Impact Statement- expanded Function Dental Auxiliary (efda) a plain language description of the request



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Impact Statement- Expanded Function Dental Auxiliary (EFDA)


A plain language description of the request:
The Connecticut Dental Association is requesting a Scope of Practice change for the practice of dental assisting to provide for the education, training, and certification of an Expanded Functions Dental Auxiliary (EFDA). An EFDA is a highly trained and skilled dental assistant or dental hygienist who receives additional education to enable them to perform reversible, intraoral procedures, and additional tasks (expanded duties or extended duties), services or capacities, often including direct patient care services, which may be legally delegated by a licensed dentist under the supervision of a licensed dentist. Training programs for EFDA are self-sustaining and can be operated in existing training programs with no additional cost to the educational system.
The EFDA practices under the supervision of a licensed dentist. Connection to the Dental Home ensures that children will have access to comprehensive care, including restorative services to eliminate pain and restore function.
Inclusion of an EFDA in the dental office as a part of the dental team will increase access to care for the underserved citizens in Connecticut, including children, the elderly and those with special needs. Research suggests that the use of EFDAs can increase the capacity of the dental office. Beazoglou, et al (2009), in an economic analysis of EFDAs in Colorado concluded that private general dental practices can substantially increase gross billings, patient visits, value-added, efficiency and practice net income with the delegation of more duties to auxiliaries. Increasing access to services within the context of a dental home will improve the oral health of Connecticut children and adults and will prevent the unnecessary suffering that comes with dental decay and infection. i
Public health and safety benefits that the requestor believes will be achieved should the request be implemented and, if applicable, a description of any harm to public health and safety should the request not be implemented:

Oral health is integral to the optimal physical, social-emotional and intellectual development of every child. Unfortunately, many children in America suffer from poor oral health and a lack of access to oral health care. In his 2000 report Oral Health in America, the Surgeon General noted that not only is dental caries the most common chronic disease of childhood, but that low-income children suffer twice as much from dental caries as children who are more affluent.ii


The impact of untreated dental disease extends to all aspects of physical, mental and behavioral health. According to Casamassimo, et al in Beyond the DMFT, “ECC exacts a toll on children, affecting their development, school performance and behavior, and on families and society as well. In extreme cases, ECC and its treatment can lead to serious disability and even death. In finding access to care and managing chronic pain and its consequences, families experience stress and, thus, a diminished quality of life. Communities devote resources to prevention and management of the condition.”iii
The change in scope of practice of dental assisting requested, which would allow inclusion of an EFDA in a dental practice under the supervision of a dentist would extend the ability of that dental practice to provide dental services to all populations, including those most at-risk for dental disease – low income, those suffering from physically and mental disabilities, and the elderly. These populations will achieve increased access to screening, preventive services, parent and caregiver education within the practice facilitated by the inclusion of an EFDA in the dental team. Research indicates that inclusion of an EFDA in the dental team can increase the number of patients seen in a given dental office and increase the productivity of the office.iv
These outcomes are consistent with the goals identified in the CT 2007-2012 Oral Health Improvement Plan. The plan identified the following objectives related to this request:

  • By 2011, increase by 50% the proportion of children, adults, and vulnerable populations who receive annual preventive and necessary restorative oral health care.

  • By 2008, develop policies to promote and facilitate the provision of oral health services.

  • By 2012, promote and implement effective and efficient models that increase access to quality oral health services.v

According to Oral Health in Connecticut (2007), published by the CT Department of Public Health:

The most vulnerable populations, including the elderly, poor, uninsured, racial and ethnic minorities, disabled, and those challenged by transportation barriers, face significant oral health problems, including tooth decay and periodontal (gum) disease. These preventable oral diseases can also act as a focus of infection which can influence the outcomes of serious health problems such as cardiovascular disease, diabetes, and pre-erm low birth weight. As a result, oral diseases place a significant burden on the healthcare system in Connecticut and on the public in terms of pain, suffering, poor self-esteem, cost of treatment, and lost productivity in school and at work.vi
According to this report, the number of dental assistants in the state in 2004 was 3,098. This number is below the national average of 1.5 assistants per dentist. HRSA ranked the state 18th in dental assistants in 2000. The creation of a professional development route that would allow dental assistants to enhance their professional satisfaction through skill development would possibly increase the number entering this profession. It would increase likelihood of retention of trained dental assistants in the workforce. Again, an increase in the number of dental assistants would increase the number of patients that could be served by a given dental office, thus increasing access.
The impact that the request will have on public access to health care:

