Threes a crowd?

"Well, I am a hygienist, and that`s what I do here Tuesdays and Thursdays, but Mondays and Wednesdays I work as an EFDA. I`ll be doing some of the preparation for your new bridge today."

Maybe. But even hygienists are enhancing their careers as Expanded Function Dental Auxiliaries.

Cathy Seckman, RDH

"Good morning, dear. What`s your name?"

"I`m Susan, Mrs. Johnson. You haven`t seen me before."

"No, I didn`t think so. Are you the hygienist? I`m not scheduled for a cleaning today, am I?"

"Well, I am a hygienist, and that`s what I do here Tuesdays and Thursdays, but Mondays and Wednesdays I work as an EFDA. I`ll be doing some of the preparation for your new bridge today."

"An ef-dah? What in the world is that?"

Haven`t you ever wondered about that yourself? What exactly is an EFDA? An EFDA (expanded function dental auxiliary) is the mystery figure in dentistry. Patients are not sure what her purpose is. Co-workers can`t figure out what her status should be. Even the employer might be confused about her responsibilities.

There is no easy definition of an EFDA. Even the acronym itself isn`t used universally. Different states may designate functions as expanded, extended, or advanced. The person performing them may be called an auxiliary, an assistant, or, simply, personnel. A definition also depends on where she went to school, in which state she is licensed, and by which dentist she is employed. Some EFDAs work as glorified assistants and are used mostly to finish off a procedure when the dentist gets behind or has an important phone call. Others have sharply defined duties and are irreplaceable members of the dental team.

In some states an EFDA can perform any remediable dental procedure, including placing and removing temporary crowns, matrix bands, and orthodontic appliances; taking a variety of impressions; doing limited endodontic procedures; and filling prepared teeth with amalgam or composite restorations.

No one seems to be quite sure about the history of EFDA work. Hygienists in the 1970s had heard of expanded functions, of course, and knew vaguely that extra training was required to perform such duties as placing restorative materials, but there didn`t seem to be any universal rules. State-by-state standards varied wildly.

In 1972, for instance, hygienists in Virginia were permitted to condense, carve, and adjust amalgam restorations. Unlicensed, office-trained assistants were permitted to remove periodontal packs and sutures. By contrast, in Michigan, hygienists were allowed only to perform prophylaxes and apply "therapeutic" mouthwashes. "Persons other than dentists" were permitted such heady duties as placing and removing cotton rolls, charting restorations, and using evacuator tips. In some states, such as California, New Jersey, Utah, and Vermont, hygienists were limited strictly to traditional cleanings and exams. No mention of assistants was made in dental practice acts of those states, and therefore no duties were legally assigned to them.

By the 1980s, the terms BQP (basic qualified personnel) and AQP (advanced qualified personnel) were in use. But many hygienists - and dentists - still didn`t know much about the training and duties involved.

In the 1990s, EFDAs are becoming common even in small dental practices, but there is still no national consensus on the definition of the term. A national EFDA organization does not exist, though some states have such groups. Education, testing, and credentialing for expanded function auxiliaries is not standardized. Each state has its own ideas and its own laws (or lack of them) for EFDA practice.

In Texas, expanded functions have been permitted for hygienists and assistants for at least 30 years, but present-day duties are ambiguous. Rule 114.1 of Texas Regulation 1095 states, "A dentist may delegate to a dental assistant the authority to perform only acts or procedures that are reversible." Delaware, Utah and Washington still do not license any type of dental assistant.

At this writing, New York state has no provisions for EFDAs, but the state`s Board for Dentistry is currently redefining practice laws. Expanded function auxiliaries, who must be graduates of a certified training program, will soon be able to select and pre-fit provisional crowns and orthodontic bands; remove orthodontic arch wires and ligature ties; place and remove matrix bands; and remove periodontal dressings and sutures, among other duties.

California grants licenses for what it calls extended functions to hygienists (RDHEF) and trained assistants (RDAEF). Six duties are recognized: cord retraction; taking impressions for cast restorations; taking impressions for space maintainers, orthodontic appliances, and occlusal guards; formulating indirect patterns for endodontic post and core castings; preparing enamel by etching for bonding; and fitting trial endodontic filling points. For the RDAEF, an additional allowable duty is applying pit and fissure sealants, which is not allowed for RDAs. Requirements for RDHEFs and RDAEFs are the same: graduation from an accredited hygiene or assisting school; completion of an additional 90- to 96-hour course; and passing a state board exam.

Incidentally, California expects to begin licensing a new category of hygienist in 1999. That will be the RDHAP, or alternative practice hygienist, who will work independently of the dentist.

The inside track in Ohio

In Ohio, EFDAs may receive training at five different sites. Dr. Rickne Scheid, who directs the expanded functions program at The Ohio State University, says there are several choices for EFDA training at the college. One class is for dental hygiene students in the baccalaureate program, and the others are for continuing education students who may be licensed hygienists or certified dental assistants. The dental hygiene students are offered EFDA certification as an optional track within the core hygiene curriculum. Other optional tracks are health science education and community health education.

"The tracks are subspecialties they can choose from," Scheid says, "like a minor in a baccalaureate program. I always advise dental hygiene students that if they choose the EFDA track, they`ll be able to do anything in dentistry that can be delegated in Ohio."

The EFDA track mandates four quarters of study, beginning with a concentrated afternoon pre-clinical class and laboratory that lasts six weeks and ends with a competency exam. Next come 2 1/2 quarters of clinical experience two half-days a week, followed by a return to pre-clinic for a quarter to prepare for boards. State EFDA boards in Ohio include a written portion and a practical portion taken on typodonts.

