Assisting ... or practicing?

Dental assistants enjoy greater career flexibility with expanded functions.

Dental assistants enjoy greater career flexibility with expanded functions.

Do you know what the assistants in your office are allowed to do?

by Joanne Iannone Sheehan, RDH

Every few months, dental hygienists are made aware of regulatory changes affecting our profession. It used to be that dental assistants had a solid set of parameters within which they lawfully practiced. Anything done outside those parameters was immediately recognizable and dealt with as illegal, possibly bringing stiff penalties to the doctor and chastising or terminating the assistant. But times have changed and so have assistants' job descriptions. Expanded duties have extended the role of the assistant to ever-increasing responsibilities. Depending on the training received, assistants now are able to extend their capabilities beyond the mere passing of instruments and other routine tasks.

Dental hygienists express concerns about the duties of assistants in certain states. In these discussions, the common question remains, "Are assistants allowed to do that?"

Sometimes an assistant will do something that the hygienist doesn't believe is within her legal rights to do. Questioning possible improprieties is the normal reaction for anyone determined to operate within the law. With all the changes in regulations and titles, it behooves hygienists to not only know their job descriptions, but that of the assistant, as the law permits. This article is a current overview of the procedures assistants may perform in different states and the titles they must have to perform them.

Since the laws routinely change, it is best to check the information below with local dental associations. Most of the information below is based on legal status per the spring 2001 legislative and regulatory reviews.

Scaling and polishing
In what states can dental assistants scale supragingivally? In 1988, Kansas began allowing dental assistants to polish teeth and scale coronally. Before doing so, assistants have to complete a course that is approved by the state's dental board.

In what states are dental assistants allowed to polish? This question requires two answers. In some states, dental assistants can perform coronal polishing as an expanded function. In Arkansas, California, Minnesota, and Michigan, the procedure can be performed by a registered dental assistant (RDA). Dental assistants in Idaho, Nebraska, New Mexico, Oklahoma, and Tennessee obtain a certificate after training is completed. Florida, Kansas, Maine, Missouri (air polishing), Ohio, and South Carolina also allow it as an expanded function. In North Carolina, the duty may be performed by a "Dental Assistant II" and a "certified dental assistant" in North Dakota.

The second answer is that some states allow coronal polishing by assistants, but do not refer to the procedure as an expanded function. These states are Colorado, Montana, Nevada, Oregon, South Dakota, Washington, Wisconsin, Wyoming, and Nevada.

Texas assistants now can polish in preparation for placing sealants, but this service cannot be billed as a prophy.

So more than half of the states allows assistants to polish in some capacity. But the number may be higher than indicated. One reason you may want to check with your local association — if your state is not listed above — is because some states' regulations only refer to functions that cannot be performed by an assistant. So a "loophole" may exist if coronal polishing, for example, is not specifically "forbidden."

Expanded function certification
Assistants who obtain EFDA certification face various challenges in earning the professional distinction. The challenges usually depend on where they are employed. It's worth examining some of the variations among the functions of an EFDA.

In New York, a licensed certified dental assistant can perform the following supportive services for a licensed dentist:

  • Provide patient education
  • Take preliminary medical histories and vital signs to be reviewed by a dentist
  • Place and remove rubber dams
  • Select and pre-fit provisional crowns
  • Select and pre-fit orthodontic bands
  • Remove orthodontic arch wires and ligature ties
  • Place and remove matrix bands
  • Take impressions for study casts and diagnostic casts
  • Remove periodontal dressings
  • Other services that the state may authorize

In Virginia, dental assistants must be certified in order to take X-rays. Texas requires certification for taking X-rays and monitoring nitrous oxide.

