Utilizing Expanded Function Dental Assistants

Utilizing Expanded Function Dental Assistants

Hiring Expanded Function Dental Auxiliaries (EFDA) is both a business and a clinicaldecision and must be approached in that manner. This document will describe various aspects that should be considered before setting up an EFDA program.

Definitions:

State laws describing Dental Assistant (DA) functions, training and supervision vary widely across the United States. Many states have dental regulations describing Expanded Function Dental Auxiliaries (EFDA) who are DAs with expanded functions. These functions are additional procedures EFDAswith special training can do that go beyondthose assigned to regular DAs.

Unfortunately, there is no standard definition describing these assistants so the procedures allowed by EFDAs also vary from state to state. The EFDA described in this document is a dental provider that is allowed to place dental restorations after the dentist has prepared the teeth for the filling. You will need to check your state dental laws to find out if this procedure is allowed in your state. Knowing your state regulations will also allow your EFDAs (and DAs) to operate at the top of their allowed duties and personal competencies to maximize your clinic efficiencies.

Purpose of an Expanded Function Dental Assistant:

Before considering hiring EFDAs, it is critical to understand the purpose of this provider. EFDAs when used appropriately:

1. Will expand access- This occurs because EFDAs enable the dentist to complete treatment plans in fewer appointments allowing additional patients to be enrolled in the dental program
2. Will improve customer service- Dental patients appreciate getting their treatment needs completed in a reasonable amount of time, so the more we can do to make this happen, the higher their satisfaction will be. This will also help foster the more timely completion of treatment plans
3. Will increase productivity- While many health centers are paid on an encounter basis, it is our ethical obligation to both our patients and our funders to be as productive as possible in each and every visit.In addition, more states are moving to managed care dental programs and/or increased accountability. EFDAs clearly improve the productivity of a health center dental program by increasing the number of restorative procedures possible.

1. Will increase staffsatisfaction- While some dentists may resist plans to add EFDAs to the dental staff, dentists quickly adapt to this provider and find they increase job satisfaction. EFDAs also provide a ladder of job progression for DAs in your clinic. Increased staff satisfaction improves staff retention, which in turn has positive effects on program productivity.
2. May increase encounters: Adding EFDAs to your program will not automatically increase dental encounters. This happens only with careful attention paid to scheduling. This will be detailed further in the following section.

Considerations for Adding EFDAs to Your Program:

There are many factors that should be analyzed when considering adding EFDAs to your staff:

1. Current staffing ratios and operatories/dentist- Increasing clinic productivity and encounters are affected by many issues, but staffing ratios and operatories/dentist are the two primary factors. Dentists cannot achieve the productivity needed for both program finances and appropriate access if they are confined to one or even two dental operatories. This plays an even greater role when deciding on hiring EFDAs. We recommend a minimum of three dental operatories per dentist and a Dentist Team consisting of the dentist, 1.5 to 2 DAs and one EFDA. Since a dentist will not be scheduled with an EFDA every day, the EFDA can be shared between multiple Dentist Teams. It is important to note that the EFDA is also a DA and will function as one when needed. Because they are paid more than a DA, it is important to keep them working at the top of their skill set for as much time as possible.
2. Increasing encounters- As mentioned previously, an EFDA will not automatically increase encounters. Encounter increases can be achieved with appropriate scheduling. By completing treatment plans sooner, your practice will produce a higher number of patients needing recalls. Recalls are not only critical for your patients’ oral health, but they also have a significant positive financial impact on our programs. Recall exams take less time to do, and therefore more can be scheduled during the day than initial exams. These patients are healthier, so they require fewer follow-up appointments as well. A healthy recall system results in a healthier patient pool and healthier finances.
3. Medicaid percentage- As a general rule, the higher your Medicaid percentage,the healthier your dental program finances will be. Most health centers find that a minimum of 60-65% Medicaid is needed for a healthy dental budget. To achieve this goal, health centers must have strict access policies and control front desk activities so that children have maximum access to dental appointments. EFDAs work very well in increasing efficiencies in clinics with a high pediatric patient population.
4. Dentists’ willingness to increase production- Our patients’ health and our clinics’ finances demand that we give our dentists the resources they need to be maximally productive and that our dentists are willing to be as productive as possible. EFDAs, appropriate support staffing and operatory assignments give the dentists the resources they need. Salary considerations do come into play if your program wants to gear up for high productivity. This will be discussed further in the section on Salary Expectations

1. Ability to schedule accurately: It doesn’t take a highly sophisticated scheduling system to operate an EFDA schedule, but the ability to schedule by units will help. The critical need is a well-trained front office staff and strict adherence to an effective scheduling policy. Dentists need the flexibility to alter schedules when required to accommodate special patient needs, but that flexibility must come with the agreement to follow basic scheduling rules.

