Introduction

Are dental care professionals (DCPs) finally gaining the recognition that they have struggled to achieve? I set out to gain a greater understanding of the history, current status and future possibilities for the DCP. As part of my project, I created a questionnaire and sent it to 50 general dental practitioners (GDPs) in the Southampton area. With this questionnaire I hoped to gauge current opinion on DCPs and how their possible remits of the future might be received. I used the GDC's DCP Scope of Practice consultation as a basis for my questionnaire.

Three copies were sent to the 50 practices: one for the principal dentist, one for an associate dentist and one for an orthodontist. Responses were received from 23 practices, including 21 from principals, seven from associates and three from orthodontists.

DCP remits

The GDPs were asked for their opinion on the need for registration, their knowledge of all DCP remits and their opinion on the proposed possible extensions to these remits.

Dental nurses

The 21 principals employ 76 dental nurses. GDPs were shown a list of 21 potential skills a dental nurse may be permitted to carry out in the future following appropriate training, and asked how these skills would relate to them; whether they thought the skills were useful; and whether they thought the skills were necessary or unnecessary.

Most GDPs considered most skills useful but unnecessary. Of 27 GDPs, 6-9 saw the following skills as a necessary development:

  • Further skills in oral health education and oral health promotion

  • Assisting in the treatment of patients with special needs

  • Taking radiographs

  • Shade taking.

The skills considered most useful – 17-19 GDPs finding them desirable – were:

  • Taking impressions for any purpose

  • Tooth whitening to the prescription/under the supervision of a dentist

  • Dental photography

  • Further skills in oral health education and oral health promotion.

Only nine GDPs thought that tracing radiographs would be useful to them. The skills the 27 GDPs found most unnecessary (16-17 of them) were:

  • Mounting models on to an articulator using facebow

  • Constructing occlusal registration rims and special trays

  • Repairing removable plastic appliances

  • Taking facebow registrations.

Dental hygienists and therapists

Seven of the principals do not employ a hygienist or therapist; 12 principals employ a hygienist; four employ two hygienists. One therapist and one dual qualified hygienist-therapist are employed.

Hygienists

Most GDPs said they felt fully aware of the remit of dental hygienists, with only two saying they were unsure. However, when shown the list of the full dental hygienist remit it became clear that there were a greater number of GDPs unaware.

Of the 17 tasks a hygienist is permitted to carry out, there were only two that all the GDPs were aware of:

  • Providing dental hygiene care to a wide range of patients

  • Complete periodontal examinations and charting and the use of indices to screen and monitor periodontal disease.

There were three tasks that only one GDP was unaware of:

  • Undertaking supragingival and subgingival scaling and root debridement using manual and powered instruments

  • Applying topical treatments and fissure sealants

  • Providing smoking cessation advice for patients.

Three to four GDPs were unaware that a hygienist can:

  • Plan the delivery of patient care to improve and maintain periodontal health

  • Provide preventive oral care to patients and liaise with dentists over the treatment of caries, periodontal disease and tooth wear

  • Use appropriate anti-microbial therapy in the management of plaque-related diseases

  • Obtain a detailed dental history and evaluate medical history

  • Identify anatomical features, recognise abnormalities and interpret common pathology

  • Give infiltration and inferior dental block analgesia

  • Make appropriate referrals to other health care professionals.

Six to seven GDPs were unaware that hygienists can:

  • Place temporary dressings and re-cement crowns with temporary cement

  • Carry out oral health screening

  • Adjust restored surfaces in relation to periodontal treatment.

Eight were unaware that hygienists can take impressions and 11 were unaware that they have the ability to take, process and interpret various film views used in general dental practice.

When offered a list of possible skills a hygienist may develop in the future, most GDPs thought that the three additional skills would be useful. Results show that:

  • Three thought that tooth whitening to the prescription of/under the supervision of a dentist is a necessary skill, although six thought it unnecessary

  • Six GDPs thought that prescribing radiographs was a necessary skill, but another six GDPs thought it unnecessary

  • The possibility of adding periodontal surgery to the hygienist remit was only seen as necessary by one GDP; seven thought it unnecessary.

Dental therapists

Five GDPs said they were not aware of dental therapists' remit and one GDP was unsure. When told that in addition to the hygienists' remit therapists are able to do the following, between three and five GDPs were unaware of all these tasks:

  • Complete direct restorations on primary and permanent teeth

  • Carry out pulpotomies on primary teeth

  • Extract primary teeth

  • Place pre-formed crowns on primary teeth

  • Plan the delivery of a patient's care

  • Make appropriate referrals to other health care professionals

There were five possible additional skills for the dental therapist. Again, most GDPs thought they would be useful additions, but more GDPs stated that the skills were unnecessary rather than necessary:

  • Tooth whitening to the prescription of/under the super vision of a dentist

  • Prescribing radiographs

  • Administering inhalation sedation

  • Extraction of permanent teeth

  • The skills necessary to vary a treatment prescription.

The GDPs were then asked if these added skills would encourage them to employ or use a hygienist or a therapist. Seven said yes to employing a hygienist and five said yes to a therapist. Fifteen said they would be just as likely/unlikely to employ one.

Dental technicians and CDTs

Most GDPs were aware of the remit of a dental technician, although five were unaware that they are able to review cases coming into the laboratory to decide how they should be progressed. Ten GDPs were unaware that dental technicians are able to make appropriate referrals to other health care professionals.

There was slightly more confusion when it came to the remit of the clinical dental technician (CDT). Five to seven GDPs were unaware that CDTs are able to:

  • Perform technical and clinical procedures related to providing removable dental appliances

  • Provide appropriate advice to patients

  • Fit removable appliances.

