Volume 5, No. 1, October 2003
By Susan Reese, Techniques
Contributing Editor
Lending a Hand for Good Dental Health
We depend on dentists for our oral health needs, but dentists in turn depend upon the support of dental assistants, technicians and hygienists.
Here is something to smile about: Americans are not only living longer?they are living longer with their own natural teeth.
Advances in dental care and an increased knowledge about the direct connection between good oral health and serious health conditions such as strokes and heart attacks have made us more aware of the importance of maintaining this aspect of our good health.
So visits to the dentist have become a regular routine for most of us, and this, combined with our continued growth in population, means that dentists are busier than ever and they are relying more on their professional support staff to perform routine tasks. All of this adds up to greater career opportunities in the field of dentistry?and a greater need for training the dental office?s professional support staff.
In a dentist?s office, a dental assistant may be found working in the office, the laboratory or at the side of the dentist. Dental assistants prepare patients for examination and treatment, sterilize equipment, set up instrument trays and make sure the dentist has the patient?s dental records at hand. They may take and develop dental radiographs or x-rays. During procedures they may also assist dentists by handing them instruments and keeping patients? mouths clear by using suctioning devices. After the procedure, they may advise patients on oral health care.
The Bureau of Labor?s Occupational Outlook Handbook notes that, "Infection control is a crucial responsibility of dental assistants. Proper infection control protects patients and members of the dental health team."
Some dental assistants may have office duties such as scheduling appointments, handling billing and payments or ordering supplies. Others may have laboratory duties that include making casts of teeth or temporary crowns. While some offices may have a dental lab technician on staff, other offices might send prescriptions to a commercial dental lab.
Commercial dental labs employ dental laboratory technicians who fill prescriptions from dentists for crowns, bridges, dentures and other dental prosthetics. While many dental lab technicians learn on the job, there are also training programs at technical schools and community colleges for this field. These programs include courses in dental materials science, oral anatomy and fabrication procedures.
Certification in dental laboratory technology is offered by the National Association of Dental Laboratories? National Board for Certification. Certification for this field is voluntary and can be obtained for five specialty areas: crowns and bridges, ceramics, partial dentures, complete dentures and orthodontic appliances.
Additional education in business and management can help a technician who plans to open his or her own lab, which is one way dental lab technicians have reached their highest earning potential.
High school students planning for a career as a dental assistant should take courses in health, biology and chemistry. A high school career academy or tech prep program may allow students to begin preparing for certification as a dental assistant or to transition smoothly into a postsecondary training program.
According to the Occupational Outlook Handbook, states vary in their regulations and standards for dental assistants, but states that offer licensure or registration have a variety of schools offering courses that meet their requirements. These are usually 10 to 12 months in length. In two-year programs at community and technical colleges, students can obtain an associate?s degree.
The American Dental Association (ADA) notes that the best way to become a dental assistant is to receive formal education and recommends studying in a program accredited by the Commission on Dental Accreditation and based on the latest procedures and techniques.
Most dental assistants seeking to become nationally certified take the Dental Assisting National Board?s Certified Dental Assistant examination. They are eligible for the exam if they have completed a dental assisting program accredited by the Commission on Dental Accreditation. Graduates of non-accredited programs or individuals who only have on-the-job training must complete two years of full-time dental assistant work experience before they are eligible to take the national certification exam.
The ADA notes that dental assistants have one of the most diverse and interesting positions in a dental office, and the Bureau of Labor Statistics expects that employment for dental assistants will grow much faster than the average for all occupations through the year 2010. Dental assistants have become a valuable asset in dental offices across the country. In fact, the ADA notes on its Web site that, "Dental assistants may be the most valuable asset to a dental practice. In addition to performing technical duties, they play an important role in helping patients feel comfortable before, during and after dental treatment."
