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Reaching Up and Reaching Out
The Extended Functions Dental Assistant
In the beginning, dental assistants were referred to as "ladies in attendance"—in order to make it respectable for a woman patient to visit the dental office unaccompanied. Back in the late 19th century, Dr. Edmund Kell hired the first three dental assistants to assist him with his patient care. However, today the same work is now accomplished with just one highly skilled and trained professional. The dental assistant has proven to be a necessity in the modern dental practice, with ever increasing educational and career opportunities.
A National Professional Community
In 1911, Juliette A. Southard started her career with Dr. Henry Fowler of New York, as his permanent assistant. In 1921, she formed a local dental assistant’s society in New York City. At the time, there were dental assisting societies being formed across the country. However, Southard’s vision was to create a national organization to unify this new profession of dental assisting, with the help of Jessie Ellsworth, President of the Chicago and Cook County Dental Assistants Association. After petitioning and receiving special permission, the two attended the 1923 American Dental Association (ADA) convention in Cleveland, Ohio.
The following year, these women developed a constitution and bylaws for their own association, then officers were elected. Southard was elected as president, and the American Dental Assistants Association (ADAA) was off and running. On March 17, 1925, in Illinois, the ADAA became incorporated. The organization and its membership made no distinction between the chairside assistant, the receptionist, and the general assistant—the idea was that they were all dental assistants.
In 1947, a certifying board was established as a separate and autonomous agency from the ADAA. Its responsibilities were to test dental assistants and "to advance the vocation of dental assistants by providing qualifying examinations." On August 4, 1948, The American Dental Assistants Certification Board, Inc was founded by the ADAA and the "certified dental assistant" (CDA) was born. This certification gained approval of the ADA in 1960, and the Board changed its name to the Certifying Board of the American Dental Assistants Association, Inc. In 1978, the organization again changed its name and structure, becoming the Dental Assisting National Board, Inc (DANB). Though DANB is no longer affiliated with the ADAA, it is because of progressive thinkers such as Southard that the profession of dental assisting advanced—and continues to expand.
The advancement of the dental assisting profession continues to be a state-by-state undertaking. Minnesota and California were two of the first states to expand the functions of dental assistants as a result of concerted, collaborative efforts by many stakeholders.
As California Goes
The evolution of dental assisting licensure in California serves as an example of the process. The legislative history of the licensed dental assistant dates back to the 1970s. On August 9, 1972, Assembly Bill 1953, Chapter 645, was approved by the governor of California (see sidebar). This Bill created the Advisory Committee on the Utilization and Education of Dental Auxiliaries, later to be known as the Committee on Dental Auxiliaries (COMDA).
The Bill stated this visionary premise, applicable not only to California but to the entire nation:
The Legislature hereby finds and declares that the improved utilization of dental auxiliaries will help in making high-quality dental services more readily available to the people of this state.1"
In addition to this goal, the legislation addressed two other main areas: additional career mobility for auxiliaries by creating a "career ladder," and legal standards to protect the public from dental auxiliaries not fully competent to perform assigned tasks and function.
The Advisory Committee on the Utilization and Education of Dental Auxiliaries consisted of one member of the Board of Dental Examiners, two dentists licensed in California, two dental hygienists licensed in California, one dental assistant, one laboratory technician, and two deans of dental schools in California. All members were to be appointed by the governor of California.
By 1974, the legislation required the Dental Board of California, with the advice of the Committee on Dental Auxiliaries, to promulgate regulations to prescribe the specific duties that auxiliaries were to perform and the modalities for licensure of the auxiliaries.
Under the Business and Professions Code, Section 1740, this legislation declared: It is the intention of the Legislature by enactment of this article to permit the full utilization of dental auxiliaries in order to meet the dental care needs of all the states citizens. The Legislature further intends that the classifications of dental auxiliaries established pursuant to this article constitute a career ladder, permitting the continual advancement of persons to successively higher levels of licensure with additional training, and without repeating training skills already acquired. The Legislature further intends that the Board of Dental Examiners of the State of California and its Committee on Dental Auxiliaries, in implementing this article, give specific consideration to the recommendations of the Advisory Committee on Utilization and Education of Dental Auxiliaries, established pursuant to Chapter 645 of the Statutes of 1972, and contained in its report to the Legislature dated March 20, 1973.2
In the early 1990s the California Dental Assistants Association established a relationship with the California Association of Dental Assisting Teachers (CADAT) to further the representation of the dental assistant and dental assisting educators in legislative issues pertaining to the profession. The affiliation between these two organizations allowed for the development of a curriculum for specific training, especially in the areas of expanded functions. With this new collaboration, the Dental Board of California and legislators took more notice of issues concerning the dental assistant and the profession. Thus, the achievement of these two state groups working together can be viewed as a successful model for initiatives in other states. The goal was to establish some type of required education and training for all dental assistants, including the unlicensed assistant, and to expand the functions of the existing licensed dental assisting categories.
