DENTAL AUXILIARIES

CONTENTS

• INTRODUCTION
• DEFINITIONS
• TYPES OF DENTAL SERVICES
• CLASSIFICATION OF DENTAL AUXILIARIES
• NON OPERATING AUXILIARIES
o DENTAL SURGERY ASSISTANT
o DENTAL RECEPTIONIST
o DENTAL LABORATORY TECHNICIAN
o DENTAL HEALTH EDUCATOR
• OPERATING AUXILIARIES
o SCHOOL DENTAL NURSE
o DENTAL THERAPIST
o DENTAL HYGIENIST
o EXPANDED FUNCTION DENTAL AUXILIARIES
• NEWER AUXILIARIES
o DENTAL AIDE
o DENTAL LICENTIATE
• FRONTIER AUXILIARIES
• FOUR HANDED DENTISTRY
• CONCLUSION
INTRODUCTION

Dental auxiliary is a generic term for all personnel who assist the dentist in treating patient. In
Britain, they have been known as “dental ancillaries, the word auxiliary means, being helpful,
subsidiary; whereas ancillary means subservient subordinate.

DEFINITIONS

AUXILIARY (WHO):

Is a technical worker in a certain field with less than full professional training.

AUXILIARY WORKER (WHO):

Is one who has less than full professional qualifications in a particular field and is supervised
by a professional worker.

DENTAL AUXILIARY:

Is a person who is given responsibility by dentist so that he or she can help the dentist render
dental care, but who is not himself or herself qualified with a dental degree.

TYPES OF DENTAL SERVICES (ADA)

Type I: Dental services are provided by dentists and dental auxiliaries and financed directly
by consumer or through NGO’s.

Type II: Dental services are provided by dentists and dental auxiliaries who are partly or
entirely remunerated by government but who are not considered to be government
employees.

Type III: Dental services are provided by dentists and dental auxiliaries who are employed
by government.
CLASSIFICATION:

WHO CLASSIFICATION 1967

1. Non – operating auxiliaries

Clinical: is a person who assists the professional in his work but does not carry out any
independent procedures in the oral cavity.

Laboratory: Is a person who assists the professional by carrying out certain technical
laboratory procedures.

2. Operating auxiliary

Is a person who, not being a professional is permitted to carryout certain treatment

procedures in the mouth under the direction and supervision of a professional.

REVISED CLASSIFICATION:

Non –operating ancillaries

1. Dental surgery assistant

2. Dental secretary/receptionist
3. Dental laboratory technician
4. Dental health educator

Operating ancillaries

1. School dental nurse

2. Dental therapist
3. Dental hygienist
4. Expanded function dental ancillaries
WHO CLASSIFICATION (OXFORD HANDBOOK OF CLINICAL DENTISTRY)

Non-operating auxiliaries:

1. Type I- dental technician

2. Type II- dental nurse
3. Type III- dental preventive worker

Operating auxiliaries:

1. Type IV- hygienist

2. Type V- dental therapist

CLASSIFICATION BASED ON LENGTH OF TRAINING

Jeboda (1982) suggested a classification based on that adopted by WHO (1968) in New
Delhi. He recognized the following categories:

1. Long term trained (2 to 4 years)

2. Short term trained (4 to 6 months)

NON-OPERATING AUXILIARIES

DENTAL SURGERY ASSISTANT

Is a non-operating auxiliary who assists the dentist or dental hygienist in treating patients, but
who is not legally permitted to treat patient independently.

The concept was introduced by Dr. Edmund Kells of New Orleans (U. S. A.), in 1885, by
hiring a woman as ‘lady in attendance’ during treatment of female patients. Apart from being
surgery assistants, the also take care of the house keeping functions at the dental office. Their
functions include reception of the patient, preparation of the patient for treatment,
arrangement of all necessary armamentarium, sterilization and infection control, mixing of
restorative materials, impression materials, documentation, x ray assistance, post operative
patient instructions.

