Their own niche

Dec. 1, 1998
Rather than being `junior hygienists,` dental assistants are carving out their own status in the dental community.

Rather than being `junior hygienists,` dental assistants are carving out their own status in the dental community.

Cathleen Terhune Alty, RDH

Who can judge the value of a good dental assistant? Ask a dentist who has to work without one for a week. Ask a patient who is kept waiting for an hour because the dentist is working without an assistant. Ask the office manager who sees production drop 50 percent because the doctor doesn`t have an assistant to facilitate production levels. Ask the dental hygienist who is behind schedule because the dentist can`t get away to check her recall patient. Ask the receptionist who doesn`t have the updated chart she needs to bill the patient because there is no assistant to write it. Ask anyone who walks past the sterilization center and sees the trays of dirty restorative instruments waiting to be sterilized.

You get the point; most dental practices run better with a good dental assistant. However, some dental assistants aren`t feeling so respected and esteemed in their ca-reers. You`ll hear:

- "Since I don`t create production like the dentist or hygienist, my job isn`t very important."

- "I`m not valued by fellow dental team members because I`m not paid as much."

- "I just don`t get any respect!"

It sounds like a Rodney Dangerfield monologue, but this one isn`t getting any laughs. Underrated, overworked, underpaid, and overloaded ... it seems to be the disheartened chant of the American dental assistant. Why do dental assistants feel this way, and what do they want to do to change it?

"I`d say it was an individual`s own perception. But, in general, as long as dental assisting remains an on-the-job-training profession, some assistants will not feel respected in their jobs," said Patricia White, CDA, and president-elect of the American Dental Assistants Association (ADAA). "If they flip burgers on Friday and put on scrubs Monday and the two jobs pay the same, their self-esteem will not be greater while wearing the scrubs."

Jennifer Blake, CDA, and immediate past-president of the ADAA, added that the perception of dental assistants starts at the top with doctors and how they treat the staff. If the clinical assistant has no educational background, formal training, or licensing, she said, they will feel like second-class citizens when comparing themselves to the dentist and hygienist.

"But the dental assistant has a wide variety of things to know," Blake said. "She is a producer of practice production in expanded duties and in general assisting. Let a dentist work without a dental assistant and just watch what happens to his overall production. It will go down."

On the surface, it may appear that assistants do not produce, but studies cited in the ADAA Task Force position paper on mandating education and credentialing show that they do. One study concluded that, with two dental chairs and one full-time assistant, a dentist was able to provide up to 63 percent more treatment. With three chairs and one full-time dental assistant, productivity was increased by 75 percent. Another study concluded that a full-time, well-trained dental assistant could help a dentist treat 50 percent more patients.

Delegating expanded functions duties to dental assistants can further increase practice production. It also has been stated that well-trained staff members have the potential to increase production by three to seven times their annual salary.

According to several officers of the nearly 15,000-member ADAA, the plan to help change this perception and to increase service to the public is based on education and credentialing. Currently, there are no standardized requirements for educating and credentialing dental assistants. Even though there are 27,000 certified dental assistants (CDAs) in the country, their credentials are not standardized from state to state. Mandating that all clinical assistants meet certain educational and credentialing requirements should give the profession a baseline for each state to develop its own specific requirements. Some states already have requirements, but only a few spell out specifics for dental assisting. The ADAA is working to make mandatory education and credentialing for clinical dental assistants a legislative reality.

Interestingly, dental assisting is in a similar position to dental hygiene`s early years - striving to use specific education and credentialing standards to help propel it into the realms of a true profession.

Carla Schneider, CDA, RDA, and current president of the ADAA, said, "Clinical assistants need education to do the procedures and to be updated on what is going on in dentistry. We live in an ever-changing world. Dentistry is changing rapidly in dental materials, procedures, infection control, etc. Education is very important."

The public`s perception also is a part of gaining expertise and respect. White pointed out there is a lack of understanding among dental consumers about what an assistant does. "What she or he does, they can`t always see. They don`t realize the knowledge required, the infection control protocol, etc. They see her handing the dentist instruments. The dental public deserves to have an educated, properly certified person assisting in treatment," said White.

"The general public usually perceives that the dental assistant has gone through formal education and credentialing. They do not realize that many haven`t," Schneider added.

Anna Nelson, CDA, RDH, director of the dental assisting program at the City College of San Francisco and vice president of the ADAA, said that when dental consumers find out clinical dental assistants may not be educated and licensed, "they are shocked."

Likewise, the rest of the dental team may need an attitude adjustment. "The entire dental team needs to have greater mutual respect for each other," said Schneider.

Salary differences between assistants and hygienists often affects self-esteem. Because clinical assistants usually are paid less, there is a perception of being worth less to the practice. "Since the pay hierarchy is usually known in the office, we sometimes aren`t as respected as other team members," said White.

Recruitment techniques could use some improvement as well. "When a dentist sees a bright, articulate person, he usually encourages them to go into hygiene or become a dentist. He never says, `Hey! Be a dental assistant. Mine is so valuable to me,`" said Blake.

In the past, even the legislation has been rather nonspecific about dental assisting, which lends an inadvertent aura of invisibility or unimportance to the profession. "Dental assistants are not even recognized in the dental practice act in some states. The dentist often is the teacher; he trains her and if she does well enough, she has the job. But nothing is there to measure what she is capable of doing. Without a standard, there is no baseline for what a dental assistant needs to do and know to work in a dental office. This standard can be followed on a state-by-state basis. Each state can use this as a starting point and expand upon this," said Schneider.

Will they all be in class?