Access to oral health care for children is an important concern that has received considerable attention since publication of Oral Health in America: A Report of the Surgeon General, in 2000.vii The report identified “profound and consequential disparities in the oral health of our citizens” and that dental disease “restricts activities in school, work, and home, and often significantly diminishes the quality of life.” It concluded that for certain large groups of disadvantaged children there is a “silent epidemic” of dental disease. This report identified dental caries as the most common chronic disease of children in the US, noting that 80 percent of tooth decay is found in 20-25 percent of children, large portions of whom live in poverty or low-income households and lack access to an ongoing source of quality dental care.


A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivery, in a comprehensive, continuously-accessible, coordinated, and family-centered way. Such care takes into consideration the patient’s age, developmental status, and psychosocial well-being and is appropriate to the needs of the child and family. Children who have a dental home are more likely to receive appropriate preventive and therapeutic oral healthcare.viii
Central to the dental home model is dentist-directed care. The dentist performs the examination, diagnoses oral conditions, and establishes a treatment plan that includes preventive services, and all services are carried out under the dentist’s supervision. The EFDA works under the supervision of the dentist to increase productivity and efficiency while preserving quality of care. This also allows for provision of preventive oral health education by EFDAs and preventive oral health services under general supervision (ie, without the presence of the supervising dentist in the treatment facility) following the examination, diagnosis, and treatment plan by the licensed, supervising dentist. Furthermore, the dental team can be expanded to include auxiliaries who go into the community to provide education and coordination of oral health services. Utilizing EFDAs to improve oral health literacy could decrease individuals’ risk for oral diseases and mitigate a later need for more extensive and expensive therapeutic services.
Numerous studies have demonstrated the efficacy and effectiveness of introducing EFDAs into the dental practice. The Navy Dental Corp and the Philadelphia Department of Dental Health have publicly stated that EFDAs allow for the leveraging of dental personnel to increase access. Researchers from the University of Colorado in a study, A Pilot Study to Determine

Barriers to Implementing Productivity Enhancement Strategies in Dental Practices found that when high delegation dentists were asked how delegation had affected their practice, they responded that they believed that expanded delegation had: (1) increased the number of patients seen, (2) increased productivity and income, (3) reduced the stress of practicing dentistry, and (4) permitted reduced hours without a decrease in income.ix
The CT Oral Health Improvement also addresses the need to increase the number of children within CT that receive dental sealants. In fact, dental sealants are one of the universally agreed upon, evidence-based preventive techniques. The EFDA programs allow sealant placement, contributing towards the increase in percentage of CT children who have receive dental sealants.
Increased access to screening, preventive services, parent and caregiver education within the dental home provided by EFDAs, will improve the oral health of high risk populations and result in a higher percentage of Medicaid-enrolled children receiving preventive, diagnostic and treatment dental services.
A brief summary of state or federal laws that govern the health care profession making the request:

A number of states have EFDA regulations in their dental practice acts. Currently 35 states allow dental assistants to perform all four Certified Preventive Dental Assistant Tasks as identified by DANB: Coronal Polishing, Fluoride Application, Sealant Application, & Topical Anesthetics Applicationx. 27 states currently allow for some form of EFDA..xi Some states, such as Colorado have had them for years. In such states, EFDAs have increased the productivity and efficiency of the dental office.


