John Durian

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For those practicing dentists and soon-to-be graduates of D-school, what do you think of this "expanded function dental assistant." Will they really increase productivity in the office, or will this take away the "bread and butter" of dentistry? According to the article given below, this new DA-nurse will be able to "do restorative work such as fillings, crowns and bridges that used to be done only by dentists... can't diagnose, use anesthesia, perform surgery or do extractions... can't prepare teeth for restorative work by drilling... but can fill cavities and install crowns and bridges" and are "expected to make about the same salary as dental hygienists." I mean, this has got to be better than the ADHP though but I still have my reservations about the creation of such a position. What do you guys think?

Article: http://sacramento.bizjournals.com/sa...08/story2.html

Bill: http://info.sen.ca.gov/pub/07-08/bil...sen_floor.html
 

bigstix808

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haha...i've seen some of this being done already by your regular ol' dental assistant.

disclaimer: assistant has been with him for 15+ yrs and knows how to do some of the simple stuff almost as well as he does - not saying its right, but im saying it happens.
 

reapply2007

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Place restorative materials and crowns. Seems simple until you've seen what happens when things go wrong. Then again, place amalgam absolutely everywhere and people might not need to replace it very soon. I saw some of these amalgams placed by an expanded duty assistant yesterday. Yikes. Anatomy carved with what looked like a thumbnail. I actually felt sorry for the patient.
 

mike3kgt

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Good all around, except if you are the patient. (Now what I say comes from both experience and rationing. I have worked with EFDAs in the midwest who can place direct restorative material and in IHS. I have personal experience with this type of assistant at a PRIVATE PRACTICE, not a school)

The EFDAS in CA have been initiated Jan 1, and by far, exceed all other EFDAs around the country in terms of scope of abilities.

My reasoning:

Good: If you are in a low-moderate income/class practice because you can increase production by delegating multiple duties. This frees you to do more productive dentistry rather than "wasting" you time on "less important" procedures like cementing crowns or placing direction restorations.

Also Good: If you are in a moderate-high income/class practice because you can increase production by redoing most of the EFDAs work done at other offices, thus increasing production. There are many parts of CA where people just won't want anybody other than the doctor doing their dentistry, so when "Suzy" walks in to "put in your filling" the patient won't be able to say anything then, but may need to have it replaced when it fails early.

In theory:

You as a dentist now in CA can meet a new patient who say, needs a RCT/build-up/crown. You anesthetize, clean caries, prep outline form of crown, extirpate pulp, clean & shape... AND NEVER SEE THE PATIENT AGAIN. The new EFDA can fit & cement endo master cones, place core-build up (direct restorative), finish, contour, and polish direct restorative (crown prep?... not if you only prep on core material), place retraction cord, take FINAL IMPRESSION, fabricate & cement provisional restoration, dismiss patient, seat patient, don't need to anesthetize because endo is done, remove provisional, clean off cement off tooth, try in & ADJUST final crown, and CEMENT crown. Heaven forbid you need the tooth anesthetized because it's still sensitive from the poor endo treatment... well... just go get your dental hygienist to give the anesthesia. Yup, they're allowed to anesthetize there, so yes, the dentist is completely out of the picture.

If that's not a scary thing, please provide your input, because from what I know of dentistry and the potential pitfalls, it's terrifying.:eek:

See below:

-------

1753.5. (a) A registered dental assistant in extended functions
licensed on or after January 1, 2010, is authorized to perform all
duties and procedures that a registered dental assistant is
authorized to perform as specified in and limited by Section 1752.4,
and those duties that the board may prescribe by regulation.
(b) A registered dental assistant in extended functions licensed
on or after January 1, 2010, is authorized to perform the following
additional procedures under direct supervision and pursuant to the
order, control, and full professional responsibility of a licensed
dentist:
(1) Conduct preliminary evaluation of the patient's oral health,
including, but not limited to, charting, intraoral and extra-oral
evaluation of soft tissue, classifying occlusion, and functional
evaluation.
(2) Perform oral health assessments in school-based, community
health project settings under the direction of a dentist, registered
dental hygienist, or registered dental hygienist in alternative
practice.
(3) Cord retraction of gingiva for impression procedures.
(4) Size and fit endodontic master points and accessory points.
(5) Cement endodontic master points and accessory points.
(6) Take final impressions for permanent indirect restorations.
(7) Take final impressions for tooth-borne removable prosthesis.
(8) Polish and contour existing amalgam restorations.
(9) Place, contour, finish, and adjust all direct restorations.
(10) Adjust and cement permanent indirect restorations.
(11) Other procedures authorized by regulations adopted by the
board.
(c) All procedures required to be performed under direct
supervision shall be checked and approved by the supervising licensed
dentist prior to the patient's dismissal from the office.
 