Patients who make frequent visits to the dentist for optimum maintenance of their oral health may find that they spend more time with the hygienist than with the dentist. Dental hygienists remove calculus, stains and biofilm from patients? teeth. They also do applications of cavity-preventive materials such as sealants and fluoride. In addition to patient screening and assessment, hygienists also counsel patients on oral hygiene practices such as tooth brushing and flossing. Counseling can also extend to the relationship between good nutrition and good oral health.
Since dental hygienists are licensed to perform different clinical tasks than dental assistants, the training required also differs. A minimum of two years of postsecondary education is required to become a dental hygienist, and the training includes laboratory, clinical and classroom instruction. For research, teaching or clinical practice in public or school health programs, a bachelor?s or master?s is usually required.
For those interested in entering a dental hygiene education program, the ADA suggests that high school courses such as health, biology, psychology, chemistry, mathematics and speech will be beneficial. Some programs prefer students who have already completed at least one year of college.
The program of study for dental hygienists will include subjects such as anatomy, physiology, chemistry, microbiology, pharmacology, nutrition, radiography, histology, periodontology, pathology, and social and behavioral sciences.
A dental hygienist must be licensed by the state in which he or she practices, which means graduating from an accredited dental hygiene school and then passing both a written and a clinical examination. The written exam is administered by the American Dental Association Joint Commission on National Dental Examinations, and state or regional testing agencies administer the clinical examination.
The training for this career can pay off with good working conditions and job security. According to the Occupational Outlook Handbook, dental hygienists are projected to be one of the 30 fastest growing occupations in the nation. There are opportunities for part-time work, flexible scheduling and good wages. Benefits are very good for hygienists who work for school systems, public health agencies and federal or state agencies, but may vary by dental practice setting. Not surprisingly, a 1999 Workforce Needs Assessment Survey by the ADA found that nine out of 10 full- and part-time dental hygienists received dental coverage.
If all of this isn?t proof enough that these are careers students could really sink their teeth into, then consider the personal rewards they can offer. The ADA cites personal satisfaction as one of the advantages of becoming a dental assistant or hygienist. This satisfaction comes from the trusting relationships established with patients and the providing of a valuable health care service.
A Promising Career Path
The journey to a rewarding career can begin in high school, and at an Ohio career center, the dental assisting program is the first step for many students. The path may then lead to training for an expanded function role or to dental hygienist training
The dental assisting program at Cuyahoga Valley Career Center (CVCC) in Brecksville, Ohio, is a highly successful cluster-based health program that is marked by high enrollment, retention and placement rates for its students. The performance of the students in the program consistently exceeds state benchmarks. These are some of the factors that earned the Cuyahoga Valley Career Center dental assisting program a designation as a national "Promising Program" by the National Dissemination Center for Career and Technical Education.
Among the replicable aspects that helped the CVCC dental assisting program achieve Promising Program status are the multiple career pathways; articulation agreements with local two-year and four-year postsecondary institutions; strong industry partnerships; effective strategies for enrolling, retaining and placing nontraditional and special needs students; and a strong community service component.
Lisa Sowinski is the CVCC dental assisting instructor, and she says she was both thrilled and honored to receive the Promising Program designation from the National Dissemination Center, adding that, "The kids were so excited!"
CVCC serves eight associated school districts in Ohio, which in turn serve 25 communities. The career center provides career and technical support for pre-kindergarten through postsecondary, but Sowinski?s program is made up of 11th and 12th graders.
She is the only instructor in the dental assisting program?although there are other teachers for subjects such as anatomy and physiology?and she has 24 juniors and 24 seniors.
She credits the support she receives from the school and the staff for helping her maintain a quality program for her students. "I have so much support from my colleagues and from the administration," says Sowinski. "My fellow teachers are super to work with."
Students in the dental assisting program learn chairside assisting, which includes identifying and transferring instruments, preparing tray setups, mixing dental materials, and exposing, processing and mounting X-rays. They study dental laboratory, in which they pour, trim and box diagnostic models; articulate models; construct base plates and bite block; construct acrylic temporary crowns and bridges; and prepare dies, carve wax patterns, invest and cast. They also learn computerized office procedures utilizing SoftDent Software. Their courses include anatomy, bacteriology, pathology, pharmacology and radiology.
