OPA EFDA FAQ

An Oral Preventive Assistant (OPA) Expanded Function Dental Assistant (EFDA) is an EFDA intended to assist dentists and hygienists to provide preventive care to children under 18, healthy adults, and patients diagnosed with gingivitis. OPAs would work under the direct supervision of dentists or hygienists to assist them in caring for the healthier segment of the patient population they serve. The pilot project will test the premise that OPAs would create more opportunities for initial appointments in dental clinics, relieving some of the long wait times for appointments some patients are experiencing, in clinics unable to recruit hygienists to fill openings. In rural or Medicaid clinics fortunate to have hygienists, OPAs would allow dentists and hygienists to operate more toward the top of their scopes of practice, concentrating on patients with more serious periodontal problems because these patients also experience long appointment wait times due to the workforce shortage. 

After completing the OPA EFDA training program, OPAs will be able to measure periodontal pockets, remove tartar deposits above the gum line, apply fluoride and silver diamine fluoride, and provide oral hygiene instructions under the direct supervision of a dentist or hygienist.

The Indian Health Service (IHS) has trained and utilized its version of an OPA since 1977 for the same reason Missouri is considering it: they had trouble recruiting enough hygienists to serve their population, especially in rural areas. Since 1977 the IHS has trained and deployed more than 1,200 Periodontal EFDA 1 (its name for an OPA) in 36 states. IHS studies showed when comparing clinics of similar size and staffing, clinics with Periodontal EFDAs delivered 6.5% more preventive services and 12.1% more total services than traditional clinics without Periodontal EFDAs. The increase in total services was thought to be due to freeing dentists and hygienists to spend more time operating at the top of their scopes of practice. Kansas scaling assistants have been in existence since 1998. In 2022, Illinois enacted rules and statutes to utilize OPA-type care providers.

A pilot project is a way to test a new method of delivering care, using accepted research protocols, to see if it really does improve access or quality of care for populations currently underserved. A statute passed in the 2022 Missouri legislative session requires pilot projects to define:

• the specific change to be tested,
• the underserved population they will study,
• when the project will start and finish,
• how success or failure of the new method will be measured and
• how and when the outcome of the pilot project will be reported to the Dental Board and the oral healthcare community.

No. The Office of Dental Health and the Missouri Dental Board are collaborating on the OPA EFDA Pilot Project to determine if it is a good idea. ODH will analyze the data from participating clinics and issue a report. Analysis of the study data will tell whether OPAs successfully improve access to care in Missouri and whether OPAs can contribute to care of the healthier segment of patient populations to existing standards of care. If the data is positive, then it will be up to the oral healthcare community, the Department of Health and Senior Services and the Missouri Dental Board to consider whether statute and rule changes should be enacted to allow OPA EFDAs to legally provide care in the state of Missouri. 

During the Pilot Project no permits will be issued, as current rules are waived so the study can occur. If an OPA EFDA eventually is created by law, a permit would be issued after training and competency testing completion—like all other EFDA training, testing and permit processing. 

Every healthcare provider’s role is made up of a hierarchy of tasks. Some require great skill and rigorous training. Other tasks require lesser skill and training. For example, Mayo Clinic has led the way in identifying skill sets of doctors and nurses, segregating lower skill sets, creating positions and targeted training for someone other than the doctor or nurse to perform tasks requiring lesser training, thus allowing doctors and nurses to operate at the ‘top of their scope of practice.’ Although this approach initially met resistance, Mayo Clinic’s outcomes consistently are the best in the world.

For example, in Missouri, diagnosis and treatment planning is reserved for the dentists’ scope, while removal of hard and soft deposits is reserved for the dental hygienists’ scope. Regarding EFDAs, the Missouri Dental Practice act defines their scope being limited to certain delegable skills, under direct supervision of a dentist, with a permit that indicates they have completed education and training to demonstrate proficiency. 

The OPA EFDA Pilot Project will study expanding the scope of EFDAs to include supragingival scaling on healthy children and adults and patients with gingivitis. Gingivitis is defined by the American Association of Periodontists as an inflammation of the gingiva most commonly resulting from an accumulation of microbial plaque in a patient that exhibits no attachment or bone loss.