As alluded to above, several states allow the classification of registered dental assistants (RDA). In Arkansas, RDAs can obtain a permit and induce and monitor nitrous oxide, as well as polish the rows of teeth after a scaling. Minnesota's RDAs, on the other hand, enjoy a greater role in the dental office, including:

  • Taking radiographs
  • Taking impressions for casts and appropriate bite registrations (not for final constructions of fixed or removable prostheses)
  • Applying topical medications
  • Placing and removing rubber dams
  • Removing excess cement from crown and bridge or orthodontic appliance with hand instruments
  • Polishing of clinical crowns
  • Pre-selecting orthodontic bands
  • Placing and removing periodontal dressings
  • Removing sutures
  • Monitoring a patient who has been induced by a dentist into nitrous oxide
  • Placing and removing elastic orthodontic separators
  • Removing and placing ligature ties and arch wires
  • Drying root canals
  • Placing cotton pellets and temporary restoratives
  • Removing excess bond materials with hand instruments
  • Etching enamel surfaces for bonding
  • Applying pit and fissure sealants
  • Making preliminary adaptation of temporary crowns
  • Removing temporary crowns

Similar long lists of allowable tasks that can be performed by RDAs exist in Michigan, Missouri, New Jersey, Pennsylvania, and Tennessee. In California, the long lists of functions for RDAs is divided into what can be performed under "general supervision" and "direct supervision."

Annual continuing education is typically required of a RDA.

The professional titles of extended duties dental assistant (EDDA) and expanded functions dental assistant (EFDA) mean the same. Different states just use their own terminology. The duties vary between states, but they exceed the duties of "regular" dental assistants. The EDDA or EFDA must be licensed as an RDA, complete a board-approved training program based in a dental school, and then complete the board's clinical examination.

Examples of duties performed by EDDAs or EFDAs under the direct supervision of a dentist include cord retraction; taking impressions for cast restorations, space maintainers, orthodontic appliances, and occlusal guards; preparing enamel by etching for bonding; formulating indirect patterns for endodontic post and core castings; fitting endodontic filling points; and applying pit and fissure sealants.

Some state's EFDA policies essentially place expanded functions on the same level with duties performed by RDAs in other states. Such expanded functions are allowed in Florida, Idaho, Iowa, Louisiana, Missouri, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Vermont, and Pennsylvania.

In addition, Pennsylvania allows EFDAs to place, condense, carve, and contour amalgam restorations, as well as etch, place, and finish composite resin restorations. In Missouri, EFDAs are allowed to place, condense, carve (Class I, V, and VI) amalgams and (Class I, V, VI) composite resin restorations. They also make impressions for the fabrication of removable and fixed prostheses, adjust (extraorally) removable and fixed prostheses, and do the final cementation of any permanent appliance or prosthesis.

EFDAs have to take approved courses and pass an approved competency examination. Usually, continuing education on an annual basis is required too.

States that have not been listed here are not included in the CDA, RDA, or EFDA categories. Again, contacting the board of dental examiners in an individual state will answer any questions you might have.

Dentistry is an ever-changing profession. In some states, the limitations imposed on hygienists are being lessened as well; for example, 27 states now allow qualified hygienists to administer local anesthesia.

In January 1998, California created the RDHAP, a new alternate practice category for hygienists. The RDHAP category allows registered dental hygienists who have been in private practice for three years, have a bachelor's degree or its equivalent, and who have completed 150 hours of required course work to own an "independent" practice. The practice settings are limited to residential care facilities, schools, residences of the homebound, institutions, and designated rural areas. In these settings, a prescription for dental hygiene services from a licensed dentist and/or physician allows the RDHAP to practice unsupervised.

Washington State allows hygienists to place restorations, and Colorado has granted alternative practice status to qualified hygienists.

In Oregon, the board of dentistry has established rules to implement the 1997 legislation to practice in a state-licensed facility under general supervision. They now are issuing permits to qualified hygienists.

The Texas legislature passed a bill to allow hygienists to provide services in nursing homes and school-based clinics without prior examination by a dentist. This opens the door for less restrictive practice settings for dental hygienists and should increase care provided to the most neglected populations of Texas.

Education and instruction are key to improving patient care and access. With that in mind, our profession should never be content to become stagnant in our knowledge or thinking. Assistants have been given the opportunity to broaden their professional horizons in many states. This makes it imperative that hygienists work to expand their parameters as well.

As with any working situation, those who are progressive and more knowledgeable in their field are less likely to be unappreciated or replaced. Let's prove that dental hygiene is invaluable, riding this wave of innovation in dentistry and striving to extend our own capabilities.

Joanne Iannone Sheehan, RDH, contributes frequently to RDH magazine. She is based in Huntsville, Alabama.

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