Why Don’t Some Dental Boards Regulate Dental Assistants?

In the mid-1970s, California began offering new opportunities for dental assistants to become registered and licensed to provide coronal polishing procedures under the direct supervision of a dentist. Becoming a “licensed and registered” dental professional not only provides a sense of pride and accomplishment but also adds the component of accountability as an important element. Licensure and registration also mean regulation by the state dental board.

In the 45 years since California began offering the registered dental assistant coronal polishing exam, dental assisting has changed drastically and become one of the fastest-growing occupations in the United States. According to the US Bureau of Labor Statistics, there are more than 350,000 dental assistants in the country. Compared to the 151,000 dentists and 226,000 dental hygienists in the US, dental assistants make up a major percentage of personnel in the dental setting.^1-3 Despite the fast growth of the dental-assisting profession, dental assistants are frequently the most underrepresented and the most undervalued employee in the dental workforce.

With the onset of the COVID-19 pandemic, many dental assistants chose to leave their occupation. The workforce shortage is not a new issue for dental assisting, but COVID-19 exacerbated it. Findings from internal research conducted by the Dental Assisting National Board (DANB) on this topic identified the following contributing factors to the workforce shortage for dental assistants resulting from COVID-19: pay not commensurate with the responsibilities, difficult working conditions, lack of childcare, and health concerns.

In addition, according to an unpublished DANB survey of dental assistants in October 2020, 75% of respondents were employed full time and 15% were employed part time. Additionally, nearly 50% said their practices were looking to fill a dental-assisting position, and 67% said it has been harder to do so than before COVID-19.⁴

“The No. 1 reason assistants are choosing to move on from the profession is lack of pay and benefits and lack of respect,” says Tija Hunter, CDA, EFDA, director at Dental Careers Institute and editorial director of Dental Assisting Digest. She also cited “pain, exhaustion, long hours, burnout, and poor professional advancement” as other reasons assistants have stepped away from dentistry.

Not surprisingly, many of these same reasons hold true for dental hygienists who have chosen to leave the profession. One main difference between the 2 professions is that one is mandated to be regulated by dental boards in every state while regulation of the other varies greatly by state.

Dentistry became regulated in the United States at the end of the 19th century.⁵ In 1915, Connecticut amended its dental practice act to include the regulation of dental hygienists, and not long afterward, other states followed suit by enacting dental hygiene laws and regulations under their own dental practice acts.⁶ By 1952, all states—48 at the time—required dental hygienists to be licensed.

Dental licensure for dentists and dental hygienists is mandated in each state and is regulated, with a few exceptions relative to dental hygiene, by the state dental board, which may be granted authority under state law to define qualifications for licensure, establish standards of practice and conduct, issue licenses to qualified individuals, and protect the public from harm by taking disciplinary action against those licensees who engage in misconduct.

Dental assistants perform highly technical work under the supervision of dentists. In addition to laboratory functions and nonclinical administrative duties, dental assistants provide direct hands-on patient care, perform radiography procedures, and are often responsible for office infection control and the sterilization of dental instruments. These are functions that directly impact patient safety.

The scope of allowed dental-assisting duties varies considerably from state to state, and as a result, there is no national consensus around what dental assistants should be allowed to do and no uniform national understanding of what the minimum requirements should be for dental assistants to perform the duties delegated to them. In some states, a dental assistant may perform specific intraoral functions after receiving only on-the-job training, and in other states, performance of the same function may require education and a license, registration, or permit.

A license is a state’s grant of legal authority to practice a profession within a designated scope of practice. It is required in order to practice or to call oneself a licensed professional. Health care licensure and registration establish that those who practice health professions have completed a minimum level of education and training to ensure public health and safety are protected.

Given that dental assistants are performing direct hands-on patient care and tasks critical to patient health and safety, prudence suggests state policymakers would want the dental board to maintain some sort of record of dental assistants who provide such services to ensure the standard of care is being met.