Dental assistants are explicitly or implicitly recognized in the dental practice acts or administrative rules of 49 states. The dental practice acts and/or administrative rules of a majority of states (31) explicitly or implicitly recognize more than one level of dental assistant and restrict the performance of certain advanced functions to dental assistants who complete certain educational or clinical experience requirements or who hold certain credentials. In Connecticut, dental assistants are not licensed, certified nor registered by the Department of Public Health but are overseen by the Commissioner of Public Health, with advice and assistance from the Dental Commission. “A licensed dentist may delegate to dental assistants such dental procedures as the dentist may deem advisable, including the taking of dental x-rays if the dental assistant can demonstrate successful completion of the dental radiography portion of an examination prescribed by the Dental Assisting National Board”, as stated in the CT General Statutes, Chapter 379 Dentistry, Section 20-112a. (9).xii
Since 2000, at least 11 states have passed new legislation or adopted new administrative rules gov­erning the practice of dental assisting. In each case, the new law or rule permitted or more clearly defined delegation of expanded functions to dental assistants, or established or more clearly defined credentialing requirements for dental assistants. Additional regulatory revisions pertaining to delega­tion of expanded functions or education and credentialing requirements are currently under consid­eration in 10 other states.3 The trend since 2000 toward enactment of new rules related to the delegation of expanded functions to dental assistants, combined with the increase since 1993 in the number of states recognizing two or more levels of dental assisting, reflects the oral healthcare com­munity’s increasing interest in allowing the delegation of expanded functions to dental assistants. These trends also indicate that the oral healthcare and regulatory communities recognize that dental assistants who perform expanded functions should be competent and qualified to perform them and that it is necessary to establish and implement a means of measuring competency and/or verifying qualifications of these dental assistants.xiii
The Commission on Dental accreditation (CODA) accredits dental, dental hygiene, and standard 10 month dental assisting certificate programs. Currently, CODA does not accredit EFDA educational programs. Consequently, this EFDA scope request requires the successful completion of an EFDA program offered through an institution that has an existing Commission on Dental accreditation accredited dental/allied dental program. Certification would be provided by the Dental Assisting National Board (DANB). The Certified Dental Assistant (CDA) credential that is conferred to dental assistants who pass the CDA Examination is administered by DANB. This credential draws national participation and recognition. The CDA Exam is made up of three compo­nents: Radiation Health and Safety (RHS), Infection Control (ICE), and General Chairside Assisting (GC). These components may be taken all at once, or each component may be taken individually. A candidate must pass all three components within five years to earn the CDA credential. xiv
DANB is recognized by the American Dental Association as the national credentialing agency for dental assistants. Its national certification programs—including the Certified Dental Assistant (CDA), Certified Orthodontic Assistant (COA), and Certified Dental Practice Management Administrator (CDPMA) Examinations, and the RHS, ICE, GC, and Orthodontic Assisting (OA) component examina­tions—are accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body of the National Organization for Competency Assurance (NOCA).xv
DANB requires that Certification be renewed annually—CDAs, COAs, CDPMAs, and COMSAs must complete, each year, 12 hours of continuing dental education (CDE) meeting the CDE guidelines es­tablished by DANB for recertification and must maintain current CPR certification.

Currently, 34 states and the Veterans Health Administration recognize or require successful perform­ance on a DANB dental assisting exam (CDA, COA, or one or more DANB component exams) for den­tal assistants to meet state or agency regulations or as a prerequisite to performing expanded functions. xvi



The state’s current regulatory oversight of the health care profession making the request:
Dental assistants in Connecticut may perform functions authorized by the Connecticut State Dental Commission/Department of Public Health as cited in the Dental Practice Act; Chapter 379, section 20-112a. Dental procedures are delegated by a licensed dentist to the dental assistant and are performed under the supervision, control and responsibility of the dentist. Dental Assistants in Connecticut are not required to be licensed or registered but must hold a certification in DANB Radiation Health and Safety in order to expose dental x-rays as cited in the Department of Public Health Statutes and Regulations; Chapter 376 c, section 20-7433 (3).xvii
A dental assistant in the state of Connecticut may perform basic supportive dental procedures specified by the state dental practice act under the supervision of a licensed dentist. There are no education or training requirements for this level of dental assisting.
Sec. 20-112a. Dental assistants:  A licensed dentist may delegate to dental assistants such dental procedures as the dentist may deem advisable, including the taking of dental x-rays if the dental assistant can demonstrate successful completion of the dental radiography portion of an examination prescribed by the Dental Assisting National Board, but such procedures shall be performed under the dentist's supervision and control and the dentist shall assume responsibility for such procedures; provided such assistants may not engage in: (1) Diagnosis for dental procedures or dental treatment; (2) the cutting or removal of any hard or soft tissue or suturing; (3) the prescribing of drugs or medications that require the written or oral order of a licensed dentist or physician; (4) the administration of local, parenteral, inhalation or general anesthetic agents in connection with any dental operative procedure; (5) the taking of any impression of the teeth or jaws or the relationship of the teeth or jaws for the purpose of fabricating any appliance or prosthesis; (6) the placing, finishing and adjustment of temporary or final restorations, capping materials and cement bases; or (7) the practice of dental hygiene as defined in section 20-126l.xviii
Pursuant to Section 20-74ee(3), Connecticut General Statutes, nothing shall be construed to require  license as a radiographer or limit the activities of a dental assistant as defined in Section 20-112a, provided such dental assistant is engaged in the taking of dental x-rays under the supervision and control of a dentist licensed pursuant to Chapter 379, Connecticut General Statutes, provided the dental assistant can demonstrate successful completion of the dental radiography portion of an examination prescribed by the Dental Assisting National Board (DANB) or a dental assistant student, intern or trainee pursuing practical training in the taking of dental x-rays provided such activities constitute part of a supervised course or training program and such person is designated by a title that clearly indicates such person’s status as a student, intern or trainee.xix
In Connecticut, dental assistants are not licensed, certified nor registered by the Department of Public Health but are overseen by the Commissioner of Public Health, with advice and assistance from the Dental Commission. “A licensed dentist may delegate to dental assistants such dental procedures as the dentist may deem advisable, including the taking of dental x-rays if the dental assistant can demonstrate successful completion of the dental radiography portion of an examination prescribed by the Dental Assisting National Board”, as stated in the CT General Statutes, Chapter 379 Dentistry, Section 20-112a. (9).

