Economic engine

What is an EFDA?

Expanded Function Dental Auxiliaries (EFDAs) are associates with advanced training and the ability to perform certain procedures in a dental office.  This format allows more patients to be seen, while maintaining a high standard of care.

What duties would an EFDA perform?

Dentists would have the power to delegate the following duties to an EFDA:

  • Placement and finishing of restoration material after decay has been removed by the dentist
  • Sealants
  • Coronal polishing
  • Impressions
  • Temporizations
  • Packing cord
  • Removal of cement from crowns
  • Adjustments to dentures and other removable oral appliances
  • Removal of sutures and dressings
  • Scaling (Note: This procedure has been on the list in the past, but the Wisconsin Dental Association may not include it due to Wisconsin Dental Hygienists’ Association opposition.)

What kind of education would an EFDA have?

The WDA supports legislation to require a minimum of 70-90 hours of training, including both didactic and clinical training. The WDA would also support legislation that sets these basic requirements for entering an EFDA training/certification program: Dental assisting experience of 1,000 hours (approximately 1 year) plus be a Certified Dental Assistant (this is a national certification) or 2,000 hours (approximately 2 years) of dental assisting experience with confirmation of those hours by a licensed dentist. (A variation of this certification program currently exists in approximately 25 states). This education would take place through an accredited technical college program.

Why is the WDA proposing EFDAs? Why now?

EFDAs have been a part of the WDA legislative agenda for over 10 years, since 2006. In the current workforce climate, we realize that while Wisconsin has an adequate supply of dentists, there are still populations who are chronically underserved. We believe EFDAs is a way for dental practices to increase capacity, help the underserved, maintain quality of care and keep the dentist at the head of the care team. This team format works in more than 25 states and the military.

Why not mid-level providers or dental therapists?

The short answer is that EFDAs are the only workforce model that is successful in multiple states and does not require government subsidy. Dental therapists exist only in Minnesota and after more than five years of the program’s existence, Minnesota has seen no discernible change in the number of Medicaid patients being seen. In fact, Minnesota’s access numbers are so low that their Department of Human Services was recently ordered by the Centers for Medicare and Medicaid Services to come up with a plan within 90 days to increase the number of children in Medicaid program being seen or risk being judged out of compliance with federal law. Gov. Mark Dayton has, correspondingly, included a 54 percent increase in MA reimbursement rates in his state budget proposal.

Other countries, particularly Canada and New Zealand, have tried the dental therapy model. New Zealand has the longest-running program in the world, but relies heavily on government subsidy. In the 1980s, Canada began a dental therapy training program with the intent that it would be self-sufficient and no longer require subsidy after a number of years. However, the Canadian government pulled the plug on the program in 2011 after discovering that it was not financially viable.

Dentistry’s impact on Wisconsin

One Wisconsin dentist employs approximately 4.1 staff (e.g., hygienist, dental assistant, office manager, billing person). Nationally, one hygienist is hired for every one dentist, compared to 1.5 hygienists for every one dentist in Wisconsin.

  • Each of Wisconsin’s 72 counties has at least one or two practicing dentists and the vast majority have many more.Dentistry’s small-business model makes it feasible to establish practices in rural and urban communities where there is sufficient economic demand. The percentage of a county’s population enrolled in Medicaid – which greatly reduces consumer demand for dental care – challenges dental practices’ financial survival.Dentistry’s economic impact on Wisconsin is currently estimated at $2 billion.A small business dental practice can have a direct economic impact of approximately $442,000 on a community. When combined with $206,000 of indirect impact and $629,000 of induced impact, total local economic impact of one dental practice can reach $1.2 million.Per capita dental care spending is currently about $389. It is expected to rise to $525 by 2020.

    Costs of establishing a dental practice

    According to contacts at two large financial lending institutions, the average cost for designing and equipping a dental office within leased office space is about $350,000 or approximately $75,000 – $100,000 for every clinical room/dental operatory in the practice.

    Building a new clinic, which includes owning the land and the structure, costs about $200 per square foot or $400,000 for an average 2,000 square foot office.

    These prices depend on the value of the real estate and include some of miscellaneous start up costs, such as legal consultation and supplies. These figures can go higher based on the technology installed by the equipment vendor.

    In addition to the loan, banks recommend a line of credit of $25,000 – $75,000 to help with cash flow and enable dentists to pay bills while building a patient base.

    Acquisition of an existing practice in Wisconsin usually involves a 50 percent buy-in arrangement. The cost would be $350,000 to $400,000 for a practice producing $1 million to- $1.2 million in gross revenue.

    Community Dental Health Coordinator (CHDC)

    This model was developed by the American Dental Association with the understanding that the best way to decrease the disease burden among the low-income population is not to create more providers who can pull diseased teeth or fill cavities but to empower the patient population to take better care of their own oral health through education. This CHDC is also modeled after the well known and successful community health worker model in medicine.

    The CDHC educational program would consist of an 18-month training program after high school.  The concept is to recruit students that come from low-income communities to encourage them to go through the program so that they can go back to their communities and help others improve their oral health.

    The services they could be delegated to provide (by an authorizing dentist) would include:

    • Patient education;
    • Fluoride treatments;
    • Sealant placement;
    • Placement of temporary restorations (this would not include the drilling out of decay but excavation with a hand instrument followed by the placement of temporization material)
    • Coronal polishing;
    • Selective scaling for Periodontal Type I patients;
    • Collection of diagnostic data for the dentist’s use;
    • Liaison between prospective patient and treating dentist.

    The ADA has conducted pilot projects for this model with urban areas, rural areas and Native American tribes in different places in the United States and there has been one that has been employed through the Oneida tribal clinic in the Green Bay area for some time.  The CDHC that works at Oneida is also a dental hygienist so there is an opportunity to utilize the skills of a dental hygienist who would also be attracted to working in certain community health settings.

    The important component of the CDHC is to reach people where they are and not anticipate that they will seek out care in a dental office for the dentist and the staff to educated them in the practice but to educate them and provide basic services to them in community locations and then to tie back to a dental clinic for restorative and other comprehensive care needs.  The Oneida tribe is very pleased with the work that is provided by this CDHC and there is some potential for the WDA to learn from their experience to develop this model into one that can be more fully implemented in other areas of our state while also upholding the standard and quality of dental care for the public.