Since that initial legislation in 1973, dental assisting in California has developed into a licensed profession with varied levels to include the dental assistant (DA), the registered dental assistant (RDA), and the registered dental assistant in extended functions (RDAEF). The dental assistant in California now has an established "career ladder," which also includes careers in education and practice management.
In July 2009, the Committee on Dental Auxiliaries (COMDA), which represented both dental assisting and hygiene, was eliminated. The Dental Board of California (DBC) then formed the Dental Assisting Forum (DAF) to represent the dental assistants in the state. The stated purpose of the DAF is to discuss requirements for dental assistant licensure and renewal, allowable duties, settings and supervision levels, appropriate standards of conduct and enforcement for dental assistants, and any other issues related to dental assisting. There are seven seats on the Dental Assisting Forum, and at the time of publication, two of them were still open, providing an opportunity for an interested dental assistant to serve. However, with the new governor having started his term this past January, changes to the appointed positions on the Dental Board of California and all associated committees are anticipated.
The scope of practice for the dental assistant in California continues to grow and challenge those in the profession to rise up to meet those new changes. As the dental assistant becomes more educated, the opportunity to expand the functions for all auxiliary categories increases. The goals to enhance the profession continue to be access to care and public protection. Table 1 shows a list of shared common expanded functions and the number of states where they apply, and the list continues to lengthen.
In 2010, California added not only auxiliary categories but also new duties for dental assisting. Table 2 is a brief summary of the categories, along with some of the new duties and educational requirements.
On the "Grow"
According to current statistics of the US Department of Labor, employment as a dental assistant is expected to grow 36% between 2008 and 2018.3 Employment statistics for dental assistants in 2008 showed 295,300 people calling themselves a dental assistant and the numbers are projected to reach 400,900 by 2018.3
As of August 2010, DANB4 estimated there to be more than 33,000 Certified Dental Assistants in the United States. Although DANB certification is offered nationwide, many states do not recognize the CDA, as their own state licensures supersede the CDA. California is an example of a state that has its own licensure, and this state licensure is the only one recognized by the State Dental Practice Act in California.
According to the 2010 DANB Salary Survey,4 there are a number of factors contributing to the growth of the profession. Salary is only one factor. Survey results showed salaries ranging from approximately $16 per hour to approximately $22 per hour for CDAs. Those who were certified earned an average of $2 per hour more than those with no certification or licensure. Salaries vary state to state, from general to specialty offices, and by years in the profession.
DANB’s survey4 reflected that CDAs ranked self-gratification and pride as the top two benefits. Other benefits mentioned were recognition by the employer, elevation of the profession, patient respect for the credentials, career mobility, and potential for more duties. Education and training literally and figuratively pay off, both in wages and in professional enhancement.
The future of the expanded functions dental assistant appears to be bright—it’s an issue of supply and demand, as more organizations advocate access to oral health. In Oral Health America’s Policy Statement5 (April 2009), recommendations include: "The Oral Health Parity Policy Agenda requires investments in dental public health and dental education, with a focus on building community infrastructure for oral health services—both preventive and restorative—as well as increasing the diversity of the dental care providers. Through research and technology advances, supported by the federal and state funding, medical and dental care providers should integrate disease management practices to improve health outcomes and cut costs. States should be encouraged to realign practice acts to reflect current capabilities and educational levels of dental care practitioners, and allow for greater participation in the appropriate treatment of the underserved populations."
Using the expanded functions dental assistant and increasing the allowable duties not only improves access to care, but also protects the public through a regulated state dental practice act.
Yearn to Learn
Education for dental assistants can be achieved in a number of ways. There are programs through nationally accredited schools by the Commission on Dental Accreditation (CODA), state accredited schools, and private schools. The facilities and requirements can be quite varied. If seeking licensure through education, it is important to know that the program of choice is accredited to meet specific state requirements for completion of the program and to qualify to sit for a state-designated board exam.