All current education, training and examination requirements and any relevant certification requirements applicable to the health care profession making the request:
In the State of Connecticut, dental assistants can be hired and trained on-the-job or complete a formal education program in a CODA-accredited dental assisting program. Both pathways provide the opportunity for dental assistants to become Certified Dental assistants through the Dental Assisting National Board (DANB). Training programs are offered by community colleges, vocational schools, or technical institutes. One-year program enrollees receive a certificate or diploma upon completion, while those in 2-year programs receive an associate degree. Dental assistants may also acquire necessary skills through on-the-job training.
Licensure is required for dental assistants in the state of Connecticut only in regard to taking dental x-rays. Prerequisite: Dental assistants must successfully complete the radiology section of the Dental Assisting National Board examination in order to take dental x-rays in Connecticut; but other than that, neither certification nor licensure is required in Connecticut.
Training programs for EFDA are self-sustaining and can be operated in existing training programs with no additional cost to the educational system.

A summary of known scope of practice changes either requested or enacted concerning the health care profession in the five-year period preceding the date of this request:
The extent to which the request directly impacts existing relationships within the health care delivery system:
This scope request would directly impact the relationships between the dental assistant, dental hygienists and dentist as it would allow the dentist, as lead member of the dental team to determine how to utilize the resources within his/her office to best meet the demand for services. This would positively complement both the dental and dental hygiene professions as it would allow for an enhanced career path for both dental assistants and dental hygienists.
Subsequent to the Surgeon General’s report in 200, a coalition of public and private organizations recommended, among other actions, taking steps to increase the oral health workforce’s diversity, capacity, and flexibility.xx The expansion of duties for the dental assistant, in line with recommendations by DANB for a uniform national model for dental assistants can:

  • increase the capacity of the oral healthcare services infrastructure by enhancing dental assistant recruitment and retention;

  • Minimize unproductive time that dental assistants spend obtaining new credentials when they change their state of residence, and reduce losses from the dental assisting workforce of experienced dental assistants who choose not to obtain new credentials when they change their state of residence;

  • Mitigate shortages in the dental assisting workforce by enhancing the ability of dental offices within commuting distance of neighboring states to hire dental assistants living in those states;

  • Allow public health initiatives designed to benefit underserved segments of the population to more effectively recruit qualified dental assisting personnel.xxi

Research supports the improved effectiveness of the dental office when an EFDA is utilized. The increase in dental services available for Medicaid and other underserved populations will positively impact the relationship between the dental profession and the population at large.


The anticipated economic impact of the request on the health care delivery system:
The request will improve the efficiency of the dental office thus allowing for the expansion of services to those patients covered by public insurance. According to Beazoglou, et al. (2009):

The impact of delegation on practice productivity and efficiency are substantial. As delegation increases, practices see more patients and generate higher gross billings and net incomes. Larger practices (e.g., more dentist and staff hours and space) are the primary employers of expanded function dental auxiliaries. This study suggests that general dental practices could substantially increase their capacity to see more patients with the effective use of expanded duty dental auxiliaries.xxii


Moreover, training programs for EFDA are self-sustaining and can be operated in existing training programs with no additional cost to the educational system.