The continuing education programs vary in length and intensity, and tuition is more than $3,000. It`s not uncommon, EFDAs say, for an employer to pay all or part of the cost of expanded function training. An estimated 90 percent of the continuing ed students, according to Scheid, are assistants, and the rest are hygienists. One class, with a capacity of 16 students, stretches over two quarters and includes 22 actual days of training. Another course, to be offered for the first time in 1998 due to increased demand, is open to 10 students at a time. It includes two concentrated weeks of pre-clinic, followed by several weeks of clinical experience. OSU has an increasing waiting list for its continuing ed programs.

Flexibility motivates the EFDA

The typical dental professional who seeks expanded functions training, Scheid says, wants increased flexibility and responsibility. "One thing hygienists are looking for is variation. They want to diversify beyond the repetition (of traditional hygiene). I think it permits good blending of daily responsibilities in the office."

Another incentive may be financial. Citing a survey done in the early 1990s, Scheid says hygienists, depending on their experience and value to the office, can expect a 5 to 10 percent increase in base salary with EFDA certification. Experienced assistants can gain anywhere from a 30 to 40 percent increase in salary after EFDA training.

Although most EFDAs started their careers as dental assistants, more are coming from the ranks of licensed hygienists. They split their duties between traditional hygiene and the sometimes more complex EFDA responsibilities.

Debbie L`Orange, who currently is president of ODEFA, the Ohio Dental Expanded Function Association, has been a hygienist since 1973 and an EFDA since 1984. She sought training in expanded functions in an effort to help her father, who is a dentist and one of her employers. He had surgery in 1983 and needed an extra pair of hands at work.

"Becoming an EFDA is the best thing I ever did because it meant I was not just cleaning teeth. I found it totally monotonous to look at dirty teeth all day, and six months later they come back and it`s the same old garbage. Hygienists get turned off by that. Now I enjoy both my professions. Being able to do both makes my days varied."

L`Orange believes EFDAs began as an experiment. "They were trying to lower the cost of dental services by giving people more training to help the dentist. It was a way of increasing the amount of people who could work on patients without raising the overall number of dentists in the area."

The experiment was a success, as far as she`s concerned. "I think EFDAs stand apart from hygienists. I hope they continue as long as dentists will hire them."

Another EFDA-hygienist, Mimi Conroy, likes her cleaning days better than her expanded function days. "Yeah, I think I like hygiene better. It`s kind of like my baby, I feel more comfortable in my skills. EFDA work is okay, I like it."

Conroy has been a hygienist for eight years and an EFDA for two. "Coming from a hygiene background, you`re very aware of margins, and you double- and triple-check yourself. I think the dentist is appreciative of that. My work frees him up, and it gives me some variety. I like the chance to do other things, like placing amalgams and composites. I can pre-fit crowns, check the margins and contacts. It`s interesting." So interesting, in fact, that dental school might be in Conroy`s future. "It`s definitely crossed my mind, but right now I have two small children. I haven`t ruled dental school out totally, though."

It wasn`t a quest for variety that sent EFDA-hygienist Carlin Booth back to school, but an offer by her employers. "Their EFDA was leaving," she recalls, "and they offered to pay half of my tuition if I`d take EFDA training." Booth had been working in hygiene for four years, and jumped at the chance because she was beginning to feel burned out. "I do very little hygiene now because the practice is so busy, there`s just no time for it. I like expanded functions much better than I ever did hygiene."

Her employer, a general dentist, also does some orthodontics, so Booth has a wide variety of responsibilities. "I can fit the bands and do etching if it`s needed. I do fillings, obviously, a lot of amalgam and composite work, and temporary crowns. It`s an advantage being an EFDA-hygienist, rather than an EFDA-assistant, because I can do pit-and-fissure sealants. If a person comes in with a problem and just needs a cleaning, I can jump in and do that without messing up the schedule."

Booth sees EFDAs as a boon for dentistry. "It`s like adding a person and a half to the staff. It gives the dentist more freedom, and there`s much less stress on him. EFDAs are good for those practices that are just large enough that they`re too big for one dentist, but not big enough for an associate."

EFDA training can give welcome relief to the hygienist facing burnout, and it can offer a sense of purpose to the underutilized assistant. EFDA training can blur the division between the boss, who has all the technical and creative abilities, and the assistant, who previously might only have been responsible for holding the evacuator tip at just the right angle.

One office-trained assistant reports that she might have left dentistry by now if not for the self-respect she gained from formal EFDA training.

"I was accepted in hygiene school three different times," says EFDA-assistant Chris Burlock, "but with a husband and a daughter and a house and a job and a life, I just couldn`t commit myself to two years of full-time college. The EFDA course was so much easier to fit into my schedule. It was hard, being so concentrated, but I got through it. Now the variety makes it interesting, and I`m proud of myself."

As EFDAs become more common in dental practices, providing an extra pair of hands for the dentist and an extra measure of responsibility for the staff, more hygienists and assistants may be attracted to the field.

"The future is there," says Scheid. "Anyone can become a good EFDA, as long as there continues to be a need for them. It depends on motivation, the ability to master the work, to perceive things in three dimensions, to work with their hands. We have graduated some outstanding EFDAs, hygienists and assistants both, who I would hire in a minute."

Around the country, EFDAs are in line for even more responsibility. "I heard someone use the analogy of the merit badge system," Scheid recalls. "Take this class, pass this test, jump this hoop, have this much experience, and get a new permit."

New duties being proposed for EFDAs include construction, placement and removal of temporary restorations; monitoring of nitrous oxide; gingival retraction; and sore spot adjustment. Another new duty being proposed for EFDAs in some states, including Ohio, is coronal polishing of the clinical crowns of teeth.

Hygienists need to monitor the emerging role of EFDAs in the dental team. We need to understand their training, their rights and their responsibilities as well as we understand our own.

Cathy Seckman, RDH, is based in Calcutta, Ohio.

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