Regarding hygienists working at the top of their scope, recently the MDA changed its policy related to hygienists administering local anesthesia under general supervision, a change that can positively affect access to care due to the change in supervision requirements. The MDA also is supportive of an Office of Dental Health grant to explore the use of teledentistry to extend oral healthcare workers into nursing homes. In this ODH pilot project, hygienist/assistant teams, working under the supervision of dentists, can use digital radiography, intra-oral video scanners, leading-edge decay detection and old-fashioned periodontal probes to collect diagnostic data necessary for dentists to review, write disease control treatment plans and triage patients according to the severity of need. The extended care teams will collaborate with distant dentists in real time using telehealth modalities. Under the direction of dentists, teams will use silver diamine fluoride to stabilize decay and periodontal debridement to mitigate periodontal infections. Definitive care plans will follow making efficient and productive use of a dentist’s time.

The OPA EFDA foundational curriculum has been modeled after the curriculum used by the Indian Health Service (IHS) for its education and certification process for the Periodontal Expanded Function Dental Assistant 1 program (IHS Perio EFDA 1). As stated earlier, the IHS has trained, certified and successfully deployed more than 1,200 Perio EFDA 1 providers in 36 states. The OPA EFDA foundational curriculum will include modules on:

• Anatomy and Physiology relevant to oral health
• Periodontal Health and Disease Classification System
• Instrument and Equipment Identification, Use and Maintenance
• Sterilization, Disinfection and Asepsis
• Patient Data Collection and Assessment
• Principles of Periodontal Probing
• Principles of Supragingival Scaling
• Principles of Coronal Polishing
• Conducting Oral Hygiene Consultations
• Placement of Sealants and Fluoride

Yes. Again, the OPA clinical training component is modeled after the IHS Perio EFDA training protocols. Clinical training includes:

• Patient Data Collection and Assessment
• Periodontal Probing
• Supragingival Scaling
• Coronal Polishing
• Oral Hygiene Consultations
• Placement of Sealants and Fluoride

Clinical training is accomplished under the direct supervision of a dentist or hygienist who has taken a training calibration workshop. The OPA EFDA candidate must successfully complete 20 patient care delivery experiences which are formally evaluated, debriefed, and mentored for improvement. In addition, the OPA EFDA candidate must complete an additional 30 additional patient care experiences meeting certain criterion/standards as evaluated by a dentist or hygienist.

Yes. There is knowledge and skills testing throughout the OPA EFDA curriculum. In the Prework Curriculum, module quizzes must be successfully completed to matriculate to the next module. When the Prework Curriculum is completed, the OPA candidate must successfully pass an examination on the prework curriculum to proceed to the hands-on clinical sessions.

Absolutely not. The OPA Pilot Project is attempting to address access to care issues caused by severe workforce shortages exacerbated by COVID-19 healthcare workforce attrition. ODH surveys indicate rural clinics and Medicaid clinics are the most severely impacted. The Indian Health Service has proven their Periodontal EFDA 1 program significantly addressed access issues in areas of workforce shortages. Their studies show a 12.1% increase in total services delivered in clinics utilizing Periodontal EFDA 1 compared to clinics without periodontal EFDAs. We believe that is because dentists and hygienists working in those clinics to operate at the top of their scope. We believe the best plan is for OPAs, hygienists and dentists to work together in the same clinic extending care to more people.

MDA agrees that advocating in the state legislature for increased appropriations for dental education is an important part of a larger plan to address oral healthcare workforce shortages. To help understand the urgency of finding solutions and why advocating for increased dental education appropriations alone can’t be the only solution, let’s look at some numbers:

