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Ask Dr. Christensen

June 1, 2011

Gordon J. Christensen, DDS, MSD, PhD

For more on this topic, go to and search using the following key words: dental assistants, in-service education, proactive planning, Dr. Gordon Christensen.

Q: When I first started practicing 20 years ago, I was able to recruit dental assistants who had experience in “real world” four-handed dentistry. In recent years, I have not been able to find such dental assistants. The result of this change is constant frustration with the slow speed of my clinical procedures. I recognize that the problem is related to the fact that the current generation of dental assistants does not appear to have experience with this concept. What can I do?

A: You are not alone. A few decades ago, there were federal grants available for dental schools to hire dental assistants for dental students. At that time, dental students in some schools were instructed on how to effectively use dental assistants. In my many CE courses, I often ask dental students how many have worked with a dental assistant. Most of them have not had that opportunity. Those grants are not available for hiring dental assistants. Similarly, in the past, many dental assistants were given in-depth instruction on how to work effectively with a dentist. The current generation of dental assistants has some knowledge of dental materials and techniques, and many have had internships in dental offices, but few new dental assistants have had in-depth instruction in four-handed dentistry. In other words, I agree with you completely. The challenge is what can be done about the situation?

I have some suggestions related to my own experience, both as a full-time dental school educator early in my career and as a long-time CE educator. In my clinical experience, I have found that most assistants want more responsibility and want to accomplish more clinical procedures. Most dental assistants are very capable of much more than they are assigned. (Fig 1)

Fig. 1 — Competent dental assistants are an essential part of any dental practice. They are a singular major part of the overall dental team.

In my practice, if I had not educated dental assistants to accomplish a wide variety of tasks and assigned them expanded clinical tasks well beyond the normally assigned dental assistant tasks, my life would have been markedly less productive. I estimate that both my service to patients and also the revenue generated in the practice would have been significantly less, perhaps half of what my staff and I have been able to generate. How was this use of dental assistant talents accomplished? It was accomplished through in-service education sessions. I suggest that this simple concept be incorporated into your practice for many reasons, not just to improve dental assistant activity.

What are in-service education sessions? These are my suggestions. Decide what topics need to be taught or improved in your practice. One of the topics should be four-handed dentistry, extended over several in-service education sessions. For maximum practice effectiveness, I suggest expanding this from four-handed dentistry to six-handed dentistry.

With the input of your staff (Fig. 2), agree on times for these sessions to be held. For our team, having them before a typical practice day is the best alternative. Only the staff persons involved with the topic should be asked to attend the sessions. Some topics require all of the staff to be present. I suggest that staff should be paid their normal wages for the time involved. That expenditure will assuredly come back to you as they increase their competency and improve the efficiency of the practice.

The sessions should be held for about 50 minutes. If you typically start practice at 9 a.m., begin the in-service sessions at 8 a.m. Start the meetings on time and expect the staff to be there on time. End the meeting about 10 minutes before the practice day starts, allowing time to adequately look over the day’s patients and prepare for the upcoming clinical activity.

Finding an instructor

You may not want to be the instructor. If not, find one in one of the dental assisting schools. Have the person come to your staff in-service meeting and provide instruction. For a reasonable fee, instructors are usually pleased to help.

Have the instructor simulate actual clinical procedures with your staff and show your assistants how to organize, package, set up, pass, clean up, sterilize, and repackage instruments; how to rapidly clean up and disinfect an operatory; how to sit in the proper position in relation to the dentist; how to use high-velocity suction in the proper manner; how to think ahead and set up for several steps beyond the stage of any procedure; how to be an overall professional representative for your office; and, most importantly, how to be an indispensable part of the clinical team.

Most dental assistants are pleased to have such instruction, and even more pleased to implement the principles involved in the various activities. They soon see the increase in practice activity produced by the new concepts, and they are eager to increase their own activity.

Visit practices in which four- and six-handed dentistry is being practiced

In your community, undoubtedly, there are some efficient practices using the four- and six-handed dental assisting concepts. Seek out those practices, ask if you can visit, have an in-service education session as soon as possible after the visit, decide what you want to change in your own practice, and do it!