omaralt

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all i have to say is thank god for how strong and strict the florida dental association is.. i'm just fearful they'll start caving in to pressure and start implementing this crap...
 

SeattleRDH

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I just want to stress how much variation in scope of practice (for assistants AND hygienists) there is from state to state.

As long as there is adequate education (and a clinical board exam!!!!!!!) then expanded functions mid-level providers can be very valuable.

I have been working as a restorative hygienist for years but I'm a minority in that less than 20% of restorative-licensed hygienists in my state are being employed as such. And Washington has had restorative licensed RDH's since the 70's!

Another thing to think about: if you were to have your assistant finish your restorative procedures would you get them an assistant? Then you would need to hire another staff member.... maybe not as cost-saving as you thought....
 

NonTradHopeful

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For those practicing dentists and soon-to-be graduates of D-school, what do you think of this "expanded function dental assistant." Will they really increase productivity in the office, or will this take away the "bread and butter" of dentistry? According to the article given below, this new DA-nurse will be able to "do restorative work such as fillings, crowns and bridges that used to be done only by dentists... can't diagnose, use anesthesia, perform surgery or do extractions... can't prepare teeth for restorative work by drilling... but can fill cavities and install crowns and bridges" and are "expected to make about the same salary as dental hygienists." I mean, this has got to be better than the ADHP though but I still have my reservations about the creation of such a position. What do you guys think?

Article: http://sacramento.bizjournals.com/sa...08/story2.html

Bill: http://info.sen.ca.gov/pub/07-08/bil...sen_floor.html
Honestly, I think it depends. If this statute says that these assitants can only do these procedures if they work for a dentist (i.e. they can't set up their own shop), then it's actually a huge help to dentists. Instead of spending time on lower-producing amalgam/fillings procedures, they can spend their time on more complex cases...leading to an increase in production.

If the assistants do not need to be working for a dentist, then that's trouble...
 

DrJeff

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all i have to say is thank god for how strong and strict the florida dental association is.. i'm just fearful they'll start caving in to pressure and start implementing this crap...
They just better have a plan, so not if, but WHEN some ignornat legislator decides that some type of mid-level provider for dentistry should work as well as say a nurse practitioner did for medicine and allow expanded access to care for dental patients :eek:

We've been going through this in CT for the last couple of years now. One of our state reps was a hygienist before she went into politics, and hence we've been deemed a "ripe" state for advancement of sometype of legislatively driven midlevel provider creation by the hygiene association. We had a bill introduced last year to our state legislatures public health committee died in committee and then again, currently (as in today most likely :eek: ) the human services committee of my state legislature will decide if it wants to vote to send another bill to create a midlevel provider out of committee to be voted on by the state house/senate.

Just simply having a dentist go and testify before a state health committee these days about why they (the committee) shouldn't create a new level of provider and how it should be dentists and dentists only doing these "irreversible procedures" doesn't always cut it. Bottomline line, to a legisaltor, we are just viewed by many a legislator as "those rich dentists" and that we're trying to protect our own well being, whereas very often at that same committee meeting they'll be many, people on welfare testifying how they could find a dentist who would treat them and as a result X,Y,Z happened. To a legislator, they're more people (potential votes) who fall into the underseved looking for care than there is dentists (potential votes also) and oh so often in hearings like this, emotion trumps science.

That's why, much to the astonishment of many in this profession across the country, the house of delegates of my state dental association voted to pursue a pilot study to see, if a mid level provider might be feasible in CT. We don't necessarily want a midlevel here, but atleast now when the next legislative attempt to create a mid level happens, and a rep from our state dental association goes and testifies before a gov't committee and someone asks them "what are you doing to help the access problem" we can answer that we're working on doing a study to see if a mid-level could work in CT (and chances are based on how much subsidy it would take to make it happen, that it wouldn't).