Klein [1944] found that addition of one dental assistant increase the number of patients
treated by a dentist by 33% if he were using one chair and by 62% if he were using 2 chairs.

This evolved into a concept called as four-handed dentistry which is widely in practice. This
contributes to decreased, stress, ease of treatment and increased quality of patient care.

Indian Scenario

Dental Operating Room Assistant (DORA) is a person, not being a dentist or Medical
practitioner who assists the dental surgeon in sterilizing and at the chair side by supplying
instruments, handling various dental materials and medicines as required by the Dental
Surgeon. The eligibility is 10+2 pass/equivalent with science subjects (physics, chemistry and
biology) from recognized Indian university/pre-university. The course duration is 2 years.
The scope of the profession includes job opportunities in dental colleges, dental clinics and
dental laboratories.

DENTAL SECRETARY/RECEPTIONIST

A dental secretary or receptionist is responsible for administering the day-to-day activities of

the dental office that include maintenance of patient records, scheduling of patient
appointments, management of accounts pertaining to dental office, maintenance of office
records, presentation of financial treatment plan options, and maintenance of recall system.
The receptionist should possess good interpersonal skills to maintain effective rapport with
patients, dentists, other staff members and community. Effective verbal skills to communicate
with patients and staff are also a mandatory requirement.
Indian Scenario: Although dental receptionists are a common place in dental practice in
India, however no specific qualification requirements exist currently.

DENTAL LABORATORY TECHNICIAN

Is a non-operating auxiliary who fulfills the prescriptions provided by dentists regarding the
extra-oral construction and repair of oral appliances and bridge – work. They are also known
as dental mechanics. Dental technicians undertake mechanical tasks, many of which are time
consuming and some of which the dentist has not himself been trained to carry out. Their
functions include casting of models from impressions made by the dentists and also
fabrication of dentures, splints, orthodontic appliances, inlays, crowns and special trays.
Dental laboratory technicians get training from dental teaching institutions. The certified
course duration can range from 2 years (full time) to 5 years (part time).

Indian Scenario: As per the Indian Dentist Act of 1948, dental mechanic is a person who
makes / repairs dentures of dental appliances. Dental Technician/Mechanic course is provided
in about 25 dental colleges in India. The eligibility is 10+2 pass/equivalent with science
subjects (physics, chemistry and biology) from recognized Indian university/pre-university.
The course duration is 2 years. The scope of the profession includes job opportunities in
dental colleges, dental clinics and dental laboratories.

DENTURISM

Denturist in the United States and Canada, clinical dental technician in the UK or
(in Australia) a dental prosthetist, is a member of the oral health care team who provides an
oral health examination, takes impressions of the surrounding oral tissues, constructs and
delivers removable oral prosthesis (dentures and partial dentures) directly to the patient.
Denturism is also active in countries like Denmark. However, this has drawn a major
criticisms from the American Dental Association claiming them to be illegal. Consumers, on
the contrary, have favoured denturism as they believe that they provide more personalized
service, more follow-up, and post-delivery care than most dentists are willing to provide.
Cost-effectiveness was also considered to be a factor.

DENTAL HEALTH EDUCATOR

Is a person who instructs in the prevention of dental diseases and who may also be permitted
to apply preventive agents intra orally.
In Sweden two additional weeks of training are given, after which ancillaries are allowed to
conduct fluoride mouth rinsing programmes to groups of school children
Indian Scenario: Dental health educator as an auxiliary is currently non-existent in India.
OPERATING AUXILIARIES

SCHOOL DENTAL NURSE

Colonel (Sir) Thomas A. Hunter, Director of the New Zealand Army Dental Service in the
1914–18 War proposed the idea of a dental school program staffed by young women trained
in preventive dentistry in 1921. In the same year, a dental school to train these dental nurses
opened in Wellington. The school was known as ‘The Dominion Training School for Dental
Nurses’

The New Zealand school dental service was a world-first, providing preventive dental care to
primary school children from clinics located on school grounds. Rather than take the children
to the dentist, the dentist was brought to the children. Considered impracticable by many, the
service was largely ignored internationally until it began to receive some international interest
for many decades until the 1960s and 1970s.