Have your most effective dental assistant provide the sessions

You may have more than one dental assistant who is competent with the four- and six-handed concepts. Ask if these people are interested in teaching the other dental assistants. Usually, they are pleased to do so.

Provide the instruction yourself

You may feel hesitant to do the teaching yourself. As with many important clinical subjects, such as emergency preparedness or scheduling, there are numerous instructional materials available. Videos, written materials from dental assisting schools, and articles are available if you contact the dental assisting schools in your geographic area.

How do you start this educational process? You did not mention the extent or depth of your own education and experience on the subject. If you feel that you have adequate knowledge with some updating, and you don’t mind doing some academic preparation for the sessions, I do not see any reason why you cannot do the instruction. How do you find the content for the in-service sessions? In spite of the observable reduced activity of four-handed dentistry in the profession, there are numerous articles on the subject. I suggest that you find some of that information on the Internet. A couple of helpful Internet sites are Google Scholar and PubMed. After reading the necessary articles, make a plan for your sessions.

I suggest identifying which areas of dental assisting in your practice are not meeting your expectations relative to efficiency. Decide what you want to do to change and upgrade these areas.Teach this to your staff. In your office, simulate the clinical environment, watch dental assistant activity, and instruct your team on how to implement four- and six-handed dentistry. One session will not be enough. Do the sessions until dental assisting effectiveness is to your satisfaction.

Dental assisting weaknesses seen in many practices

I have visited many practices and observed everything from well organized, highly efficient ones to those that could use significant help. Here are some areas for improvement that I routinely see. Determine if they exist in your practice.

Fig. 2 — Some dental assistants need to have additional education to become competent in four-handed or six-handed dentistry procedures.

Dental assistants

• Awaiting dentist direction for most activities

• Not organizing several steps ahead for clinical procedures

• Not setting up for procedures with all of the necessary equipment and supplies for the expected procedure

• Not checking the emergency equipment and supplies

• Not having instruments set up in order of operatory use

• Not reorganizing instruments on the tray as they are handed back to them by the dentist

• Running to get materials (such as impression material or bonding agents) while the dentist and patient wait

• Passing an instrument so that the dentist has to turn the instrument around or change its direction to use it

• Sitting in an inefficient or awkward position or at the wrong height in relation to the dentist

• Not operating the sterilizing area in an efficient manner

• Being passive in all things

• Not being proactive relative to setting up for procedures or during clinical dentistry

• Using suction system inappropriately or traumatically

• Not retracting cheeks effectively

• Not aiming the operating light adequately


Your question is of significant importance. The services provided by most American dentists and their level of income could be increased significantly with easily implemented increases in dental assistant efficiency. I have suggested numerous ways for you to upgrade the knowledge and abilities of dental assistants, including bringing an instructor from a local dental assisting school into the practice for an in-service educational session, and implementing four- or six-handed dentistry. The important aspect of this challenge is that it can be overcome with proactive planning on your part.

Practical Clinical Courses has many videos that will assist you in educating and upgrading your dental assistants. Three that relate directly to this article are:

• V4714 Effective Use of Four-Handed and Six-Handed Dentistry (This DVD compares the use of dental assisting with four-handed and then six-handed procedures.)

• V4748 Essentials of Effective Dental Assisting, 2nd Edition (This title is a complete update of our most popular dental assisting video.)

• V4745 Dental Assisting for Posterior Restorations (Observe effective dental assisting procedures for composite resin restorations, crowns, and fixed prostheses.)

For more information, visit or call (800) 223-6569.

Dr. Christensen is a practicing prosthodontist in Provo, Utah. He is the founder and director of Practical Clinical Courses, an international continuing-education organization initiated in 1981 for dental professionals. Dr. Christensen is a cofounder (with his wife, Rella) and senior consultant of CLINICIANS REPORT (formerly Clinical Research Associates), which since 1976 has conducted research in all areas of dentistry.

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