Metrics:

For optimal efficiencies, it is critical for the practice using EFDAs to develop metrics and manage to them. Suggested metrics for EFDA programs are:

1. Gross dollar production/ dentist measured for days the dentist is assigned an EFDA and those days the dentist does not have an EFDA
2. Encounters/ dentist comparing days with and without EFDAs
3. Recalls: Track all patients who have had a dental exam by the percentage that makes their recall appointment. Having recall lists generated with patient names and phone numbers is extremely valuable when used to actively track and call patients who miss their recall.
4. Medicaid percentage (payer mix): This is an essential measure to track even if you do not employ EFDAs

Quality:

Quality is important to achieve and measure throughout all aspects of dental. EFDAs are directly supervised by the dentist. This means that the dentist is responsible for the final restoration even when an EFDA places it. When EFDAs are first hired, the dentist should explain in detail what expectations they have for the final restoration. If your program has more than one dentist, the dentists should collaborate and compile a written list of their restorative expectations.

When the EFDA first begins restorative care, the dentist must check all the final restorations and continue to check them until all expectations are satisfied. After that, spot checks should be made. When supervised correctly, EFDAs can place restorations as well as any dentist.

Newly graduated EFDAs should be scheduled with one or two surface restorations and patients with no behavior issues in the beginning. As their confidence and competence increases, more complicated restorations and patients can be assigned. If your clinic has intraoral cameras, you could assign the EFDA to take pictures of restorations placed as a basis to further document quality. The EFDA could also take pictures of the dentist’s preps for comprehensive peer review.

Recommended Schedules:

Even if your program is staffed with EFDAs, a dentist should not be scheduled with EFDAs every day. It is important to understand that the purpose of the EFDA is not to make the dentist’s job easier. Scheduling by units is the most effective way to schedule all dental appointments, including those involving EFDAs. Typically, dentists in health centers are scheduled on the hour. This means that on the hour, the front desk is swamped by patients trying to check in and patients trying to check out. It also means that a patient who only needs 30 minutes is scheduled for the same amount of time as a patient needing a full hour. Scheduling by units means that a provider determines the amount of time needed for the next visit. That time is factored typically into 10- or 15-minute units. If a patient has one filling to complete at the next visit and the dentist estimates 30 minutes, then the patient is scheduled for 2 units (or three if the practice uses 10-minute units). Unit scheduling is more precise and will increase encounters. One downside is that the dentists will have less flexibility to squeeze in patients during the day if needed.

The EFDA schedule works in this manner. The dentist and the EFDA shift back and forth between the restorative patients in a coordinated manner with the objective of completing both restorative patients in an efficient manner with quality care. The dentist has two restorative columns and if additional operatories are available, can easily handle a third chair. In the two restorative columns, two restorative patients are scheduled each hour. The dentist anesthetizes the first patient and while waiting for the teeth to numb and the DA to place the rubber dam, the dentist goes over to operatory 2 and anesthetizes that patient. Once that is done, the dentist shifts back to the first operatory and preps the teeth for the restorations. Once the teeth preps are completed, the dentist turns the patent over to the EFDA who will restore the teeth.

It is important to note that the dentist at times will restore teeth even with an EFDA present. If the EFDA is running behind, the dentist should jump in to ensure the schedule stays on time. As stated previously, the primary reason the EFDA is there is to complete more patient care and to give the dentist more time to see more patients. This does not mean more time to rest.

The dentist then shifts back to the second chair and preps those teeth. If the dentist has time, he/ she can attend to a patient in the third operatory; these typically are patients who need just a small amount of the dentist’s time. It is important to note that a multi-operatory schedule is extremely common in private practice and is one that needs to be emulated in community health whenever possible(see the sample schedule attached to this policy).

Types of Patients and Procedures:

While EFDAs do not require a highly sophisticated schedule, the ability to schedule by units instead on the hour and the ability to select specific patients for a dentist’s schedule are important for efficiency. Whether you have a paper or electronic chart, you should find a way for the dentist to identify patients for the EFDA schedule. Ideal EFDA patients are at least 4 years old or higher, have little dental anxiety and teeth with class 1-3 lesions. They should be visits with relatively uncomplicated restorative care to help insure a smooth running schedule. The smoother the schedule flows, the more efficient, productive and cost effective the EFDA schedule will be.

Even if your program is staffed with EFDAs, a dentist should not be scheduled with EFDAs every day. Difficult restorative procedures should be scheduled on non-EFDA days. Extractions, root canals, dentures and partials should not be scheduled with EFDAs since those contain procedures that EFDAs are typically not allowed to perform.

Dentist/ EFDA Teams and Operatory Ratios

As stated before, the addition of EFDAs give you a chance to do quality dental care, expand access and increase productivity, but to do so the right staffing and operatory ratios are needed. The ideal EFDA team consists of the dentist, the EFDA and 1.5 to 2 FTE DAs. This team would work out of 3 dental operatories. This allows the scheduling flexibility needed (see schedule section).

