According to a report from the University of Michigan, in a team with one nurse, the dental practitioner's capacity grew by 35.8% and with two nurses -by 68.8%. [4] European studies showed that the additional assistant increased productivity and reduced stress by 20-22%. [5] In Bulgaria, most of dentists work independently, and there are few practices with more than one assistant. [6,7]

PURPOSE OF THE STUDY
The present study aims to establish the socio-demographic and professional characteristics of the sample of dental assistants and their opinion on their duties and contribute to the teamwork and the main factors supporting to the establishment of an well-functioning dental team.

MATERIAL AND METHODS
Respondents: An anonymous pilot survey was conducted among 108 dental assistants working in dental offices in the Bulgarian cities of Sofia, Plovdiv, Lom, Kozloduy. The survey tool was an anonymous questionnaire form, with 18 closed, open and mixed questions, which were personally completed. The voluntary self-filling of the questionnaire, according to ethical norms, was a form of individual informed consent for the participants to participate in the survey.
Data Processing: The present study was a pilot survey of a dissertation thesis named "Teamwork in Dental Practice". The poll was conducted among dental assistants working in dental practices in Bulgarian cities of Sofia, Plovdiv, Lom and Kozloduy in the period November 2018 -March 2019. The survey was approved by the Ethical Committee of Medical University, Sofia -Approval No. 1772/19.04.2019.
Methods: The methods used were sociologicalanonymous inquiry and statistical -alternative analysis. We calculated the maximum permissible error (∆), defining the confidence interval at the coefficient value t=1.96.
The majority of respondents were in active working age -81 (75%), but 25% of them worked as dental assistants

RESULTS
The dental assistant's profession was more widely practised by women (103 -95%) than by men (5 -5%)this result is shown in fig. 1:

Fig. 1. Distribution of dental assistants by gender
The work experience of the surveyed dental assistants was divided in the following way: 34 (31.48%) -up to 5 years of apprenticeship in dental practice; 24 (22.22%) -up to 10 years; 25 (23.15%) -up to 20 years; 15 (13.89%)up to 30 years and with over 30 years of service as a dental assistant were 10 (9.26%). It is very common for dental assistants to work in several practices, especially in part-time work. To the question, "Is the dental practice your single job?" 72 (66.67%) of respondents said "Yes"; 16 (14.81%) -"No, I work in more than one practice"; 20 (18.51%) -"No -I'm still working another, non-medical job": ( fig. 7.)

Fig. 7. Number of assistants' work places
In order to analyze the turnover in the organization and the functioning of the team, we included the question, "So far, how many dentists have you worked with?". Only 24 respondents (22.22%) answered "Only 1", the remaining 84 (77.78%) have worked with "More than one dentist": (fig. 8.) Dental assistants are valuable members of the team. Their duties vary and include: assisting the dentist, disinfection and sterilization of the tools, workplace hygiene, taking care of the patients before and during the treatment, providing instructions for patients' oral care, administrative duties, etc. [8] The answers of the inquired dental assistants for their duties in the dental team are presented in Table 1: All dental assistants assisted in the treatment process, the majority of them (85.19%) prepared, arranged and sanitized the workplace, disinfected and sterilized the instruments and sanitized the premises in practice 70.37%), welcomed, accommodated and sent out the patients (82.41%). Less than half of them had the obligations to prepare the work schedule (45.37%), to keep the records (23.15%), and only 4.63% of them performed manipulations in the patient's mouth and settled financial issues with the patients.
The opinion of the dental assistants regarding their contribution to the effective work of the dental team was established by Question No. 17, and the results are shown in table 2: Improving the organization of work in the dental office 63 58,33 9,3 Shortening the time for treatmentprocedures 62 57,41 9,33 The volume of work is increased 59 54,63 9,4 The quality of the activity is increased 59 54,63 9,4 Patients feel morerelaxed 57 52,78 9,42 The majority of respondents said that their assistance released the doctor from a number of duties below his or her level of competence -sanitation, maintenance of aseptic and antiseptic treatment in the office, maintenance of documentation and help for faster and better work and that patients feel more relaxed in the presence of an assistant.
The proper functioning and effectiveness of a professional team depends on a number of factors -the personal and professional qualities of its members and their interpersonal relationships. The opinion of dental assistants on the significance of these factors is reflected in Table 3: Sharing personal information 12 11,11 5,92 In first place -74.07%±8.26 of the surveyed assistants indicated that the mutual respect among the team members helped to build an effective professional team. The respected personality of the doctor and his/her professional qualities were also essential (72.22±8.45%). More than 50% of respondents believed that the professional qualities of the assistant, the correct financial relationships, the execution of the rights and obligations of each member of the team, the constant exchange of information and the quiet working environment created good conditions for effective work. According to 24.07±8.58% of the respondents, the correlation in the age of the doctor and the assistant was a necessary factor, while 11.11±5.92% believed that the friendship between them, in terms of personal information sharing, also contributed to effective teamwork.

