What Has Happened to Dental Assisting? Gordon J. Christensen, DDS, MSD, PhD and Paul L. Child Jr., DMD, CDT

Do we have to impress any dental practitioner about the importance of dental assisting? In our opinion, much of the success or failure of typical dental practices is directly related to the effectiveness of dental assistants. The public relations, the productivity and the revenue of a practice can be significantly increased when dental assistants are motivated, educated and trained in the essentials of dental assisting, and have become genuine "team" members (Fig. 1).

Figure 1: Developing a genuine team requires proactive planning, organization and implantation of correct concepts by the dentist.

Several decades ago, many dental schools had a significant amount of integrated dental assisting-dentist education in their curricula. Usually, these programs were funded by federal grant programs, which subsequently have disappeared. Highly valuable studies to determine the desirable ergonomic characteristics for dental practices were also funded by the government at that time. The result was development of operating chairs of the most desirable size and function; recognition of the necessity for correct positioning of dentist and dental assistant; the most adequate sterilizing and storage systems; efficient instrument passing to dentists; simple infection control and myriad other important subjects directly related to effective dental assisting. Dr. Christensen was involved in structuring and teaching in these programs many years ago. Unfortunately, as these programs lost funding, most of the teaching of dentist-dental assistant interaction ceased. There are now many dental students graduating from dental school who have never worked with a dental assistant, and who have no idea about any of the necessary characteristics for optimum use of dental assistants. Poor habits and practices learned in other practices are often brought into the new dentist's office because of this inexperience.

In the following information, we will list and discuss the optimum characteristics of dental assistants, emphasize some of the most important clinical tasks that can be legally delegated to properly prepared dental assistants and make suggestions on how to best implement these important characteristics into your practice.

Maximizing the Professionalism of Dental Assistants
Most dental assisting schools provide many of the aspects of becoming a true professional dental assistant. However, just as with new dentists, professionalism usually requires time for development. Over many years, we have heard and observed the dental assistant characteristics that are sought by dentists. See if you can develop these and other characteristics you might consider important in your dental assistants. Among the most important and desirable dental assistant characteristics to us are the following:

Training/Education: Although many dental assistants learn primarily by preceptor experience, we suggest for a person entering dental assisting, to enroll in and complete an accredited dental assisting program. There are many such programs available in local community colleges or private schools. The following Web site is an excellent source of information: www.dentalassistantschools.net

Constant Continuing Education: Dentistry changes rapidly, and dental assistants must keep up with those advancements. We suggest you encourage your dental assistants to take CE on a scheduled basis. Taking CE courses periodically is mandatory to keep up with the ongoing changes in the profession. Dental assistants can gain significant useful information by attending courses that are primarily oriented toward dentists.

Certified Dental Assistant (CDA) Designation: Encourage your dental assistants to obtain the CDA designation. This distinction adds to their professional identification and enhances their self-esteem.

Leadership: Many people, including some dental assistants, are satisfied to let others lead them, while others are always thinking ahead and making suggestions for improvements in whatever they are doing. This characteristic can be stimulated by congratulating and thanking dental assistants for their creativity and innovativeness as they exhibit such characteristics. Some practices have incentive programs for dental assistants who provide methods for improvements in the practice, increasing revenue or cost savings.

Outgoing and People-oriented: An introverted dental assistant is a liability. These persons must have excellent interpersonal skills. They must be constantly looking for ways to make people feel welcome and comfortable in your office. Encourage the development of such characteristics.

Cheerful and Optimistic: This is an attribute that is extremely necessary in almost every vocation. A happy employee makes happy patients. Encourage and praise these characteristics and be an example yourself. Your dental assistant can make people feel as though you have the best office and staff in the country, and that you, the dentist, are highly competent and qualified. Encourage such behavior by recognizing the optimism and thanking staff for their support.

Empathetic Behavior: Dental assistants are the staff persons who make your patients feel comfortable, informed and confident in your office environment. They should be thinking of the patients at all times, and recognizing the feelings of the patient. Give your dental assistants instruction on how to best develop and maintain this characteristic.

Clean, Neat, Well-groomed: This one goes without saying. However, it is a delicate subject to tactfully present your feelings to a dental assistant who might have dirty shoes, bad breath, smoke odor, body odor, greasy hair, too much makeup, potent perfume, dandruff, unkempt appearance or other unpleasant physical characteristics. We suggest personal interviews with individual staff persons on a routine basis, asking them to evaluate themselves. You should also critique your own behavior and demeanor, because you are the example for your staff. In a personal interview, the staff person's physical negatives will naturally emerge without significant embarrassment for either party.

Clinically Competent: Having dental assistants master the essentials of four-handed and six-handed dental assisting is a major asset to any practice. Such concepts greatly improve productivity, patient comfort, speed of operation, quality of the procedures and ultimately office revenue. If your assistants do not have these abilities, it is time to develop them as soon as possible. Within reason, adding an additional dental assistant almost always increases revenue beyond the expense of the additional salary. Expanded clinical functions can easily double the productivity of a typical general practice. However, it requires that the dentist and staff are willing to learn how to integrate the expanded clinical functions into office activity, create a true team and make practicing dentistry easy and enjoyable for all involved. The following section of this article lists and discusses many of such responsibilities.

Figure 2: Properly implanted four-handed dentistry can significantly improve patient care, office efficiency and income. Figure 3: Developing the ability to use six-handed dentistry is a major advantage in a busy practice. Figure 4: Two dental assistants are average in the U.S. However, incorporation of expanded functions requires using additional assistants for optimum efficiency.

