Summer 2001 Editorial:

When I graduated from UCSF in 1968, I applied for an associate position in my hometown where the orthodontist was seeing 15 patients per day, using one assistant - and he was making a living.

He was using some preformed bands, welding molar attachments, and there were no pre-adjustments in any of the brackets. Fees were $1,800 per permanent dentition case.

In our office we have two registered dental assistants and see 55 patients. The appliances are more sophisticated, but less technically demanding. While inflation has increased tenfold, fees have not. The fact that we can see more patients per day has made orthodontics a much better value for patients.

Curious about the use of dental assistants in orthodontics, I sent a short survey to orthodontists in several PCSO states and provinces. There are some interesting differences.

A Look at Other States

Alaska has the least government control. Assistants are not certified and the orthodontist takes responsibility for training and the level of duties and tasks assigned.

There are training programs, however, and graduates are offered higher salaries than untrained applicants for assisting positions. While the orthodontist can freely delegate, supervision in the treatment area must be direct.

Dr. Rebecca Poling says that a trained assistant earns a full-time salary that is about four times the cost of a one-bedroom apartment, and that competent assistants are not overly difficult to find.

California and British Columbia have similar programs for assistant certification. In BC, for general dentistry assisting, students study for one year and then take a licensing examination.

Dr. Robin Jackson told me that to obtain an orthodontic certificate, assistants must take an additional module to be allowed to place separators, polish teeth, fit bands (not cement), and place bonds (without curing) - all under direct supervision.

California has a similar licensing exam for the registered dental assistant, but no required specialty module. In California, the monthly salary might be five times the rent for a one-bedroom apartment. In both BC and California it may be difficult to find a credentialed assistant. Continuing education is required.

Oregon has a certificate program for radiology, and for expanded orthodontic assisting. Students are also required to take an ADA-approved, dental assistant training course.

In addition to the usual tasks, graduates can recement loose bands and scale cement from the teeth and appliances if under direct supervision. When the orthodontist is absent, they can also remove parts of the appliances that are causing the patient pain.

The Dental Practice Act states that assistants may perform any duties except prohibited duties. This important use of language differs from that used in other states and provinces. Prohibited duties include adjusting wires or appliances in the mouth, using high-speed handpieces, and many others, but the orthodontist has leeway to allow any unlisted procedures. Dr. Parker Fuhriman tells me that the rent-to-salary ratio is about 1:4, and that certified assistants are somewhat scarce in urban areas.

Washington does not provide certification. Orthodontists have the responsibility to assign duties, although assistant cementation of attachments or bands is prohibited. Removal of composite is okay with hand instruments, but not rotary.

As in California, assistants may take impressions for study models, but not for oral appliances. Training programs for orthodontic assistants are lacking except for the annual WSSO assistant CE program. A typical salary pays about 20% of a one-bedroom rental.

Dr. Rod Dubois pointed out the conundrum that while certification may stimulate more training outside the office, it limits employment opportunities and increases salaries. I also think that urban density leads to more regulations, especially if the public has had bad experience with irresponsible or unprincipled professionals. In states with large urban populations, politicians are tempted to solve service problems with regulations rather than engaging professionals in the solutions.

In the PCSO, assistant certification varies considerably. It appears that certification does lead to higher salaries and a tighter job market. I also think it sets the stage for higher job satisfaction and professional confidence.

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