Every professional worker in the dental office has a thorough training process they must complete. Wikipedia summarizes the education of the dentist with reasonable completeness, and you may find many sources of information regarding hygienists and assistants.
Organization of this Chapter
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The Training of the Dentist
The Dental Hygienist
The Training of the Dental Assistant
The Dentist is Responsible for the Actions of Every Employee – even Unspeakable Crimes!
Education of Dental Professionals: The Dentist
Dental school education is a strenuous 4 year program, covering far more disciplines than is typical for a profession. As far as the medical side of things are concerned, the education is almost identical to that of a medical student. On top of that there are countless hours practicing cutting plastic teeth on a simulator before another countless hours doing procedures on patients. And there are classes that help the prospective dentist learn how to efficiently run a dental office, in terms of both organization and management of employees. There is training about how to work with a chairside assistant effectively. And there is often a research requirement, where the students work with a professor to discover something that other people don’t know about any aspect of dentistry.
There are very few students that are naturally good at everything that they need to learn in dental school – but it is an exciting experience!
In the first couple of years of dental school education there is no work on patients. The classroom courses include those which teach how the human body is designed: histology, anatomy, biochemistry, physiology, immunology, neuroanatomy and neurophysiology. There also courses that teach how the human body is susceptible to disease and genetic disorder – pathology. And dental students need to know how the disease states of the human body can be addressed by pharmacological means – medicine. There may or may not be courses involving the psychological wellbeing of patients. Psychoactive drugs are certainly covered, but modalities of psychological therapy are typically not.
Then there are all of the courses having to do specifically with the mouth and associated structures. Head and neck anatomy, dental anatomy and tooth morphology, occlusion and the physiology and immunology of the mouth. Specific pathological states affecting the mouth and surrounding tissues are studied as well.
Then there are all of the courses dealing with the REPAIR or amelioration of disease states that affect the mouth – including many of the topics covered in this website. This would include restorative dentistry (covering fillings, crowns and dentures), periodontics, endodontics, implants, orthodontics, and pediatric dentistry.
For all of these clinical topics the courses involve both the classroom presentations and assignments, and a laboratory where projects are assigned that require understanding of the principles and execution of detailed preparations or procedures that require the development of good hand-eye coordination. Everything is practiced on patient simulators prior to even getting close to a patient.
Transition to Patients
There is a significant program to make the transition between the laboratory training and the clinical experience. As a teacher, that was my favorite course to teach, as it is a real “rubber meets the road” course. For the students to get used to working in a dental chair in the clinic, following all of the procedures as they are done in the clinic, but for them to see their first patient and work well with that person who has placed their trust in them – that is a huge experience.
Once the dental student starts his/her clinical years, generally the last two of the four years of school, there are requirements that need to be met in order to graduate. There are a certain number of various types of fillings, many quadrants of root planing, a proscribed number of root canals successfully completed, some specific number of crowns and bridges, and some partial and full dentures. There will be requirements for procedures on children as well, and some number of surgical procedures including extractions.
All of these requirements need to be met in order to graduate with that DDS or DMD degree. Now – one things that has happened over the last few decades is that the requirements have decreased! I’ve mentioned before that when I was in school the minimum requirement for crowns was 30, whereas now it is more like 5!
The students that I teach now who are dentists from overseas, that are applying to dental school in this country with advanced standing, only needing to complete the clinical last two years, are mostly in need of more experience in making crowns. I ask them how many crowns would they LIKE to do in dental school before graduation so that they would expect to be confident in the procedure – the answer is commonly around 50. There is great disappointment, not to say consternation, when I tell them they can be graduated with only 5. On the other hand, this is NOT a MAXIMUM that they can do, only a minimum.
Dental students CAN in most schools far exceed the minimum graduation requirements as long as the school provides adequate “chair-time” in the clinic, AND the student goes out and gets patients. There are not enough patients coming to the school as is – students that are determined to have their best clinical experience will have to advertise and bring patients in from the outside.
The fact is that THESE DAYS a typical dental school graduate will NOT be confident in several areas of practice to immediately start working in a private dental office. Thirty years ago this was not true, and it does NOT have to be true now, but it takes a very aggressive and determined dental student. For those that do not have enough clinical experience at graduation there are Residency Programs available in dentistry that allow the new graduate to learn more by practicing in a hospital or dental school setting on more varied patients.