With such a broad curriculum, Sowinski believes that it would be almost impossible to complete it all in only one year, but "two years is perfect."
As juniors, the students learn infection control, sterilization, laboratory procedures and fourhanded dentistry (two hands belong to the dentist and two to the assistant). They learn about the eight different dental specialties and get CPR and first aid training. They also learn employability skills and even do mock job interviews.
"Then as seniors," says Sowinski, "they eat, drink and sleep business administration and radiology."
In November, the seniors go to Case Western Reserve University where they work as assistants for the student dentists. It?s a two-week unpaid internship that provides invaluable experience for the CVCC students.
"When the students first go, they are scared to death," Sowinski says. "But then they don?t want to come back because they find out that they excel there."
The students have the opportunity to go through all eight of the dental specialties, and Sowinski explains how they might be working on root canals one day and on fillings the next day. After that, they might work with an orthodontist, then with an oral surgeon. She has found that the student dentists love having her students there because it gives them an extra set of hands, and they soon find that those hands have the skills to truly assist them in their work.
"By senior year," Sowinski says, "they know everything they need to know to work in a dentist?s office, but every dentist is different, and they find that out when they go to work with the student dentists."
There they have to learn flexibility. They may see that one dentist does a procedure differently than another dentist, and that?s okay. It?s the same procedure, just using a different technique.
The students have to keep journals in which they describe the cases they work on each day, which helps Sowinski follow up on their work. It also gives the students a record they can take home to show their parents. The dentists at Case Western add their comments in the student journals, and often these say things such as, "She is well rounded, excellent with dental skills and people skills."
"The students come from my classroom very well prepared to go to Case and apply what they have learned," notes Sowinski, adding that often the students are asked to come back.
Case Western is appreciative of the skill and professionalism that the CVCC students exhibit, and Sowinski is grateful for the opportunities the university gives her students. She has high praise for the university, saying that they are "...great to work with, absolutely unbelievable."
In January, seniors who have an A average and good attendance can go on early placement working in a dentist?s office. A student with a B average or less than perfect attendance will have to wait until the end of February.
Sowinski stresses professionalism and a good work ethic in her program and sees this as another opportunity to teach her students important life skills. "It?s a good incentive to make sure they?re on time and on task so that they can go into a job," she explains.
Her seniors also do special projects such as creating their own dental office. This is a 300-point project that ends up filling two five-inch binders.
Once a month she organizes an activity that includes both her junior and senior students. Sometimes it may be just for fun, as when she and her husband?and 48 kids?go cosmic bowling or out to dinner. Others are community service projects such as answering the phones for the public television station?s pledge week. They also feed the homeless, and then they have lunch together. Sowinski says that after seeing how little others may have, "You wouldn?t believe how thankful the students are for what they have."
The end of the year is marked by a pinning and capping ceremony?a lovely event featuring candlelight, a harpist and flautist. The juniors are capped by the seniors and Sowinski pins the seniors. The event takes four or five months to plan, and the students raise the funds for it themselves.
Every other year, Sowinski takes her students to Chicago for the mid-winter dental conference held there. The students get to do a lot of networking and learn about the advantages and disadvantages of new products. The seniors sit in on continuing education courses and then do a report.
The year that they don?t go to Chicago, Sowinski and her students go to Baltimore where they visit the University of Maryland dental school and the Samuel D. Harris Dental Museum. Like the pinning and capping ceremony, the funds for the trips are raised by the students through car washes, candy sales and an entertainment book. A lot of the students have never even been out of the state of Ohio before, so the trips are educational and exciting for them in many ways.