As the licensure requirements vary from state to state, so do the continuing education requirements for license renewals. Some states have mandated education requirements, such as in California, where the licensed assistant is required to submit 25 hours every 2 years for renewal. However, other states are very flexible about the education required for licensure renewals, while others do not require any training or education for their dental assistants.
In order to provide the best care possible for all patients, continuing education needs to be ongoing. Time invested for growth and enhancement could be viewed as a reflection of one’s dedication, both personally and professionally.
Overcoming the Objections
As early as 1975, Lipscomb and Scheffler6 examined the economic implications of expanded-duty dental assistants and concluded that dentists could more than double their net revenue by working with this level of auxiliary. Though there have been many successes, there continue to be roadblocks in the dental community in regards to the licensed dental assistant and expanded functions. Addressing dentists’ objections, Gordon Christensen published an article in 2001 in which he explored some practitioners’ arguments against expanding the role of dental staff members.7
For example, regarding the potential difficulty of delegated tasks for staff members, he wrote that "properly educated and trained dental assistants, hygienists and technicians can perform relatively difficult clinical responsibilities well." Another concern was the possibility of a "take over" of the profession, reducing the number of dentists, although as Christensen noted, that had not yet happened in all the years of liberal practice acts.
Stating his support for expanding the roles of dental staff members, Christensen wrote, "Patients benefit from expanding the role of dental staff members. Dental staff members benefit from expanding their role in the dental practice. Additionally, staff members have greater job satisfaction because they consider themselves to be professionals who are valuable to their respective practices. It cannot be denied that practices using expanded functions staff members are more productive than those practices not using staff on an expanded basis."
This is more recently supported by a study conducted in 2008 in US Department of Veterans Affairs facilities. It found that teaching residents had a negative impact on staff dentists’ productivity, but the addition of 1 to optimally 1.5 dental assistants offset this negative impact.8
The Future is Bright
The one thing that is constant is change—especially in dentistry. Though the scope of practice continues to change and vary from state to state, the overall goals within the profession remain the same: access to care, competency with duties through licensure to protect the public, and opportunity for career advancement. The endeavors to maintain licensure in any state can be challenging: for example, in California, this has required a significant investment by stakeholders, costing hundreds of hours and thousands of lobbying dollars. These projects are ongoing in order to continue the advancement of the dental assistant and raise public awareness about the issues of access to care and consumer protection.
For dental healthcare workers, the field is growing rapidly. Now, more than ever, the licensed dental assistant is considered necessary. Add expanded functions and the possibilities are endless. It is a common goal: to provide the best possible care to the patients in our communities and protect the public through required licensure. The expanded functions dental assistant allows for those goals to be achieved: it is a valuable concept with immense possibilities.
1. The Committee on Dental Auxiliaries. Joint Legislative Sunset Review Committee: 2001 Sunset Review Report. Available at: http://www.sen.ca.gov. Accessed February 15, 2011.
2. Daoudian M. California Dental Practice Act. American Dental & Medical Institute website. Available at: http://adminstitute.com/pdf/CDPA.pdf. Accessed February 15, 2011.
3. Bureau of Labor Statistics website. United States Department of Labor. Occupational Outlook Handbook, 2010-11 Edition. Dental Assistants. Available at: http://www.bls.gov/oco/ocos163.htm. Accessed January 31, 2011.
4. Dental Assisting National Board. DANB CDAs report rising salaries. Certified Press. 2011:30(1):1.
5. Oral Health America Policy Statement. Oral Health and Healthcare Reform. April 2009. Available at: www.oralhealthamerica.org/Oral%20Health%20America%20Policy%20Statement%202009v3.pdf. Accessed February 1, 2011.
6. Lipscomb J, Scheffler RM. Impact of expanded-duty assistants on cost and productivity in dental care delivery. Health Services Research. Spring 1975:14-35.
7. Christensen GJ. Why expand the role of dental staff members? J Am Dent Assoc. 2001;132(4):529-531.
8. Lam HC, Ward T, O’Toole TG, et al. Impact of infrastructure on graduate dental education and dental clinic productivity. J Dent Educ. 2009:(73)2:184-191.
About the Author
Shari L. Becker, CDA, RDA, FADAA
ADAA 12th District Trustee
Treatment Coordinator for Dr. Stephen Snow