An answer that several states have come up with to monitor dental-assisting professionals is to require registration. According to the Institute for Credentialing Excellence’s Basic Guide to Credentialing Terminology, 2nd Edition (December 2020), “Registration is the process by which a governmental agency grants a time-limit status on a registry, often determined by specific requirements (eg, experience, education, and/or examination) and often authorizing those individuals to practice—similar to licensure.” States that register dental assistants maintain this list of individuals who are qualified for certain tasks. Registration also allows state dental boards to charge a fee for registration, which helps offset board expenses.

Some states recognize or require passing DANB exams and/or holding DANB certification to meet registration requirements or in lieu of or in addition to passing a state-specific exam. Where registration is not required, some states require dental assistants to earn a national certification, such as DANB’s certified dental assistant (CDA) certification, before performing certain tasks, and other states may require 1 or more state certificates or permits in specific functions.

Many states require dental assistants to achieve certification, certificates, or permits before exposing radiographs, providing coronal polishing procedures, monitoring the administration of nitrous oxide/oxygen, and performing other hands-on duties authorized in the state. Other states choose to defer the responsibility of monitoring and oversight of dental assistants to the supervising dentist. Unfortunately, sometimes this is not always in the best interest of the public.

A prime example of this relates to one of the duties of a “basic” Georgia dental assistant who, after acquiring appropriate training, may perform a phlebotomy (a blood draw from a vein) and “venipuncture” for the purpose of initiating an intravenous (IV) port for patients undergoing sedation. During the November 14, 2014, Georgia Board of Dentistry meeting, when queried about its definition of “appropriate training,” the board determined it was up to the dentist or doctor to decide.⁷

Under Georgia Board Rule 150-9-.01 for General Duties of Dental Assistants, Georgia dental assistants are not required to have formal education, specific training, or even a cardiopulmonary resuscitation certificate. As such, many dental assistants in the state are trained “on the job.” The concern with the Georgia board’s response about “appropriate training” for the provision of phlebotomy and venipuncture was that a supervising dentist might interpret the rule to allow on-the-job training for these medical procedures.

Data provided by DANB indicate that, among 8 US states that expressly addressed the initiation of an IV line by dental assistants in their statutes or rules, Georgia was the only state to authorize a dental assistant to initiate an IV port without having received specific training or earned a state dental-assisting credential.⁸

In 2015, the US Supreme Court held that state dental boards and other occupational regulatory boards must be actively supervised because they are comprised mostly of active market participants (that is, in the case of dental boards, actively practicing dentists) and run the risk of “confusing their own interests with the state’s policy goals.”⁹ In 2010, the Federal Trade Commission (FTC) brought a suit against the North Carolina State Board of Dental Examiners, stating the board was motivated by financial self-interest when it sought to prevent nondentists from offering cosmetic whitening treatments at cheaper prices.¹⁰ The Supreme Court said it took up the case to try to decide when a state licensing board “is regulating to serve the public interest and when it is acting to protect the private interests of its licensed members.”¹¹

Almost all dental boards in the United States develop standards of professional conduct, including continuing education requirements to maintain a high level of integrity and performance in the practice of dentistry. However, according to FTC records, a number of regulating dental boards have overstepped their authority by making decisions not to “protect the public,” but to protect the special interest group they represent.¹² In March 2020, USA Today published an extensive article on state dental boards that showed they rarely sanction dentists for wrongdoing.¹³

Nearly all dental clinicians know the difference between right and wrong, but some just don’t care because they do not have a license to lose. For example, there are Atlanta dental assistants advertising power chain braces, deep cleanings, teeth whitening, and tooth-filing services.

Fashion braces are not just a trend. These services provided by unqualified dental assistants are occurring across the country and may be harmful to the public at large. Unfortunately, in states where dental assistants are not regulated, dental boards are often unable to take any action in these matters.

Dental assistants are vital members of the oral health care team and, as such, should have some form of recognition of their qualifications and competence via registration and/or certification, as well as board oversight and regulation.

