The Future Dental Auxillary Is Here

Joe Zuaro, DDS


You step into your operatory and greet your patient. Then, the local anesthetic is administered and allowed to reach a profound state. Next, you prepare the teeth to completion, then, here is where things change. Your assistant slips on a pair of loupes and takes a seat in the operator stool. You then leave the operatory, turning the placement and completion of the restorations over to your highly trained dental professional who is an expanded function dental assistant (EFDA).

This professional, arguably the most misunderstood and underutilized dental auxiliary, takes over the most time-consuming part of the procedure while you see to the needs of a patient in the next operatory. This allows the clinician the time to perhaps prepare more teeth, do some surgery, or perform any number of other tasks. When the EFDA has completed the restoration placement, you are summoned back to the operatory to check the final results before dismissing the patient. In this way, the successful collaboration between 2 dental health professionals accomplishes more than just a procedure well done; the EFDA advantage can take dentistry to a new level of productivity, patient care, and professional satisfaction.

Dental auxiliaries have been around for many years. At some point, a dentist decided he was tired of cleaning his own instruments and found someone to help with that. As time went on, this individual was given more tasks, and eventually the modern dental assistant evolved to a licensed auxiliary. It was Dr. Alfred Fones, in the early 1900s, who had a vision for preventive services in dentistry and trained his assistant to clean teeth. He started the first dental hygiene school in Connecticut in 1913. However, as integral as dental hygienists are to dentistry now, it took a long time for them to be fully accepted as a part of the treatment team in the profession. As with other advancements in dentistry, the evolution of dental auxiliaries continues, so that the changing needs of patients and dentists can be met with innovative practices.

To become an EFDA, a dental assistant or hygienist must meet rigorous requirements, including the successful completion of an accredited EFDA course to obtain state licensure. Then, the EFDA must work to maintain licensure by taking regular mandatory continuing education. Not all states permit EFDAs, but the specialty is being seriously looked at as an alternative to the dental therapist. Procedures that an EFDA can perform are all reversible, and all clinical tasks must be prescribed and checked, upon completion, by a licensed dentist. Permitted procedures vary slightly from state to state, but the following are the basic tasks that an EFDA can perform in addition to those of a certified dental assistant or a dental hygienist:

  • Placement of dental medicaments
  • Placement of dental restorations (amalgam, composite resin, and glass ionomer)
  • Adjustment and polishing of restorations
  • Cosmetic mockups for aesthetic demonstration.

EFDAs cannot diagnose or perform any irreversible procedures, and it is important to note that the dentist is ultimately responsible for any procedures completed by the EFDA.

Having an EFDA adds flexibility to the doctor’s schedule. Preparing a tooth for a restoration may be the most intense part of the procedure, but placement of that restoration is often the most time-consuming part. With this newfound time in the schedule, the doctor can now do any number of things, from seeing a patient in another operatory to doing a hygiene check, or simply taking a break from clinical work for administrative tasks.

In addition to freeing up time in the dentist’s schedule, there are many advantages of having an EFDA. A clinician can practice longer before retiring when the most common procedures become less strenuous when using an EFDA. A dental office can also consider decreasing hours without decreasing production. Our profession can better address access-to-care issues by increasing production, which results in more patients being treated at a reduced overhead. All the dentists that I have spoken to agreed that the biggest advantage of employing an EFDA is the marked reduction of stress in the practice.

Profile of a Successful EFDA
The interpersonal skills of an EFDA are key. An EFDA must have good communication skills and be comfortable interacting with a wide range of patients. Procedures need to be explained so they are easily understood by the patient. Successful EFDAs have a positive attitude and are eager to learn and enjoy new challenges with a commitment to the dental profession and to their continuing education. Most EFDAs come from a dental assisting background; however, a significant number were also originally trained as dental hygienists. In all cases, these professionals want to increase their skill set and value to the practice.

The success of the EFDA does not just rest on the shoulders of the individual. The entire practice team needs to be invested in the concept. Once the dentist has a positive vision of how the EFDA fits into the office, that vision is then brought to the staff. The front desk and the other auxiliaries need to be confident that having an EFDA is a positive part of the practice. The dentist, as the practice leader, becomes a coach and mentor for the EFDA.

Patient Acceptance of an EFDA
Patient acceptance relies heavily on the confidence the doctor and staff have in the EFDA. The way an EFDA is introduced to a patient is of paramount importance. The procedure to be completed by the EFDA should be discussed in technical terms, in front of the patient. The patient needs to be assured that the doctor will return to check the completed work. The doctor should honestly evaluate and compliment the treatment when deserved. Adequate time needs to be given for the EFDA to complete the treatment, so there is no perception of being rushed. If patients have confidence in the practice, they will also have confidence in the EFDAs who treat them.

EFDA Dental Practices
EFDAs are found in many different practice situations; in both single- and multiple doctor practices. Doctors who prefer to spend more time speaking with their patients find that EFDAs help them stay on schedule. In a practice that is too busy for just one dentist but not busy enough to take on an associate, an EFDA position could be a great solution. A dentist may have an EFDA because he or she is not ready to retire, but wants to cut back without having to sacrifice income. In a cosmetic practice, an EFDA would be instrumental in doing intraoral composite mockups for patients who are interested in improving their smile. For high-production practices, one dentist can utilize several EFDAs to increase patient flow, better serving a lower fee demographic.

A dental therapist can perform certain dental procedures without direct supervision of a dentist. Examples of these procedures are diagnosis, tooth preparation for restorations, placement of restorations, and simple extractions. I had not heard the term simple extraction until the advent of the dental therapist. The development of this subspecialty in dentistry was to address the problem of dental access. The 2 major reasons for the documented access-to-care issues in the United States are logistics and finances. In some remote parts of the country, people have to travel great distances to see a dentist (defined as more than 2 hours by car). Most practices have patients who are willing to travel an hour or 2 to be treated while they may have a dentist closer. This is because their trust in a particular practice makes the trip worthwhile for these patients. If there is a population center that has no dentist, and distance poses a barrier to its dental treatment, perhaps a dental therapist is indicated. As for issues where there are an adequate number of dentists in an area but a population is underserved due to income, a practice with several EFDAs might be more appropriate. When one dentist can triple the number of operative patients who can be treated, a practice can thrive even with a lower reimbursement for services rendered.

A high-volume practice of low-reimbursement patients is not for every dentist. However, for those dentists who make this their calling, this clinical business model can be very rewarding. These dentists should be held in high regard.

So next time you find yourself at the end of a work day after being swamped with operative dental procedures, and you and your back are tired from doing it all yourself, it might be time to think more about the EFDA advantage.

Dr. Zuaro received his DDS from the Georgetown Dental School in 1976 and is a past member of the ADA and Vermont State Dental Society. Currently, he is the lead instructor for the Vermont Expanded Function Dental Assistant (EFDA) program as well as consulting with schools on starting EFDA programs and with dental groups and practitioners on how to utilize EFDAs. He is a recipient of the United States Public Health Service Commissioned Officer Award. He can be reached at

Disclosure: Dr. Zuaro reports no disclosures.

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