It all sounds like a good plan, but educational and credentialing requirements may cause a short-term scarcity of available clinical assistants while they are being educated and tested. A quick scan of any metropolitan newspaper clearly shows that dental assistants currently are in great demand. Add this training delay to the demand that already exists, and the education and credentialing plan becomes a bit stickier to implement.

"I think we can safely say there is a shortage all over the country," said Schneider. Besides a general lack of available laborers in many professions and industries, Blake cited several factors for why dental assisting has a shortage:

- Not enough pay or benefits.

- An attitude of "it`s just a job" instead of a profession.

- Lack of appreciation.

- The perception that it is not seen as a fulfilling, rewarding career.

Education and credentialing are seen as the tools to help make dental assisting a highly desirable, respected position within the dental team. There are some fears expressed by dentists and clinical dental assistants who now practice without certification. As mentioned above, dentists are concerned about an even greater shortage while assistants undergo more training and testing. They are concerned about autonomy issues - that assistants or the ADAA will become as challenging politically as dental hygiene has become in the past 20 years. As in the case of other small business owners, dentists also are concerned about a greater demand for ever-increasing paychecks. More education, skills, and credentials equal more salary.

"Dentists recognize the value of having a well-educated dental assistant," said White. Without the independent practice issue advocated by dental hygiene, dental assistants who support more education and credentialing are confident of meeting little resistance from organized dentistry.

Dental assistants, on the other hand, voice concerns about credentialing requirements that demand more education, regulation, and money from their pockets. The concern is how they would fit into this new status with their current level of expertise. Will they have to go back to school? Who will offer training? Who will pay for it? Will they miss work because of it?

All of these issues and concerns are being considered as the ADAA plans how mandated credentialing could be implemented. With requirements for education, more programs will need to be offered. "Accessibility (to education) is certainly a problem," said White.

"There are 232 nationally accredited dental assisting programs in the country," said Nelson. "We have to offer alternative educational access for credentialing. Right now, we are looking at two programs: Mentoring on the job, which uses check-off sheets as well as testing evaluated by an outside source through the mail, and a mentoring with an accredited dental assisting program." She commented that Florida has an operating program and is finding it to be a successful alternative.

Education also includes educating non-ADAA members that credentialing is not a threat. "We want them to feel they are doing something worthwhile. We want them to stay in dentistry," said Blake. "Staying in dentistry doesn`t necessarily mean they have to go into hygiene - although there is nothing wrong with that - but into whatever they want, which includes dental assisting as a life-long profession."

Education and credentialing is touted as offering benefits for the individual, as well as the profession as a whole. "Qualified people who have proven they are qualified means better dentistry for the patient," said Blake. "I`m here to serve the patient first. To give the best care, I need all the qualifications I can to see that happen."

"If a person comes in off the street and is on-the-job-trained to do dental assisting," said Schneider, "she is working for minimum wage and has to learn a lot. As she learns more, she feels she is worth more to the practice and increases the production because of her greater efficiency. The longer she stays the more she is able to do. If she leaves, the production goes down while the dentist finds a new person to bring in and retrain all over again."

Consultants frequently emphasize that it makes economic sense to retain one trained and knowledgeable dental assistant who is well paid than to let her leave over salary issues and go through the process of hiring and training a novice.

An entry into a good profession

To avoid the "overeducated" or "overqualified" conundrum, Schneider pointed out that interviewing for a job is a two-way street: Knowing what the job is and what it can or can`t lead to is important. For those so inclined, dental assisting can be a good start into many other careers. "Maybe you want to advance into education, sales, or other jobs. Dental assisting is a good step," she said.

White said, "We are seeing more and more people, including men, with other educational degrees entering dental assisting. A dental background opens many doors. There are many avenues to explore. When I worked in sales for a dental supply company, every female sales rep had either been a former assistant or hygienist," said White.

Anna Nelson sees an exciting future for dental assisting. "We need more and more dental assistants each year. All the lights are green for advancement. It really is a win-win situation for everyone. The patient benefits with an educated and licensed dental assistant, as well as the rest of the dental team."

Blake is hoping to see big changes in her lifetime. "Before I get to that dental assistants` home and sit in my rocking chair, I hope that credentialing of dental assistants is a reality. The person who cuts my hair has a license, but I can place an amalgam restoration in a person`s mouth in Indiana with no license. This seems backwards. Why wouldn`t a dentist want to say, `My staff has every credential they can possibly have.`"

Schneider sees great opportunity ahead for dental assistants, especially for dental assistants in specialty practices. "Dentists are seeking more qualified and more educated specialty dental assistants. They want a high standard, but each assistant must have a baseline of dental knowledge just like the specialty dental practitioner is a general practitioner prior to specializing."

Other forces are shaping the future of the dental assistant. Managed care looms as a change maker in dentistry as dentists will be pressured to increase the numbers of patients seen. Delegation of more duties to clinical assistants and dental hygienists is seen as the natural solution, particularly to expanded functions such as restorative procedures.

How can dental hygienists support dental assistants? Encourage communication and share knowledge. Promote increasing knowledge through attending continuing education courses and professional meetings. Respect each other for capabilities and knowledge, as well as for what the clinical assistant provides the team.

The dental assisting association is working hard to achieve a more professional status through credentialing and education. The association is trying equally hard not to infringe upon traditional dental hygiene functions. Rather than trying to be "junior hygienists," the ADAA appears to be carving out their own niche. Casting a shadow on any other members of the dental team does not appear to be their agenda. Instead, their mission seems to be the same as dental hygiene`s: A deeper commitment to serving the dental health needs of the public and enhance the current system of health care.

Cathleen Terhune Alty, RDH, is a consulting editor for RDH and a frequent contributor of articles.