• Currently there are approximately 3,488 licensed, in-state dental hygienists. They are concentrated in metropolitan areas. The Office of Dental Health classifies 56 of Missouri’s 114 counties as being critically short of hygienists with less than one-half of the recommended level of hygienists. These are predominantly rural counties with a larger portion of the population dependent on Medicaid. The MDA and ODH have fielded many communications from rural dentists indicating they cannot recruit hygienists to fill openings.
• To make matters worse, the Oral Healthcare Workforce survey coordinated by ODH in 2022 indicated more than 20% of responding hygienists were considering retirement in the next 5 years due to age, job stress or other reasons.
• With Medicaid expansion, approximately 170,000 people have newly registered for coverage. FQHCs and existing clinics serving Medicaid patients are expected to provide care for these newly eligible patients now. If only 25% of these people seek dental care, ODH estimates we would need an additional 500 hygienists to care just for the newly eligible Medicaid patients.
• Even if we were extraordinarily successful in advocating for increased investment in dental education in the very next legislative session, the impact to workforce is years away. Facilities would have to be expanded and students would have to matriculate through 2-year or 4-year curriculums.

The short and the long answer is yes, we need to advocate for increased appropriations for dental hygiene education, but that can’t be the only answer. We know EFDAs work in other dental disciplines like orthodontics, fixed and removable prosthetics and have increased productive capacity of dental clinics by 12% or more. We need a Periodontal (OPA) EFDA to increase access, especially in rural Missouri and in Medicaid clinics.

Similarly, this concern was voiced at the beginning of the Missouri Expanded Function Dental Assistant program in the late 1990s. Essentially the concern is some dentists won’t honor the rules and regulations governing the EFDA program. The truth is that has not been a significant concern in the last 25 years. The Missouri EFDA program has been very successful. Few, if any, complaints have occurred about misuse of EFDA (we know of none). If misuse of EFDAs occurs, there are mechanisms in place to discipline both the license of the dentist and the permit of the EFDA.

Such as, the dental offices that will gain from this will be those willing to employ lesser-trained assistants to provide those services, while the losing offices will be those trying to maintain a staff of highly trained (and highly compensated) hygienists, in addition to assistants and other staff.

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If eventually permitted in the State, an OPA EFDA would be regulated by the Missouri Dental Board (MDB) and under the direct supervision of the provider.

If a provider chooses to practice in this manner, there are safe-guard mechanisms to be investigated and disciplined by the MDB. There are no known reports of poor care delivered by a permitted EFDA in Missouri. As a profession, we cannot let the accusation of unethical behavior or fraud taint the prospect of increased access to care and an enhanced dental workforce, with all members working at the top of their scope.

The MDA has full faith and trust in a dental hygienist’s capabilities, which is why the OPA EFDA Pilot Project allows an OPA EFDA to work under the direct supervision of an RDH. Like current EFDAs and the patient care delegated to them, OPA EFDAs work will be evaluated and checked by a dentist or hygienist before leaving the office. For example, a patient would not leave the operatory without the work of the OPA EFDA being checked. If there is subgingival calculus present, it still must be removed by a RDH or dentist.

Regarding the language of “a lesser-trained assistant”, the MDA takes seriously its stewardship of the EFDA program since it commenced in the late 1990s. Many dentists employ EFDAs to their fullest scope, trusting them to take removable and fixed impressions and placing and finishing restorations.

There are two important things to remember when considering how OPA EFDAs might contribute to the care of patients diagnosed with gingivitis:

• OPA EFDAs work under the direct supervision of either a dentist or hygienist.
• The premise of Periodontal EFDA is they leverage the skill and expertise of the dentists and hygienists they work with, especially in the situation of workforce shortages.

Let’s discuss these separately to see how OPAs can productively contribute to gingivitis patients.

Because OPA EFDAs work under the direct supervision of a dentist or hygienist, the OPA’s supervisor must see the patient before and after the OPA has delivered their portion of care. That means the hygienist or dentist must inspect what has been done, complete any necessary care and ensure the patient’s perceived needs have been met. Specifically, if there are subgingival deposits remaining, those deposits will be removed by the supervising dentist or hygienist. An OPA EFDA doesn’t work independently of the dentist or hygienist, but with them.

The Indian Health Service has found there are many tasks a Periodontal EFDA can perform to greatly reduce the amount of time a supervising dentist or hygienist will need to spend to successfully treat a gingivitis patient. Specifically: seating and interviewing patients, updating medical and dental histories, updating radiographs if necessary, assessing oral hygiene, preliminary screening for inflammation, removal of supragingival plaque and deposits, and discussing oral hygiene. Everything an OPA can do for a gingivitis patient within the scope of the OPA saves time for the supervising professional with whom they collaborate. That leverages the skill and expertise of the dentist or hygienist who can perform the tasks the OPA cannot but can use time saved by the OPA to operate at the top of their scope to provide care to other patients.