Expanded Clinical Activities for Dental Assistants
Dental practitioners are finitely limited in our productivity by our own two hands. Whatever we can do in a specific time period is readily identifiable. In spite of attempting to speed up clinical procedures, the outcome is limited to only minimal increases, unless you add additional staff. Adding more skilled hands to the clinical team can increase productivity significantly. The American Dental Association reports that the mean number of dental assistants used in most U.S. dental offices is slightly less than two (Figs. 2 & 3). However, the dentist and this team of two dental assistants might still have limited productivity.

Dentists have only two methods to increase productivity and still maintain the production of quality services. They can increase fees, which is the mantra of some continuing education courses in practice management, or they can elect to educate staff members on how to accomplish some of the clinical tasks usually done by dentists.

Significantly increasing fees is not a viable alternative in most communities. Patients are educated to find those practitioners who have moderate fees, and third-party payers are critical of dentists who are charging fees significantly above the community levels.

The most logical alternative for increasing productivity while still maintaining clinical quality is to delegate clinical tasks to qualified staff, increase practice organization and efficiency and obtain the fastest, easiest and best products for use in practice. Some states, provinces and countries limit the tasks that can be delegated to staff, while others are relatively liberal on this subject. We suggest dentists limit themselves to doing only those tasks that no one else can legally accomplish. You need to obtain a copy of the practice regulations for your geographic area to determine the laws related to your practice activity.

The following tasks are some we have found to be very appropriate for delegation. Please look over the list and determine which of the tasks can be delegated in your practice. Do you have staff persons who are capable of learning to accomplish the specific tasks? Do you need to hire additional staff (Fig. 4)? Which tasks do you want to delegate? Are these tasks legal for staff in your area? Some might not be allowed in your area because of specific local regulations. We suggest that you compare the potential delegated staff tasks with your practice regulations to avoid delegating illegal tasks. The following tasks are listed alphabetically, and are not prioritized. You might already be delegating some of them. Some of them are what we call "escape tasks," in other words, they are dental assistant optional tasks that you, the dentist, might commonly accomplish, but a phone call, a hygiene check, a denture adjustment or whatever interruption, takes you away from the patient being treated, and you delegate the escape task to a qualified staff person. We have noted the primary tasks by the word "recommended," which a staff person usually accomplishes (Fig. 5), and those that are occasionally accomplished by staff as "optional" (Fig. 6).

Figure 5: Some tasks, such as patient education can be delegated almost entirely to dental assistants and others, thereby freeing the dentist for clinical treatment. Figure 6: Some tasks can legally be accomplished by the dentist or qualified staff. Educating staff in such responsibilities allows dentists to leave the treatment room when other responsibilities or emergencies arise. Figure 7: Consulting with dental assistants on a routine basis allows the dentist to know the needs and the challenges faced in the office and potential methods to improve them.

Please note that the majority of the previously described recommended tasks are accomplished primarily by staff with dentist supervision required, and that the optional tasks allow the dentist to leave the treatment room when a need arises or can be accomplished by the dentist if desired.

In a typical general dental practice, delegation of the described and other tasks significantly increases productivity, allows treatment of more patients, increases gross revenue with only a moderate increase in overhead and provides a much more diverse and interesting vocational role for staff. After years of delegating all of the described tasks and many more, we can factually state that after an expected period of learning and repeating the tasks, the staff person to whom the tasks were delegated becomes more proficient in completing the task than the dentist who taught the person to accomplish the task. Additionally, the diversity of dental assistant activity provides much more job satisfaction for the staff person.

In-service Education for Dental Assistants
In-service education sessions should be a part of every practice. These sessions are easy to organize and conduct. We suggest the following sequence of events:
  1. Decide as a team the areas in which you need education (Fig. 7).
  2. Decide which team member will provide the education.
  3. Set a time. Early morning before practice is a great time. One hour before practice starts usually offers adequate time for the session, as well as a 10-minute "huddle" before the practice day begins. If more time is required, either use two separate one-hour sessions or a longer single one with lunch.
  4. Start the session on time, provide the education, end on time and expect implementation of the concept immediately.
  5. Continue the sessions as needed. Once per month is usually a good schedule.
Dental school and dental assisting education could be integrated better to assist in producing more efficient practice characteristics, faster and better patient service, higher quality treatment and increased office revenue. Because of the need for more integration of dentists and dental assistants, dentists can overcome the challenge by proactive training/education of dental assistants and expanding clinical functions for dental assistants. This concept can improve patient care and make it easier, speed up procedures, create happy patients and also improve office income.

Author Bios
Dr. Paul Child is the CEO of CR Foundation, a nonprofit educational and research institute (formerly CRA). He conducts extensive research in all areas of dentistry and directs the publication of the Gordon J. Christensen Clinicians Report, and their other publications. Dr. Child is a prosthodontist, a certified dental technician and maintains a private practice at the CR Dental Health Clinic in Provo, Utah. Dr. Child lectures nationally and co-presents the "Dentistry Update" course with Drs. Gordon and Rella Christensen. He lectures on all areas of dentistry, with an emphasis on new and emerging technologies. He maintains membership in many professional associations and academies. Further information is available at www.cliniciansreport.org.

Dr. Gordon J. Christensen is founder and director of Practical Clinical Courses (PCC) in Utah. This group is an international continuing education organization providing courses and videos for all dental professionals. He is also co-founder of the nonprofit Gordon J. Christensen Clinicians Report (previously CRA), as well as an adjunct professor for Brigham Young University and University of Utah. He is a diplomate with the American Board of Prosthodontics. Dr. Christensen has presented more than 45,000 hours of continuing education throughout the world and has published many articles and books. Further information is available at www.pccdental.com.


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