In fact, New York State requires that for a dentist to get licensure there, they need both dental school and a year of post-graduate clinical experience.
Speaking of licensure, every state is different in their requirements. They all DO require a clinical examination, where the candidate performs procedures on patients that they bring into the examination site. Some states subscribe to regional examinations conducted by organizations set up for this purpose and regulated by the American Dental Association. Some states have their own licensure exam, but this is becoming a thing of the past. The most difficult examination in the country for many years was the California Clinical Dental Board Exam. This exam separated out well those with less clinical aptitude, experience and judgment. Now in the state of California it is approved for prospective licensees to take a regional exam which always had a somewhat higher passing rate.
Don’t even ASK me to explain the history of how that came to be. But, doesn’t politics and power explain everything that is otherwise unfathomable?
Of course, this discussion applies only to GENERAL DENTISTS, probably like the dentist you typically go to. But, if you are referred to an orthodontist, endodontist, prosthodontist, oral surgeon or periodontist, they will have had an additional 2 or 3 years of study and training. For the oral and maxillofacial surgeon, they go through dental school, AND medical school, and a full surgical residency – for that we’re looking at up to 10 years of education past college!
Education of Dental Professionals: The Hygienist
Dental hygienists are mostly trained in dental schools, at least the most prestigious programs often share clinic space with the dental students. The dental hygienist does most of the periodontal procedures in the typical dental office. They might do routine cleanings as well as root planing by quadrant, and be well versed in the administration of local anesthetics. If the dental office HAS a hygienist, they will be the one that collects information from the patient regarding their periodontal condition, and tracks this over the years. They will also be responsible for making sure that the patient understands what they need to do at home, and how to do it, so that the teeth and any dental appliances are protected and have the longest life possible.
Often those looking for a dental hygiene degree start right out of high school and earn an Associate’s degree in Hygiene. There are bachelor and even masters degrees available in some places, but this is not required to practice.
The school program can vary from around two years to three years of study and clinical experience – and involves a lot of the same didactic courses that the dental students take, but focusing more on the head and neck than covering as well the whole body. A dental hygienist does need, however, to be quite familiar with the various diseases and health conditions they are likely to run into with their patients, and the medications that the patient might be taking and how it would affect the periodontal work.
Licensure and Scope of Practice
Dental hygienists take examinations to become licensed in most states. But, also in most states and under most typical circumstances, dental hygienists are not allowed to practice independently – they can only practice WITHIN a dental practice owned by a dentist. The dentist is ultimately responsible for the treatment and management of the patient by the hygienist.
There are exceptions to this – in fact, a hygienist in Alaska may obtain a license to practice as what is called a “mid level dental practitioner” for many years now. This has been a controversial program which was fought by the ADA, but was seen to be of benefit for the indigenous population living in the more distant areas of the state. The additional training needed for a hygienist to remove decay and place fillings has been provided by the University of Washington. Other countries have something like this as well, an independent operator taking responsibility for their patients, while providing a level of service at the periodontal level while also managing modest amounts of decay. The statistics on whether this geographically more far reaching care is beneficial to the patient-base suggests it is uncertain at best. But, it is clear that some people are able to get care where otherwise they would not.
Education of Dental Professionals: The Dental Assistant
The job of the dental assistant is to make sure that the chair is ready for the patient and everything necessary is there for whatever procedure is planned, and that the dentist is handed everything smoothly during the procedure to make it go as rapidly and smoothly as possible for the patient.
The training may be a few months in a community college program, involving practicing in a laboratory setting, followed by an internship program for some period of time before employment. On the other hand, the dentist may elect to simply train his assistants him/herself.
What they are Allowed to Do
In California there are several levels of dental assistant. Those that are not licensed or certified are very limited in what they are allowed to do in the office with the patient. The dentist may feel he/she has trained them well enough to do a variety of procedures, but certain things just are not allowed, depending on the state.