Although many dental assistants earn certification or a certificate of knowledge-based competence because it is required by their state, many do not. According to DANB, approximately 11% of dental assistants are DANB certified, although many more hold DANB certificates of knowledge-based competence. DANB offers opportunities for dental assistants to earn CDA certification or certificates of knowledge-based competence in a number of areas such as radiation health and safety, coronal polishing, and infection control. DANB even offers more advanced certifications, such as certified preventive functions dental assistant and certified restorative functions dental assistant certification.¹⁴

In June 2020, theAmerican Dental Assistants Association (ADAA) submitted correspondence to state dental boards recommending a minimum standard of training and annual continuing education in infection control for all dental assistants be instituted to protect the public from harm.¹⁵ Unfortunately, the recommendation was met with resistance or fell on deaf ears in states that do not provide oversight of dental assistants. Although state dental boards may write rules for the scope of duties a dental assistant may provide, unregulated dental assistants are usually not required to take continuing education courses to stay current in dental materials, occupational safety, sterilization procedures, proper personal protective equipment, or standard infection control procedures.

The ADAA had this to say about some dental boards choosing not to regulate dental assistants: “It is possible that the costs of regulating the dental-assisting profession may be influencing decisions. If this is the case, the ADAA believes public safety and health outweigh the costs of regulation. There may also be lack of awareness when evaluating the important role filled by dental assistants in a dental team. Greater awareness recognizing the critical role of a dental assistant as a defender of public health is a fundamental step in helping dental boards understand that the regulation, education, licensing, and/or credentialing of dental assistants is necessary.”¹⁵

Dental-assisting education and certification are not just recognition of knowledge-based competence; professional credentials also provide the public with a sense of safety and well-being. When the most important job a dental assistant performs on a day-to-day basis is infection control to keep the public safe from unnecessary transmission and harm, isn’t it time for dental assistant education and regulation to become a priority for state policymakers and regulators?

References

1. Dental assistants: Occupational outlook handbook. U.S. Bureau of Labor Statistics. Published April 9, 2021. https://www.bls.gov/ooh/healthcare/dental-assistants.htm.

2. Dental hygienists: Occupational Outlook Handbook. U.S. Bureau of Labor Statistics. Published April 9, 2021. https://www.bls.gov/ooh/healthcare/dental-hygienists.htm.

3. Dentists: Occupational outlook handbook. U.S. Bureau of Labor Statistics. Published June 2, 2021. https://www.bls.gov/ooh/healthcare/dentists.htm.

4. Dental Assisting National Board, Inc. (2021). [Effects of COVID-19 pandemic on dental assistant employment]. Unpublished survey data.

5. Holly. The history of dentistry - advances in science and EDUCATION (19th century). Bell Family Dentistry. Published October 23, 2017. https://bellfamilydds.com/history-dentistry-advances-science-education-19th-century/.

6. Milling LA. Dental hygiene's grand history. rdhmag.com. Published July 1, 2010. https://www.rdhmag.com/career-profession/article/16407684/a-history-of-the-dental-hygiene-profession.

7. 2014 meeting minutes. Georgia Board of Dentistry. https://gbd.georgia.gov/2014-meeting-minutes.

8. 2020 State Career Ladder Templates. Dental Assisting National Board. September 2020.

9. NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS v. FEDERAL TRADE COMMISSION. (THE UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT 2014).

10. Westman-Cherry Gand M. Supreme court: Self-interested boards must be Actively supervised. Federal Trade Commission. Published February 26, 2015. https://www.ftc.gov/news-events/blogs/competition-matters/2015/02/supreme-court-self-interested-boards-must-be-actively.

11. Savage DG. High court considers if state boards serve public or limit competition. dailypress.com. Published October 14, 2014. https://www.dailypress.com/la-na-supreme-court-state-licensing-boards-20141013-story.html.

12. Newkirk S, Slim LH. Who is the dental board serving? rdhmag.com. Published February 13, 2015. https://www.rdhmag.com/career-profession/students/article/16405402/who-is-the-dental-board-serving.

13. Heath D. Dental boards rarely punish dentists for unnecessary treatment. USA Today. Published March 19, 2020. https://www.usatoday.com/in-depth/news/investigations/2020/03/19/dental-board-rarely-suspend-dentist-license-bad-dentistry/5014443002/.

14. Exams & Certifications. danb.org. https://www.danb.org/Become-Certified/Exams-and-Certifications.aspx.

15. American Dental Assistants Association. Call to Action. June 2020.