Thus, from 1921, and under the supervision of Sir Thomas Hunter, much of the responsibility
for the dental health of schoolchildren in New Zealand had been given over to school dental
nurses.

Her functions included oral examinations, cavity preparations and restorations (with copper
amalgam, silver amalgam, and silicate cement), preventive restorations, topical fluoride
application and pulp capping. She could also extract deciduous teeth, was responsible for oral
health education, and could refer children to dentists.

There was a significant change in the oral health conditions after the beginning of the School
Dental Nurse in New Zealand.

Indian Scenario: School dental nurses are absent in India.

DENTAL THERAPIST

This is a person who is permitted to carry out to the prescription of a supervising dentist,
certain specified preventive and treatment measures including the preparation of cavities and
restoration of teeth.
In Great Britain, during the First World War, 'dental dressers' were used to carry out
examinations and treatment for children in parts of England. Their role however, was
eliminated by the Dentist Act of 1921 because of hostility to the role on the part of the dentist
profession. They were later re-introduced, on the strength of the New Zealand scheme, as
dental therapists when the high dental needs of children were 'rediscovered' in the 1960s,
carrying out similar services but under the prescription of a dentist who carried out the
examination and care plan.

In the United Kingdom, dental dressers (as the equivalents of therapists were called) came
into being because of a shortage of dentists to work in the school dental service. The
auxiliaries based on the New Zealand type graduated in 1962 from the Erstwhile training
school, which was in the New Cross area of London. Hence, they were known as "New Cross
Auxiliaries". In 1979, in the U.K., the name auxiliary was changed to therapist. In Australia,
therapists the personnel categories who are derivatives of the New Zealand Dental Nurse
model - have been in service since 1966. They are like New Zealand type school dental
nurses but their role is quite different, as they are not permitted to diagnose and plan dental
care.

Dental therapists are no longer trained in Australia, and instead Oral Health Therapists are
being trained. An oral health therapist is trained as both a dental therapist and a dental
hygienist with a focus on health promotion and disease prevention.

The duties performed by the dental therapists include intra and extra oral assessment, scaling
and polishing, applying materials to teeth such as fluoride and fissure sealants, taking dental
radiographs, providing dental health education on a one to one basis or in a group situation,
undertaking routine restorations in both deciduous and permanent teeth, on adults and
children, extracting deciduous teeth under local infiltration analgesia

Indian Scenario: Dental therapists are non-existent in India.

DENTAL HYGIENIST

Is an operating auxiliary licensed and registered to practice dental hygiene under the laws of
the appropriate state, province, territory or nation. They work under the supervision of a
dentist.
In the late 1800s dental disease prevention methods became popular amongst dentists and
dental nurses, with dentists being trained to perform routine prophylaxis treatment in the fight
against dental disease. During this period D. D. Smith of Philadelphia demonstrated the
prophylactic methods to his colleagues and patients and the acceptance of his theories
become increasingly popular. In 1906 one of his followers Alferd C. Fones took a great
interest into Smith’s theories and began to train his cousin, Irene Newman, to act as an
apprentice, scaling and polishing teeth as well as giving instructions on how to keep their
mouths clean with daily home care practices. She became the first recognised dental
hygienist. In 1913 the term dental hygienist was devised and Alfred Fones began the first
school for dental hygienists in Connecticut. In 1914 the first legal dental hygienists graduated
from Dr. Fones’ dental hygiene program and legally allowed to provide patients with
prophylaxis treatment.

Their duties include oral prophylaxis, oral hygiene instructions, and demonstration of tooth
brushing techniques, topical fluoride and sealant applications. Dental hygienists are found in
USA, UK, Canada, India, Nigeria, China, Japan, Korea, Poland, Denmark etc.