During one week in March, both juniors and seniors participate in the Tooth Fairy Program for preschoolers and kindergarteners in the eight school districts served by CVCC. Working from their own script, each class does a puppet show for the young children?and of course the Tooth Fairy pays a visit. The Tooth Fairy is actually one of the students in a prom dress; she is elected each year by the other students. Another popular character will appear each year?maybe Sponge Bob Square Pants or Scooby Doo?because Sowinski rents a character?s costume each year. The children get goody bags with coloring books, crayons and a toothbrush, and the parents have the opportunity to ask questions they might have, such as, "When will my child lose his first tooth?"
Sowinski comments that, "Students feel like a million bucks when they can answer the parents? questions."
If all of this sounds like a huge undertaking for one instructor, that?s because it is.
"It?s a lot of work," says Sowinski, "but so worth it. It may be a 24-hour-a-day job, but I love it."
She also spends time filling out a lot of paperwork because, as she puts it, "I?m big on scholarships."
Students who complete the dental assisting program at CVCC may continue to work in the offices of the dentists they went to work for during the summer (Sowinski tries to place them all in summer jobs), or they may decide to continue with their education. Sowinski says CVCC is known as one of the area?s "hidden treasures," so employers feel confident in hiring their graduates. Sometimes dentists hate to lose such valued employees and tell her they wish she wasn?t always pushing college, but the articulation agreements that CVCC has in place, in addition to a $500 tech prep scholarship, help students make the transition to postsecondary education.
Some CVCC students may return to Case Western Reserve University?where they got experience working with the student dentists?for expanded function dental assistant training. Others may go on to Cuyahoga Community College to become dental hygienists.
Whichever path they choose, they have embarked on a promising career with the education they received from CVCC?s Promising Program-designated dental assisting program?and its dedicated, hardworking instructor Lisa Sowinski.
Expanding the Role
In Ohio, if a dental assistant would like to expand his or her duties, then the Expanded Function Dental Assistant Program at Case Western Reserve University might be the place to turn.
In this nine-month program, students attend the university one day a week, which allows them to continue working in a full- or part-time job. When they complete the training and pass a licensure exam, the students become expanded function dental auxiliaries (EFDAs)?meaning they are licensed to do work that includes placing silver and bonded fillings in patients? teeth.
According to the Ohio State Dental Board, to be eligible for the program, students must be certified dental assistants or registered dental hygienists. As Shelly Feiwell, the director and the instructor for the Case Western Expanded Function Dental Assistant Program, says, the EFDA is "just a different pathway" for these trained professionals to follow in order to increase their abilities to assist the dentists for whom they work. Indeed, most of the students are already working for dentists who will use them as EFDAs when they complete the training and are certified.
"That?s what?s unique about the program," notes Feiwell. "We?re not training a lot of people who will then have nowhere to go."
There are three other schools in the state with expanded function dental assistant programs?Ohio State, Jefferson Community College and Sinclair Community College?but Case Western?s program is the largest. Feiwell has two classes, each with 20 students. There were 70 applicants to the program this year, and she usually sends out about 150 applications, so as she notes, "It?s a little competitive."
Since there is such a demand for the program, the school can be selective, so they give an entrance exam to help determine the applicants they feel will be the most successful in the program.
Those fortunate enough to be accepted into the Case Western program will be training in a new state-of-the-art center that just opened this year. The students begin by working on models and on simulators, but in the middle of the program they transition to working on human patients, both in the university?s dental school where they work with the senior student dentists and at neighborhood clinics in Cleveland where the school has affiliations.
Students come from all over the state of Ohio to train in the program at Case Western. Feiwell says that they are predominantly women?although she has two men in her next class?and they are of all ages. They may have been encouraged to pursue the training by dentists for whom they work, but Feiwell says that usually it?s something they decide on their own. They may have been working as a temp in an office that employed an EFDA, or they may have just read about EFDAs in a publication and decided they would like to pursue such an expanded role.
Feiwell has been teaching the Case Western program for five years, but it has been in existence since the early ?70s. "It began as a federal grant to address a workforce issue," she explains. "They wanted to train assistants to do more to help dentists. So the Ohio State Dental Board narrowed down the functions?they do mostly fillings. Once the grant ran out, it continued as a tuition-based program."