Dentist, DA and Patient Perceptions:

As stated earlier, if your dentist are unfamiliar with EFDAs they may resist allowing an EFDA to place their restorations since this is historically a procedure performed by dentists. It helps to have a dentist in your center to champion this concept. If this is an issue at your clinic, all that is needed is one dentist to champion this effort. Once one EFDA team becomes successfully established, the resistance of your other dentists will vanish quickly. In general, EFDAs increase dentists’ satisfaction.

EFDAs are a pathway of job progression for DAs. You may be able to retain your top DAs longer by offering them the chance to advance.

Patient perception is typically not an issue, but you may want to prepare a conversation script to answer any patient questions.

Salary Expectations: EFDA and Dentist (Incentive)

Salaries will vary from state to state, but there is an expectation that EFDAs will be paid more than a DA due to the training required for the position. You will want to check with your local area, but we have found salaries in the $17- $25/ hour range. In general, EFDAs receive about 15 to 30% more in salary than DAs.

Another salary aspect to consider is an incentive program for the dentists. While this is clearly not a requirement to run an EFDA schedule, a well-structured incentive program will result in more efficiency and productivity from your dentists and more income to the health center.

Job Descriptions/ Competencies: (See Competency attachment)

Dental Law: Supervision

Understanding your state’s dental laws is critical to ensure appropriate supervision. Most states allow varying supervision levels depending on the specific procedure in question.

Issues with Recruiting EFDAs:

EFDA training programs are typically located in larger urban centers. This can cause difficulty in recruiting EFDAs if your health center is in a rural area of your state. You may need to create a marketing campaign at the EFDA schools and offer potentially higher salaries than more urban centers would require. You should also consider promoting from within by offering scholarships to current DAs that are eager to advance in the dental field. The scholarships should include a provision that requires a specific number of years working at the health center.

Attachment 1: Sample Schedule for Dentist Utilizing an EFDA

Operatory 1 / Operatory 2 / Operatory 3
8:00- 8:15 / Expanded Restorative / Recall Exam
8:15- 8:30 / Expanded Restorative
8:30- 8:45
8:45- 9:00 / Expanded Restorative / Post-op check
9:00- 9:15 / Expanded Restorative / Sealants
9:15- 9:30
9:30- 9:45 / Expanded Restorative / Recall Exam
9:45- 10:00 / Expanded Restorative
10:00- 10:15
10:15- 10:30 / Expanded Restorative / Recall Exam
10:30- 10:45 / Expanded Restorative
10:45- 11:00
11:00- 11:15 / Expanded Restorative / Fluoride Tx
11:15- 11:30 / Expanded Restorative / One-Year-Old Exam
11:30- 11:45
11:45- 12:00 / One-Year-Old Exam

Attachment 2: EFDA Competency Checklist

Please note that EFDA competencies will vary from state to state, as each state has different laws regarding what expanded functions can/cannot be done. Be sure to check the dental practice acts in your state to identify what procedures EFDAs are permitted to do. The following is a checklist from Washington State. The expanded function competencies are indicated in bold type.

1. Properly sets up charting for Dentist, x-rays ready for review, proper instruments open and

appropriate supplies available.
A. Keeps pace and accurately records data from dentist marking caries, conditions and
restorations along with proposed treatment.

1. Accurately performs age appropriate fluoride treatment.

A. Explains procedure to patient before beginning treatment in an age appropriate manner.
B. Accurately time the fluoride treatment and gives written and verbal instructions to the parent.
C. Properly applies fluoride varnish and gives written and verbal instructions to the parent
and/or guardian.
3. Accurately places rubber dams.
A. Makes certain rubber dam is correctly punched and centered.
B. Ligates appropriate clamp for dentist and tooth and seats securely without trauma to tissue.
4. When using Nitrous in a pre-medicated situation, monitors pulse oximeter and provides dentist
with accurate updates.
5. Perform oral inspection with no diagnosis.
6. Take preliminary and final impressions as well as bit registrations, to include computer assisted
design and computer assisted manufacture applications.
7. Remove the excess cement after the dentist has placed a permanent or temporary inlay, crown,
bridge or appliance, or around orthopedic bands.
8. Place a matrix and wedge for a metallic and nonmetallic direct restorative material after the
dentist has prepared the cavity.
9. Placement and removal of periodontal packs.
10. Place a temporary filling (as zinc oxide-eugenol (ZOE) after diagnosis and examination by the
dentist.
11. Fabricate, place and remove temporary crowns or temporary bridges.
12. Pack or remove medication for extraction sites.
13. Take impressions, fabricate and deliver bleaching and fluoride trays.
14. Place topical anesthetics.
15. Place retraction cord.
16. Place, carve and polish direct restorations.
17. Take impressions for temporary oral devices, such as but not limited to space maintainers,
orthodontic retainers and occlusal guards.
18. Take a facebow transfer for mounting study casts.
19. Select orthodontic bands for size.
20. Place and remove orthodontic separators.
21. Select denture shade and mold.

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