Indian Scenario: The eligibility is 10+2 pass/equivalent with science subjects (physics,
chemistry and biology) from recognized Indian university/pre-university. The course duration
is 2 years. The scope of the profession includes job opportunities in dental colleges and dental
clinics.

EXPANDED FUNCTION DENTAL ANCILLARIES

Is a dental assistant / dental hygienist in some cases, who has received further training in
duties related to the direct treatment of patients, though still working under the direct
supervision of a dentist.

They are also referred to as Expanded function Dental Assistant, Expanded function dental
hygienist, Expanded function Auxiliary, Technotherapist, Expanded duty dental auxiliaries.

EFDA undertake reversible procedures, that is which could be either corrected or redone
without undue harm to the patient's health. They do not prepare cavities or make decision as
to pulp protection after caries has been excavated, but work alongside the dentist and take
over routine restorative procedures, as soon as the cavity preparation and base have been
completed. The first large-scale service applications of the expanded duty principle were
made in Philadelphia. They were called “Technotherapist”.

In an attempt of build a logical career structure for assistants and hygienists, four levels of
training and qualification were recognized by the Canadian province of Ontario (1974)

1) Certified Dental Assistant: Training course is of 8 months duration. Assistant is taught

traditional chair side duties Only intra oral duty was taking radiographs.

2) Preventive Dental Assistant: The trainer had to be a certified dental assistant. Full time
courses were of 3- 6 weeks duration. They were permitted to polish coronal portions of teeth
without instrumentation, take impression for study models, topically apply caries –
preventive agents, place and remove rubber dams

3) Dental Hygienist: A student has to the certified / a preventive dental assistant. The eight –
month training program allowed them to carry out scaling, conduct a preliminary
examination of oral cavity including taking a case history, periodontal examination and
recording clinical findings, provide complete oral prophylaxis including scaling, root
planning and polishing of fillings, apply and remove a periodontal pack, apply fissure
sealants.

4) Dental Hygienist with Expanded Duties: Training of 4 months duration was given to dental
hygienist who had at least 1-year practical experience. They were allowed to removing
sutures, place, finish and polish restoration of amalgam and resin, place and removing matrix
bands, placing cavity liners

NEWER DENTAL AUXILIARIES

These auxiliaries are recommended by the World Health Organisation in countries with acute
shortage of dentists. The two types suggested are – Dental Aide and Dental Licentiate

DENTAL AIDE

The work involves chair-side assistance, preparation of restorative materials and medications,
sterilization of dental instruments, laboratory work, patient scheduling, and record keeping.

Assists dentist chair-side by delivering and receiving dental instruments, restorative and
impression materials, and medications. Mixes and prepares the proper solutions, restorative
materials, and/or medications for the procedures to be performed. Cleans and sterilizes dental
instruments using an autoclave or cold sterilization technique. Performs laboratory work such
as preparing impression material, pouring impressions, preparing models, making base plates,
performing minor prosthetic repairs, trimming, and polishing prosthetics. Takes X-rays,
processes, labels, and stores X-ray film. Takes inventory of dental instruments and supplies.
Logs all treatment data and maintains patient records. Answers telephone and schedules
appointments. Orders necessary dental supplies. Performs related work as assigned.

Training lasts for 4-6 months, followed by a period of field training under direct and constant
supervision.

The Dental Health Aide (DHA) program, selects people with strong ties to their communities
and provides them with basic health care education. The DHA program includes 4 types of
dental care providers. The Primary Dental Health Aide (PDHA) concentrates on delivering
preventive services at the village level. The Expanded Function Dental Health Aide
(EFDHA) has an elevated skill set that enables their function under the direct or indirect
supervision of a dentist and their performance of simple to complex tooth restorations and
supra-gingival dental cleanings. The Dental Health Aide Hygienist (DHAH) is able to
administer local anaesthetic. The highest level of provider is the Dental Health Aide
Therapist (DHAT), a dental provider, similar to a Physician Assistant in the field of
medicine. While the DHAT is a new type of provider in the United States, DHAT-like
providers work in over 50 countries worldwide, including Canada and New Zealand..