Although expanded function dental auxiliaries in Ohio currently must be certified, Feiwell says that there is legislation in the works to require licensure. Other states have on-the-job training for EFDAs, but Ohio is the only state now with formal training and state board exam requirements. However, that could be changing in the future, according to Feiwell. Michigan is working on formal training programs and exams and trying to pass legislation governing them. Pennsylvania, which currently only has on-the-job training, may be considering similar action.
Another Step Along the Career Path
A student who completes the dental assisting training at Cuyahoga Valley Career Center may also expand his or her role by entering the dental hygiene program at the Metro Campus of Cuyahoga Community College in Cleveland, Ohio.
The dental hygiene program at Cuyahoga Community College (CCC) is a two-year academic program and is fully accredited by the Commission on Accreditation of the American Dental Association. Requirements for entry into the program include completion of core courses with an overall GPA of 3.0 or better. The core courses are English composition, fundamentals of interpersonal communication, introduction to biological chemistry, anatomy physiology I, and applied algebra. The school also requires 20 hours of observation in a dental facility?with a strong recommendation that four to eight of those hours be in their own Metro Dental Hygiene Clinic?or verification of employment as a dental assistant.
During the first year of training, the student studies liberal arts, basic science and dental hygiene preparatory courses. The second year concentrates on dental hygiene courses.
In order to understand the relationship between general health and oral health, students in the CCC dental hygiene program study anatomy and physiology, public health, pharmacology, chemistry and nutrition.
As assistant professor in the CCC dental hygiene program, Michelle Florencki teaches dental radiology and dental anatomy to the students in their first term. The students learn about preventive oral health services, infection control and begin to work on manikins. They learn how to expose and process radiographs (X-rays).
"It?s a very rigorous process," says Florencki of the training, "and we tell the students that before they enter the program. There is a lot of course work, and a lot of the course work is in the sciences."
And then they have to be able to turn all of that knowledge into hands-on practice, or as Florencki puts it, "They have to transfer what they learn in class to their hands."
It?s important to be able to work well with your hands to become a skilled dental hygienist. "If you don?t have good control," comments Florencki, "then it?s probably not a good profession for you."
In the fall term of the second year, students get real-life practice when they see patients in the school?s Metro Dental Clinic, which is located in the heart of Cleveland. According to Florencki, the clinic sees between 1,500 and 2,000 patients a year, and some of the patients have been receiving treatment at CCC for many years because the fees are so reasonable. A visit that includes preventive dental care, radiographs, oral cancer exam, hard tissue exam, cleaning, oral hygiene instruction, fluoride treatment, nutritional counseling, and, if needed, referral to an appropriate source for treatment costs $10 for an adult or $6 for a child. Sealants are $1 extra per tooth. There are also treatments for periodontal conditions with referrals for follow-up care.
There are four registered dental hygienists in the clinic at any given time, along with one dentist. So all of the students? work is checked by someone with a current license.
But there is much more than just clinical instruction going on in a program such as this. As a front-line health care professional, the dental hygienist must understand and practice dental hygiene care ethics. That?s why CCC started a new course this fall to teach students how to interact with their peers, instructors, dentists and patients. Florencki says, "We thought there was a need to let them know what is expected of them in the way of professionalism."
There are now daily assessments to evaluate students on their function as an effective team member, maintenance of patient confidentiality, appearance and personal hygiene, how they maintain the condition of their unit and equipment, and time management. Students learn that how you treat a client is very important and to be aware of when a patient is in need of a doctor?s consultation.
Among the goals of the CCC program stated on the school?s Web site are "to graduate clinically competent and ethical dental hygienists prepared as primary oral health care providers while encouraging the development of individuals with a professional commitment to the caring, health-oriented career of dental hygiene," and to "inspire the dental hygiene student to assume a leadership role as a resource person within the community and to advance the profession of dental hygiene in a rapidly changing health-care conscious society."