Regional and national trends concerning licensure of the health care profession making the request and a summary of relevant scope of practice provisions enacted in other states:
Please see the following printed attachments:

Dental Assisting National Board, Inc. Position paper of the ADAA/DANB Alliance: Addressing a uniform national model for the dental assisting profession. 2005.
Dental Assisting National Board, Inc. National Overview of Dental Assisting Job Titles. The chart on the next page illustrates the various job titles given to different job function levels across the United States. xxiii

Identification of any health care professions that can reasonably be anticipated to be directly impacted by the request, the nature of the impact and efforts made by the requestor to discuss the request with such health care professions:

A description of how the request relates to the health care profession’s ability to practice to the full extent of the profession’s education and training:
The EFDA certification will all for enhanced professional development and skill development for dental assistants in CT. Training will develop specific knowledge, skills and competencies essential for the dental assistant to assist the dentist in delivery of quality dental care. EFDAs can perform expanded duties for which they are trained under specific guidelines that incorporate clinical evaluation. The certification process will ensure that EFDAs are competent to perform the skills identified in the expanded scope of practice. The additional services performed by the EFDA will help the dentist to expand the number of patients the practice serves and to best allocate the dental resources within the practice.
This program will offer dental assistants a chance to elevate their professional status and will promote longevity in the profession. Dental assistants who are DANB-certified stay in the profession an average of 14.5 years (3 times longer than non-certified dental assistants). The enhancement of scope of services is in line with the recent Institute of Medicine report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations which concluded that “states should examine and amend state practice laws to allow healthcare professionals to practice to their highest level of competence.”xxiv By requiring the scope of services to be provided under the supervision of a dentist, the change will maintain the quality and integrity of the dental home.


i Beazoglou T, Brown LJ, Ray S, Chen L, Lazar V. An Economic Study of Expanded Duties of Dental Auxiliaries in Colorado. Chicago: American Dental Association, Health Policy Resources Center; 2009.


ii U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.


iii Casamassimo PSThikkurissy SEdelstein BLMaiorini E. Beyond the dmft: the human and economic cost of early childhood caries. J Am Dent Assoc. 2009 Jun;140(6):650-7.


iv American Academy of Pediatric Dentistry. Policy on workforce issues and delivery of oral health care services in a dental home. 2011.


v Connecticut Department of Public Health, Office of Oral Public Health. CT oral health improvement plan: 2001-2012. 2007.


vi Connecticut Department of Public Health. Oral health in Connecticut. 2007.


viiIbid.


viii American academy of Pediatric Dentistry. Definition of a Dental Home. 2006.


ix Domer, LR and Call, RL. A pilot study to determine barriers to implementing productivity enhancement strategies in dental practices. Unpublished report, School of Dentistry, University of Colorado. June 14, 2005.


x Dental Assisting National Board, Inc. DANBs CDPA Summary Chart. 2011.


xi Dental Assisting National Board, Inc. National Overview of Dental Assisting Jobs. 2011


xii Dental Assisting National Board, Inc. Position paper of the ADAA/DANB Alliance: Addressing a uniform national model for the dental assisting profession. 2005.


xiii Ibid.


xiv Dental Assisting National Board, Inc. 2011. CDA Exam Application Packet.


xv Dental Assisting National Board, Inc. 2011. www.DANB.org


xvi Ibid.


xvii CT General Statutes. Chapter 397. Dentistry.


xviii Ibid.


xix Ibid.


xx U.S. Department of Health and Human Services. A National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, and the National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, May 2003.


xxi Dental Assisting National Board, Inc. Position paper of the ADAA/DANB Alliance: Addressing a uniform national model for the dental assisting profession. 2005.


xxii Beazoglou T, Brown LJ, Ray S, Chen L, Lazar V. An Economic Study of Expanded Duties of Dental Auxiliaries in Colorado. Chicago: American Dental Association, Health Policy Resources Center; 2009.

xxiii Dental Assisting National Board, Inc. National Overview of Dental Assisting Job Titles. www.danb.org. Accessed 9-27-2011

xxiv Institute of Medicine of the National Academies. Improving access to oral health care for vulnerable and underserved populations. July, 2011.


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