But between 10-15 GDPs did not know that CDTs are able to:

  • Take a detailed dental history and relevant medical history

  • Undertake clinical examinations

  • Distinguish between normal and abnormal consequences of ageing

  • Recognise abnormal oral mucosa and related underlying structures and make appropriate referrals

  • Take and process radiographs and other images related to providing removable dental appliances.

The possible additional skills a dental technician may develop in the future were met with fairly equal results for useful and unnecessary, with the minority finding them necessary.

There was only one possible additional skill for the CDT: tooth whitening to the prescription of/under the supervision of a dentist. Only one GDP thought this was a necessary skill. Nine thought it would be useful and 16 thought it unnecessary.

Orthodontic therapists

The separate questionnaire for orthodontist recipients asked for their opinions on the orthodontic therapist. There was no task that all three orthodontists replied they were unaware of. Most were unaware of the tasks (similar to those a dental therapist can perform) that the orthodontic therapists are not able to undertake. The possible additional skills were all thought of as necessary or useful.

Discussion

The possible additional skills were all thought of as necessary or useful.

It is apparent from the results of this questionnaire that there is some misunderstanding about the remit of DCPs (other than dental nurses) and there is perhaps evidence of a feeling of resistance towards the possibility of DCPs extending their remits further. This may be because these skills are usually reserved for the dentist and dentists feel they would not want to relinquish these tasks to another operator.

It was evident when comparing the results that this was more prevalent amongst the GDPs that have been qualified for a greater number of years. This could be because in more recent years dental education has included interaction with students from other sectors such as hygiene and therapy. This could encourage them to perhaps employ or refer to them when working in the practice setting.

Future possibilities

An article in Vital discussed the possibilities of registration for dental practice managers and dental receptionists.1 The GDC President at that time stated ‘while we are not going to register these groups in the immediate future, it is something we may think about in the future.’

The article examined the reasons for their registration, and gave two opposing views: one from the British Dental Practice Managers' Association (BDPMA), who felt that ‘registration is needed only for those that are in the clinical environment and where there are public protection issues involved.’ The second was from Glenys Bridges, of the British Dental Receptionist Association (BDRA) who stated that ‘the BDRA would welcome the decision to register receptionists with the GDC, not least to ensure a knowledge of the ethical and legal obligations placed on their employers by the GDC.’

The BDRA was discontinued in December 2006 due to an inability to attract new members. This could indicate a lack of enthusiasm among dental receptionists to be recognised professionally by way of registration.

Debate

An article published in the BDJ2 examined the attitudes of GDPs in Wales towards the employment of dually-qualified hygienist-therapists. The article concluded that there was a lack of knowledge and understanding and that future planning should work towards all members of the dental team understanding the roles and responsibilities of their colleagues.

D. G. Hillam wrote a letter in response to the article.3 He thought that the dental therapist may be likely to push the boundaries of their legal limits which could jeopardise the safety and quality of their dentistry. He also voiced concerns over the combined hygiene and therapy course being at the expense of the hygienist: ‘we seem to be moving from preventively orientated DCPs to operatively centred ones. We need more of the former and fewer of the latter.’

A retort by Margaret Ross4 echoed the article suggesting that Hillam's letter confirms that lack of understanding. Ross questioned why Hillam expects hygienist-therapists to have any less rigorous ethical standards than dentists and contemplate undertaking illegal practice, pointing out that they are subject to the same disciplinary procedures. On the question of the ‘safety and quality’ of a hygienist-therapist's work Ross pointed out that ‘significantly more time is spent by these individuals in doing more “routine dentistry” than many an undergraduate in the UK. This is certainly the case in the treatment of periodontal disease where even in an integrated hygiene-therapy programme, the practical experience gained is far greater.’

The future's bright

DCPs can perform tasks they have had sufficient training for, so could CPD almost be an open invitation for extended remits?

It is encouraging to see that although there is still confusion from some GDPs, there are others who are working towards evolving the whole dental team to improve the dental health of the population. The British Society of Dental Hygiene and Therapy (BSDHT) is working on communicating with practitioners to ensure a greater understanding of the value of employing a dental hygienist or hygienist-therapist, particularly encouraging PCTs to ensure that larger practices have a hygienist or hygienist-therapist available to provide NHS dental care.

The qualification and registration of the UK's first orthodontic therapists in Leeds Dental Institute this year could be a sign of things to come.5

With the dental therapist remit extending to diagnostic skills and treatment planning looking ever more possible, a pilot scheme at Cardiff University was completed in 2007, where three dental therapists took part in a three month diagnosis and treatment planning course. Gill Jones, the director of the DCP Training and Development Centre, was pleased with the overall success of the programme: ‘We are here for the patients and correct referral is more important than treatment. These students are now so good at recognising the history of pain that it just seems good sense to give others the same opportunity. Surely that would benefit the whole team?’6

New skills for all

DCPs can perform tasks they have had sufficient training for, so could CPD almost be an open invitation for extended remits? There is already a wide range of post qualification courses available for dental nurses. With enforced continued education it should be expected that some DCPs will want to gain new skills as well as keep up-to-date on their current ones; this could in turn put pressure on the GDC and Government to extend DCPs' remits further.

It is a very exciting time to be working in dentistry and I am looking forward to completing my Diploma in Dental Hygiene and Therapy in 2009. Through studying DCP status and evolution and collating opinion from so many different sources and people, I am convinced that the future looks bright.