Indian Scenario: No such auxiliaries are present in India

DENTAL LICENTIATE

Is a semi-independent operator trained for 2 years to perform dental prophylaxis, cavity

preparation and fillings of primary and permanent teeth, extraction under local anesthesia and
drainage of dental abscess.

FRONTIER AUXILIARIES

This concept was developed for use in countries where there existed an acute shortage of
dentists for providing oral care. The lay people preferably nurses and other dental assistants
are given a minimum training to take care of the basic oral health care needs. Training is
provided for handling emergency dental services, preventive care, first aid, simple denture
repairs.

FOUR HANDED DENTISTRY

Glene Robinsonin 1968, summarised the concept of four-handed dentistry: four handed
dentistry involves the coordinated work of both the dentist and assistant, working as a team to
perform those operations in a manner that has been carefully and deliberately planned. The
term “Four handed dentistry” was first recorded in the proceedings of a conference on
“training dental students to use chair side assistants” in 1960.

Four handed dentistry involves a vigilant study of all steps of office management to save time
and minimise stress associated with the practice of any form of conventional dentistry. It
implies that the dentist will discharge those obligations that only he can legally do and that he
will assign all other tasks to auxillary personnel.

Principles of four-handed dentistry:

This concept of delivering dental services consists of four basic principles:

1. Any sort of operation being done in a seated position.

2. Utilizing the skills if the dental assistant is skilled.

3. Organising every component of the practice.

4. Simplifying all tasks to the maximum.

Basic tenets of four-handed dentistry:

To practice true fourhanded dentistry, the following criteria must be met:

1. To minimize unnecessary motion, equipment’s must be ergonomically designed.

2. Both the operating team and the patient should be comfortably seated

3. Practice of motion economy should be done.

4. Pre-set cassettes/trays are utilized.

5. The dentist assigns all legally delegable duties to qualified auxiliaries based on the state’s
guidelines.

6. Treatment Plan of the patient is designed in advance in a logical sequence.

Zones of activity:

All treatment activity generally revolves around the patient. The dental team should be aware
about the spatial relationships around the patient at chair side. The work area around the
patient is divided into four “zones of activity”. Zones of activity are identified using the
patient’s face as the face of a clock. The four zones are:

a) Operator’s zone,

b) Assistant’s zone,

c) Transfer zone,

d) Static zone.

The operator’s zone for a right-handed operator extends from 7 to 12 o’clock, the assistant’s
zone from 2 to 4 o’clock, the instrument transfer zone from 4 to 7 o’clock, and the static zone
from 12 to 2 o’clock. The operator changes position depending upon the dental arch and tooth
being treated. The assistant rarely moves much in the zone of activity, but may find it
necessary to raise the operating stool when working on the mandibular arch to improve the
line of sight into the oral cavity These zones are self-explanatory except for the static zone,
which is the zone of least activity. Instruments that are infrequently used such as the blood
pressure equipment, portable curing light, or the assistant’s mobile cabinet when not in use
can be stored in this area.
CONCLUSION

Dental auxiliaries, both operating and non-operating are quintessential in oral healthcare
delivery system. They make the delivery of oral care easier, accessible to a larger population,
affordable, less stressful thereby contributing to better quality of care. The dental auxiliary
present in India are dental hygienist, laboratory technician and dental surgery assistants,
which have been recognized by Ministry of Health; Government of India and certificate
courses, recognized by Dental Council of India. Effective utilization of dental auxiliaries with
a concept of four handed dentistry can result in improving the oral health care delivery – both
in quantitative and qualitative aspects.