DISCUSSION
The socio-demographic characteristics of a sample of dental assistants in our survey were analogous to the data in literature -the gender structure was analogous to the findings in the study of Durkan C, Belsi A, where 95% of respondents were women. [9] In our survey, the respondents in active working age were 81 (75%), the remaining 27 (25%) were retired, the situation in the Durkan C, Belsi A's study was almost similar -80% of the dental nurses are between the age of 25 and 44 years. [9] Labour law in Bulgaria allows dentists to hire for dental assistants' position persons without medical education and to educate and train them in the job. Despite this, many dentists (45.50%) believed that dental nurses have to possess Bachelor's degree in medicine. [10] In some surveys, the authors described as duties of dental nurses expanded functions, such as fluoride prophylaxis, taking X-rays, maintaining conscious sedation etc. [9,11,12] The contribution of dental assistants to better results of dentists' work was proven in the study of M. Simov [10], where 96.70% of respondents said that the assistance of dental nurse would improve the quality of services. Almost the same number of dentists -94.93% believed that teamwork would increase the productivity of dentists' work [2] and decrease stress. [5] Like in our study, in the study of Hakanen JJ, the dental assistants believed that interpersonal and hierarchical relationships between partners played an important role in building a well-functioning team. [13] In a study of Mindak MT, the inquired dental nurses reported one factor -the lack of praises, which demotivated their work. [14] CONCLUSION The results of the study allowed us to draw the following conclusions: 1. The socio-demographic characteristics of the inquired dental assistants -their distribution by sex and age were similar to the data from the literary sources -95.4% women and 4.6% men, 75% in active working age and 25% -pensioners.
2. The socio-professional characteristics of the dental assistants included in the sample were as follows: -Most of the respondents -43.52% worked in the capital city, 25.92% -in big cities, 22.22% -in small towns and 8.33% -in villages.
-The majority of them -51.85% worked in individual practices and the rest -in group practices and dental centres.
-During the period of their work experience, 77.78% have worked with more than one dental practitioner.
3. All respondents assisted the dentist in the treatment process, and between 70.37 and 85.19% of them cleaned, disinfected and sterilized the instruments, the workplace and the premises of the practice. Only 4.63% have dealt with financial issues with the patient and worked directly in his/ her mouth.
4. Dental assistants were convinced of the benefits of their assistance, with between 79.63% and 58.33% believing they relieved the doctor of duties below his or her level of competence, and helped him to work faster and better and contributed to the patient's peace of mind and comfort.
5. The opinion of the respondents for building a wellfunctioning dental team was that both the personal and professional qualities of the team members are essential.

ANNEX 1:
QUESTIONNAIRE Dear Dental Assistants, The purpose of this study is to investigate dental assistants' opinion on team work in dental practice. This research is part of a dissertation. The voluntary self-filling of the questionnaire will be accepted as a form of individually informed consent to participate in this survey.
The survey is anonymous. Please tick the correct answers or write your answer to the question
Your age is: Active working age Retirement age

3.
Your work experience as a dental assistant is: Up to 5 years From 6 to 15 years From 16 to 30 years Over 30 years 4.
The location of the practice you are working in is: In the capital city In a big city In a small town In a village 5.
The type of practice you work in is: Individual practice Group practice Dental Centre 6.
Your education is: General medical Dental assistant Non-medical 7.
Is dental practice your only job: Yes, from continuing education courses My doctor teaches me 16. What additional training do you need: On new modern methods and remedies for treatment