In California there is the “dental assistant“, who is locally trained and not licensed, there is the Certified Dental Assistant, CDA, and there is the Registered Dental Assistant, the RDA. There is an increase in expected pay for each higher level of achievement and confirmed capability – for one reason because they are allowed to DO more that will save the dentist more time. Also in some states there is an EFRDA – an Extended Function Registered Dental Assistant, who typically will have far more training, and in a dental school, so that they may be comfortable doing more invasive procedures.
For example, when the dentist prepares a tooth for a crown, the next step is to take the impression and make a temporary crown out of plastic that will be worn by the patient for a few weeks while the actual crown is being fabricated (unless CAD/CAM). A dental assistant may not make the temporary crown, but the RDA may make it, and cement it. The RDA may not take the impression for the crown, but an EFRDA may, under DIRECT supervision of the dentist.
Here’s the thing – there are very specific rules about what assistants are allowed to do, legally, and whether these things must be done under the direct observation of the dentist, or they can do them on their own. It is a VERY good idea for the dentist, who is ultimately responsible for everything done to patients in the practice, to KNOW what is being done and that whoever is doing it is fully qualified. When some dentists train their own assistant, to save money, they may overestimate the actual abilities of this person to make sound judgments in their haste to save money.
The Dentist is Responsible for the Actions of Every Employee – even Unspeakable Crimes!
The WORST example is a dentist that was referred to me in my faculty position to see if I could design a program for him to get his license back, by doing some kind of remedial educational program. WHY did he lose his license? He lost his license because of something the dental assistant had done.
He was used to working on kids in his practice, but was not a pediatric dentist. He made his life easier while working on kids by sedating them. A common sedative used in dentistry up into the 90s was chloral hydrate. If you go back a few years, as do I, you may remember the term “knock out drops” – well this is it. It was not that unusual for dentists to even prescribe such drops to the parents to use with their kids and bring them into the office “asleep”. This was so that the dentist didn’t have to wait for the child to “go under” while they were in the dental office.
This dentist was in the habit of dispensing the drops to the children while they were in the office, but so it didn’t take any of his time he had the assistant do it.
The assistant in this case DIDN’T KNOW how much to give! She was told to give a certain amount, but got the decimal point wrong and didn’t know any better. This was an assistant trained at the lowest level, by someone who just didn’t take their responsibility seriously. FIRST – NO assistant may dispense sedatives. SECOND – if the hazards of such sedatives is not thoroughly understood by a responsible party, it is a recipe for disaster.
Disaster struck. The patient was a four year old girl, who was given 40 ml of chloral hydrate instead of 4 ml. She never woke up. It brings tears to my eyes to just think about that!
That is what can happen when you provide a service to a human being and don’t take it seriously – and ask someone else to do your bidding who is not trained for the task.
You might wonder what happened to the dentist. I refused to work with him, and so did the pediatric department at my school. I don’t know if he ever got his license back. But I am more concerned about the dental assistant than I am for him. The dental assistant was put in a position of committing an unspeakable crime by trusting her employer – but how does one come back from that?
Other Dental Auxiliaries
The dental office does not run without other people involved, who have some training in the dental field as well, but are not in direct contact, other than conversationally, with the patient.
There is the billing specialist – who will make sure that when insurance coverage is involved the appropriate codes are put in the right places so that the dentist will get paid. Also they are responsible to make sure that every patient pays what they owe, or are on a payment plan which is monitored well.
There is the appointment assistant. They need to have some awareness of what needs to be done and how much time to allow in the chair in order for it to get done, and make sure the patient knows when to come and actually shows up.
Imagine how poorly an office would run if appointments were scheduled for inappropriate periods of time. The dentist may tell the assistant how long to allow for what he knows he will need to do, but the assistant must find a way to fit the time required into a day that may be tightly scheduled. If the dentist works in several chairs at the same time, moving back and forth between them, then the nature of the procedures done in each chair must allow for that “multi-tasking” on the part of the dentist.
While the Billing Specialist may be trained by a program in a community college, the appointment assistant may well be trained by the dentist.
The Education of Dental Professionals: Bottom Line
But, everyone in the office has work to do, and everyone’s work will dovetail together to accomplish the goal, getting every patient the highest quality care with the least discomfort, while having the office flow smoothly. While everyone’s level of education and training is different, there is an important element of everyone’s education to be able to fit together as functioning parts of an integrated whole.