In situations like this, were very often emotion can trump science when dealing with dentally ignorant legislators, the old addage "The best defense is a good offense" applies. So stay PROACTIVE on this topic in whatever state you may practice in eventually
 

SeattleRDH

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They just better have a plan, so not if, but WHEN some ignornat legislator decides that some type of mid-level provider for dentistry should work as well as say a nurse practitioner did for medicine and allow expanded access to care for dental patients :eek:

We've been going through this in CT for the last couple of years now. One of our state reps was a hygienist before she went into politics, and hence we've been deemed a "ripe" state for advancement of sometype of legislatively driven midlevel provider creation by the hygiene association. We had a bill introduced last year to our state legislatures public health committee died in committee and then again, currently (as in today most likely :eek: ) the human services committee of my state legislature will decide if it wants to vote to send another bill to create a midlevel provider out of committee to be voted on by the state house/senate.

Just simply having a dentist go and testify before a state health committee these days about why they (the committee) shouldn't create a new level of provider and how it should be dentists and dentists only doing these "irreversible procedures" doesn't always cut it. Bottomline line, to a legisaltor, we are just viewed by many a legislator as "those rich dentists" and that we're trying to protect our own well being, whereas very often at that same committee meeting they'll be many, people on welfare testifying how they could find a dentist who would treat them and as a result X,Y,Z happened. To a legislator, they're more people (potential votes) who fall into the underseved looking for care than there is dentists (potential votes also) and oh so often in hearings like this, emotion trumps science.

That's why, much to the astonishment of many in this profession across the country, the house of delegates of my state dental association voted to pursue a pilot study to see, if a mid level provider might be feasible in CT. We don't necessarily want a midlevel here, but atleast now when the next legislative attempt to create a mid level happens, and a rep from our state dental association goes and testifies before a gov't committee and someone asks them "what are you doing to help the access problem" we can answer that we're working on doing a study to see if a mid-level could work in CT (and chances are based on how much subsidy it would take to make it happen, that it wouldn't).

In situations like this, were very often emotion can trump science when dealing with dentally ignorant legislators, the old addage "The best defense is a good offense" applies. So stay PROACTIVE on this topic in whatever state you may practice in eventually
Ahhh Politics....

If you want to see something that's really scary look at the DHAT in Alaska.

As an RDH I would have loved the opportunity to move up in my career to an ADHP. If it existed. Instead I'm on the long road to applying to dental school.

There really needs to be an education track in place before these mid-level providers get the go-ahead from congress. Nurse practitioners and physicians assistants have masters degrees! Expanded functions is only ok if it is accompanied with expanded education.
 

John Durian

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I know this is harder to do than said, but wouldn't it be wiser to lobby for an AEGD-type of program requirement that will require all new dental graduates to practice 1-year in underserved areas? For example, put all new recent graduates in a pool and then randomly (lottery system) assign underserved areas for them to practice for a year. That way, they'll get experience and work in the most "deserving" areas.

I see this 1-year req as a better option than allowing mid-levels to set up shop... and it'll shut the legislators up (for awhile). Probably a bit naive, and I know a lot of people don't like the idea of being FORCED to do an extra year (at a random place to boot), but it's better than competing with EFDAs and ADHPs for the same market. Feasible? Opinions?
 

mike3kgt

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all i have to say is thank god for how strong and strict the florida dental association is.. i'm just fearful they'll start caving in to pressure and start implementing this crap...
Amen Omar!! I love Florida and have tremendous respect for the FDA and the people who fight hard to keep it that way.

An EFDA in FL is allowed to make temporaries. Yup, that's what it means to be EFDA here, nothing more.

But FL is not immune from potential major changes. I was not happy about the change in advertising laws regarding AGD, AAID etc. credentialing. Nothing wrong with putting "Master or Fellowship of 'xyz' is not a recognized specialty of the ADA. "

Problem is, what starts in CA, ends up everywhere else. I am a proponent of direct-supervision EFDA for helping improve the supposed "access to care" but I cannot believe the scope of what they are allowed to do in CA. EFDAs in the midwest are only allowed to place direct restorations (amalgam/composite) and can't cement endo points or crowns. The EFDAs that I have worked with have been very hit or miss, but a few of them have been competent at what they do, caring, respectful, and work very well with patients. In the right practice, EFDA works very well.