It has been stated there is a hygiene shortage, but we need more assistants, too.

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This point about the oral healthcare workforce shortage cuts across all roles and is well taken. That is why there is no one solution to the difficult workforce situation we’re in. We have more patients to treat than we have care providers to treat them.

Specifically regarding dental assistants, the MDA has been working on a plan for more than a year to take a multifaceted approach to increasing the number of dental assistants, including:

We know EFDAs are the fastest way to respond to a workforce that has been debilitated by attrition during the COVID-19 pandemic. Experience with EFDAs in Missouri and Colorado has proven an EFDA can increase the productive capacity of a clinic by 12% or more. The MDA has been working with the Missouri Dental Board to streamline the EFDA process and remove bottlenecks. The Missouri Test of Basic Skills (a prerequisite for taking EFDA training) has been updated to ask more relevant questions and exam venues have been expanded; additionally, the MDA is hosting preparatory review courses to help dental assistants prepare the Exam.

The MDA supports efforts to lobby for increased funding for dental education in Missouri. Even though it will take a long time for increased funding efforts to actually impact the workforce, it’s another avenue we should take.

Career Centers/Vo-technical schools in rural areas of Missouri offer educational opportunities for high school students as well as adults already working in the community. The Office of Dental Health (ODH) would like to develop a 10-month educational pilot program for high school juniors and seniors that would allow the students to graduate with a dental assisting certificate and complete their Basic Skills Exam. If the high school juniors completed their Basic Skills Exam, then they can continue their education and earn their Expanded Functions Dental Assisting (EFDA) certificates as seniors. The didactic ("book" learning) portion of the program would be delivered in the school classrooms and the majority of the "hands-on" portion would be in dental offices. The clinical observation/internship would be arranged with local dental offices and Federally Qualified Health Care Centers (FQHCs) in the area. After completing their requirements and evaluations in the dental offices, the students have the potential of job opportunities after graduating from high school and the program.

Once the program is established, ODH would like to offer the didactic portions of the program to rural areas, utilizing Teledentistry, across the state to address the dental assistant shortage across Missouri. Ideally, all the didactic modules would be filmed and provided by synchronous and asynchronously to other parts of the state and the “hands on” portions would be provided in local dental offices and FQHCs. With the program offering the EFDA training, this will increase the student's skill set and their ability to make dental offices more efficient and able to serve more patients. This EFDA training provided in the second year of the training would specifically teach the EFDA Restorative I and II courses, as well as the Removable and Fixed Prosthodontic modules. With the addition of Restorative and Prosthodontic EFDA certification, productivity for the dentists has increased as much as 15%, which increases access to care.

Specifically regarding hygienists, the MDA has long supported RDH education programs across the state, including past donations to start or maintain programs, some of which subsequently closed. Most recently the MDA advocated for continuance of the UMKC School of Dentistry RDH program (and asked our members to do so) as closure was being considered as part of the 2020 UMKC Forward initiative.

The MDA has and continues to advocate for an increase in hygienists graduating in Missouri, however some of the circumstances around this are beyond MDA’s control, as they are decisions made by educational institutions and their governing bodies.

Currently MDA is working with 19 other states to lobby the Commission on Dental Accreditation (CODA) to lower the faculty-to-student ratio at CODA-accredited dental hygiene programs. The current faculty to student ratio in hygiene programs is higher than any other dental education program, including that for dental education. We believe this change would help ensure the viability of current programs and could allow programs to increase their class sizes without a decrease in quality of education.

MDA will also be reviewing its support on several other workforce related matters including, Dental and Dental Hygiene Compacts, legislation to allow foreign trained practitioners to provide hygiene care and new models for dental hygiene education. All areas that can assist with the severe shortage of dental team professionals will be researched and explored.