Indeed, one role of the dental hygienist that is cited by many sources is the role as community educator and counselor on good oral health practices and nutrition. Community service activities are part of the dental hygiene program at CCC, but students are also required to do 15 hours of community service that goes above and beyond their regular clinical requirements.
There are plenty of opportunities for such service. Students may go to local schools to educate children or they may volunteer for one of the programs in which CCC participates. Among these are the national event known as "Give Kids a Smile"?in which CCC participated last February offering free dental screening for children?and "Seal in a Smile," which involves placing dental sealants that prevent dental caries on the teeth of children. CCC does at least one of these free events every year, notes Florencki, and they have participated in "Seal in a Smile" two or three times. She says that, in addition to the students, the volunteers include faculty from the school and local dentists, and contributions of money and products are solicited from industry sources.
After completing their classroom, clinical and community service work, students in the CCC program still cannot become practicing dental hygienists without passing two exams. Qualification for the exams means graduating from an accredited institution. The Northeast Regional Board Exam is a clinical exam in which students perform hands-on skills, but it includes a computer portion with questions. The other exam is a written national exam. Once the dental hygienist is licensed to practice, he or she must maintain that license with continuing education.
The efforts will likely be worthwhile, because the profession does have its advantages. Florencki calls it the perfect job as far as flexibility goes, and her graduates in the Cleveland area report they are earning salaries that range from $22 to $30 an hour.
Finding employment is another positive aspect of dental hygiene education. When asked about job placement statistics, Florencki responds, "Generally all students who want a job have one."
Dental Laboratory Technicians
With our improved dental health, there may be a decreased need for full dentures but an increased demand for bridges and crowns. If job opportunities exist for dental laboratory technicians due to a growing demand for esthetic dentistry, then why are students not flocking to training programs in the field? Christine Freese says it?s because most people simply don?t know about the field. So while most labs would prefer to hire someone who has already had technical training, there just aren?t enough graduates to fill the need.
Freese is an instructor in the dental lab technician program at Milwaukee Area Technical College, and she explains that impressions are taken in the dentist?s office and then are sent to the lab where the dental prosthetics are actually made.
"Consumers don?t go to the dental lab themselves," says Freese, "so they don?t know what a dental lab technician does. "
The dental lab technician program at Milwaukee Area Technical College (MATC), which dates back to 1966, used to be a two-year associate degree program, but like many others in the country, it is now a one-year technical diploma program. The majority of the students do not come to the program straight from high school; instead it seems to attract more people in their 20s and 30s, either because they have found themselves unemployed or are looking for a change in career. The one-year program means they can get back into full-time employment?and a full-time paycheck?more quickly. And since the classes are held Monday through Thursday from 8:30 a.m. to 12:30 p.m., most students are able to hold down a job while completing the training. The program includes both classroom lecture and lab work, but the first four weeks focus strictly on dental anatomy. From learning dental terminology and anatomy, the students progress to dental materials, crown and bridge, ceramics and fundamental dental laboratory concepts.
MATC has a well-equipped dental lab where students acquire the necessary hands-on training. They don?t work on anything that will go directly to a patient, but instead use models, either purchased from a company or donated by dentists.
This type of training helps the students perfect their skills before filling actual prescriptions. "They can make their mistakes at school," says Freese, "So when they are working in the real world, they can keep mistakes to a minimum."
It helps to have artistic ability and good manual skills if you want to be a dental lab technician. However, notes Freese, "You can?t just be good with your hands and do the work. You have to know why you?re doing it, and you have to be able to troubleshoot."
That?s why employers are so happy to have graduates of programs like MATC?s. Some of the students even work part time in labs while they are in school, and their training can enable them to move into management positions. It can also lead to self-employment and financial success.
"I have a handful of students every year who know they want to be their own boss," says Freese. "So they work for a few years at a lab, get some experience and then open their own business. Many of our students over the years have started their own labs, and they can really be successful."