Adding EFDAs everywhere doesn't fully address "access to care" because regular DAs can convert to EFDA and now command an increase in salary from $10-20/hour to $30-40/hour. This increase doesn't necessarily allow the dentist to charge less for the procedure because he/she can delegate half the procedure because he/she now has to pay the assistant far more for the time. So that means we have to get a less educated team member to be faster than a highly skilled doctor to justify a lower fee. Hrmm.....

The only reason there is not more outcry in CA at this time is that there are so many other problems going on there far more critical than who can do your filling, that it is getting lost in the rhetoric.
 

HupHolland

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Honestly, I think it depends. If this statute says that these assitants can only do these procedures if they work for a dentist (i.e. they can't set up their own shop), then it's actually a huge help to dentists. Instead of spending time on lower-producing amalgam/fillings procedures, they can spend their time on more complex cases...leading to an increase in production.

If the assistants do not need to be working for a dentist, then that's trouble...
:thumbdown:

What about the patient??????????

I know that you're only pre-dental, but there is more to dentistry than how much you can produce. You can make a very good living providing QUALITY dentistry to your patients. Treating your patient's like inanimate objects on an assembly line is just wrong. Hope you learn a thing or two about what's in the patient's best interest by the time you graduate dental school.

Hup
 

mike3kgt

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In situations like this, were very often emotion can trump science when dealing with dentally ignorant legislators, the old addage "The best defense is a good offense" applies. So stay PROACTIVE on this topic in whatever state you may practice in eventually
Jeff,

Great post. I love getting your opinion on the board. I was watching "Up in the Air" and had to write down this quote... it is very topical right now.

Clooney in "Up in the Air" - "THIS is the most personal situation that you are going to enter. So before you try to revolutionize my business [profession], I'd like to know that you actually KNOW, my business [profession]".

One thinks that Al Franken hasn't spent much time with the dental profession, rather, he'd like to drastically modify our profession from his office chair with utter disregard for the professionals who contribute to its success.

:cool:
 

SeattleRDH

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What about the patient??????????

I know that you're only pre-dental, but there is more to dentistry than how much you can produce. You can make a very good living providing QUALITY dentistry to your patients. Treating your patient's like inanimate objects on an assembly line is just wrong. Hope you learn a thing or two about what's in the patient's best interest by the time you graduate dental school.

Hup
I agree.

The reason why state legislatures pass expanded functions for mid level providers is to improve the "access to care" in their state. The purpose is not to increase production for the business owner.

In Washington, hygienists have limited independent practice in nursing homes, senior centers, and prisons. These populations are greatly underserved by the private dental community and it was somewhat of an easy sell to our representatives.

If a dentist were practicing in an underserved rural community then yes, an expanded functions assistant would improve access to care. But in the city? With so many dentists that they must advertise to be competitive... Is there really so much work that you need to be freed up for more complex cases?
 

DrJeff

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Jeff,

Great post. I love getting your opinion on the board. I was watching "Up in the Air" and had to write down this quote... it is very topical right now.

Clooney in "Up in the Air" - "THIS is the most personal situation that you are going to enter. So before you try to revolutionize my business [profession], I'd like to know that you actually KNOW, my business [profession]".

One thinks that Al Franken hasn't spent much time with the dental profession, rather, he'd like to drastically modify our profession from his office chair with utter disregard for the professionals who contribute to its success.

:cool:
We had the perfect example of emotion vs. science in a legislative committee hearing in CT yesterday. A legislator, from an urban area of CT, made a blatant, FALSE statement about dental access for medicaid (Husky program it's called in CT) children, involing two issues (one a large, free clinic (Mission of Mercy) that we had in CT 2 weeks ago, and one that 50% of Husky kids couldn't get access in the state - when the administrator of the HUSKY program testified to the same committee a few weeks ago that there "is no access problem for kids in CT now") and the committee, swayed by the emtoional issue voted to send the mid-level bill out of committee and to for a state house conisderation :mad:
 
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