Letters the MDA, ODH and Missouri Dental Board (MDB) have received since its meeting that passed the pilot project allowance have confirmed support of an OPA EFDA. Some of those sample statements from dentists follow:

• I am one of the many dentists searching for a hygienist in my practice. I can tell you that even if all my assistants were OPAs, I would still be looking for that hygienist to join me. The level of care needed for specific procedures can only be accomplished by a hygienist. An OPA would allow hygienists to see more of these complex procedures in a timely manner increasing care to Missourians.
• Urban, suburban, or rural, there has not been a dentist that I have spoken with who has not mentioned the difficulty in finding a hygienist at some point in the past three years. This workforce shortage has led to hygiene departments being completely booked out 6+ months and limiting a practice's ability to have slots for SRP or perio maintenance patients. This workforce shortage hurts both patients and practices in that the access to care for all patients (healthy and perio) is compromised.
• I am grateful for language in this pilot project that allows for the supervision by dental hygienists as I feel they can benefit from this project addressing workforce issues detrimental in maintaining a healthy recall schedule for children and adults, but also for hygienists’ mental wellbeing by accomplishing so much more patient care with an OPA assistant at their side. I am in an extremely rural dental practice and dental hygienists are nearly impossible to hire. I am blessed to have at least one dental hygienist, and I am excited at the prospect of her being able to work with an OPA assistant to see our Medicaid children and healthy adults in a timelier manner.
• If my healthy patient population could be serviced by an EFDA, my hygienists could use their expertise in treating my unhealthy patient population much more effectively.
• I am still aggressively recruiting hygienists as best I can. I am happy to pay competitive wages and have offered thousands of dollars of sign‐on bonuses too. Still, I have had little success hiring. This isn't a financial issue. There are simply not enough hygienists to treat the current population. We would still have an incredible need for hygienists since they are the only ones capable of treating periodontal disease. The OPA EFDA could even work alongside my hygienist to see more of my patient base and treat some of the thousands of patients who are behind on their preventive care.
• The past year has been very difficult to get patients in for care because of the lack of hygienists available/ looking for work. I am confident that qualified assistants can provide quality periodontal treatment under my supervision and improve access to care among our patients. This will also allow hygienists more time to provide SRP to patients who are on a months-long waiting list right now.
• I am a dentist and prior dental hygienist. I am a big supporter of the hygiene profession, as my daughter plans to become a Dental Hygienist after high school. I want the profession’s integrity to be maintained and elevated as the important HCPs they are. With that being said … there is a detrimental shortage of hygienists in the state. I feel the Dental Hygienist can focus on Periodontal Disease Therapies. Patients not getting in for their Recare/Periodic Dental Wellness Exam/Oral Cancer Screening/Airway Evaluations are less healthy for it. Something must change. We can do this and provide care for Missourians in a safe and effective way. The danger is not in providing this level of OPA EFDA … the danger is in NO ACCESS TO CARE for many Missourians.

Letters the MDA, ODH and Missouri Dental Board (MDB) have received since its meeting that passed the pilot project allowance have the doctors’ confidence in the skills of their EFDAs in practice. Some of those sample statements from dentists follow:

• I have successfully used EFDA assistants in my office for years. The restorative assistants are particularly impressive. They can place and shape beautiful fillings as good or better than many dentists. This has helped me treat thousands more patients over the years. Furthermore, it has given them a new level of satisfaction and made a true career for them. These individuals have been very professional, and I have not had any safety concerns while they have worked with patients.
• We utilize EFDAs at our office on a regular basis and I am comfortable with the care they provide for our patients with the proper training. I do not doubt that with proper training and supervision a dental assistant can safely and effectively perform the scaling that is being discussed for the pilot program.
• I am in support of this program. Personally, I believe it is far overdue. Although we are not sure that we would utilize an OPA, we have for years employed expanded function dental assistants. It has been my experience that these auxiliaries are completely competent and take tremendous pride in their work.
• My EFDA assistants are trained to place ALL of my restorations, orthodontic attachments, pack cord, scan/impress for crowns/bridges/dentures/implants, remove cement after crown/veneer cementation, etc. Once the skill has been proven, there is no reason a highly trained EFDA could not remove calculus off the lower anteriors/buccals of the upper molars (typical places of buildup in a healthy recare patient).