Dental therapy in the United Kingdom: part 2. A survey of reported working practices

It's not just about the money: recruitment and retention of clinical staff in general dental practice - part 2: dental care professionals

As described in the first paper of this two-part series, increasing difficulties in recruitment and retention of dentists and dental care professionals (DCPs) in general dental practice in the UK is affecting delivery of NHS dental services. There is a significant risk to the future dental workforce supply which will affect access to dental care and worsen oral health inequalities. Understanding what factors contribute to job satisfaction and prevent job dissatisfaction of dental professionals would be useful in managing recruitment and retention issues. The aim of this literature review was to identify factors which contribute to job satisfaction of DCPs in general dental practice. Database searching was conducted systematically through PubMed/Medline, Scopus, Ovid, and the National Grey Literature Collection. Eleven relevant articles were identified, which were qualitatively analysed using Herzberg's motivation-hygiene theory as an analysis tool. Unfair remuneration is a major contributor to dissatisfaction of DCPs, but job satisfaction could be promoted through increased recognition, variety of work, and opportunities to progress. Dental contract reform in the UK should aim to minimise factors contributing to dissatisfaction and increase factors which increase satisfaction, including the development of an acceptable remuneration model for NHS dentistry that facilitates skill mix.

Investigation into the enablers and barriers of career satisfaction among Australian oral health therapists

OBJECTIVES

This qualitative study explored the enablers and barriers of career satisfaction among Australian oral health therapists (OHTs) and the reasons behind career changes.

METHODS

Participants were recruited in 2 ways: 1) recruitment posts were made on the Facebook pages of two professional groups; and 2) an email was sent to the Doctor of Dental Medicine students of the University of Sydney School of Dentistry, inviting those with OHT qualifications to participate. Each participant completed a semi-structured interview which was guided by open-ended questions. The average interview length was 45 min. All interviews were recorded, transcribed verbatim and manually coded. Thematic analysis of the qualitative data was completed using an inductive approach.

RESULTS

Twenty-one OHTs participated in this study. The enablers of OHT career satisfaction include clinical practice, job variety, career flexibility, being in a supportive team environment and the opportunity for constant learning and growth. The barriers to career satisfaction include musculoskeletal problems, restrictions on the scope of practice use, psychological stress and lack of recognition from others. OHTs remain in the profession due to stable income and employment opportunities. The main reasons for retirement were burnout and pursuing dentistry. OHTs pursue dentistry to expand their scope of practice.

CONCLUSION

This study revealed the enablers and barriers of OHT career satisfaction in an Australian context. OHTs are an important component of modern dental workforces, and reasons for attrition within the workforce are essential for maintaining responsiveness to community oral health needs.

A survey of mental wellbeing and stress among dental therapists and hygienists in South West England

Introduction Mental health and wellbeing of the dental team has been brought into sharp focus during the COVID-19 pandemic. Despite this renewed interest, there has been longstanding issues with poor mental health and wellbeing in the dental profession for some time. While there is some evidence that documents poor mental wellbeing amongst dentists, there appears to be a lack of evidence concerning dental care professionals.Aims To explore the level of mental wellbeing and stress amongst dental hygienists and therapists (DHTs) in South West England.Method An online survey was distributed to DHTs in South West England via two professional networks.Results A total of 129 surveys were completed. The mean levels of reported wellbeing were lower amongst DHTs than the general population and 45% of respondents reported high anxiety levels. Younger respondents reported lower levels of life satisfaction. Plus, 43.5% of dental therapists reported performing solely dental hygiene treatments, with those performing no dental therapy reporting lower happiness levels.Conclusion Low mental wellbeing amongst DHTs in the South West has been identified in this survey and this is likely to impact negatively on the morale and motivation of the workforce, leading to increased levels of absenteeism and ultimately, loss of colleagues from the dental workforce. The stress encountered by DHTs is largely workplace-related and therefore, there is an increased need for team- and organisation-delivered interventions to improve mental wellbeing for this group.

The perceptions and attitudes of qualified dental therapists towards a diagnostic role in the provision of paediatric dental care

Objectives This study explored the perceptions and attitudes of qualified UK dental therapists (DTs) to act in a diagnostic role in the dental care of paediatric patients.Methods A mixed methods study. An electronic questionnaire was sent out to the members of associations and closed social networking groups for qualified DTs across the UK. The questionnaire explored the training, clinical experience and working practices of the participants and measured their agreements with applicable statements using Likert scale scores. Semi-structured interviews were also undertaken to explore how UK DTs perceived a diagnostic role for them and what barriers and facilitators they experienced.Results A total of 155 questionnaire responses were returned and 11 interviews conducted. Participants were mostly women (94.8%) with a broad range of working experience, with a mean experience of 9.5 years (± 8.8 standard deviation [SD]) (range: 1-42 years). From the questionnaires, when asked to score agreement on a Likert scale from 0-5, DTs agreed that in a diagnostic role, they could increase access to dentistry for patients and a high proportion were in agreement that they had the knowledge to carry out examination (mean = 4.43 ± 0.87 SD), diagnosis (mean = 4.37 ± 0.90 SD) and care planning for paediatric patients (mean = 2.74 ± 1.32 SD). The interviews yielded three qualitative supra themes: 'working in the UK as a DT today'; 'the perceptions of dental therapists on acting in a diagnostic role in paediatric dental care'; and 'barriers and facilitators to acting in a diagnostic role' and within these, eight major themes were identified.Conclusion Within the limitations of a small sample who were representative of the workforce demographic and educational structures, we found that DTs felt that if they were to act in a diagnostic role, it would improve access to dental services benefitting patients, dentists and the DT profession. DTs identified and explored barriers and facilitators to a diagnostic role. Change is required to overcome these barriers in order to support DTs to act in a front-line diagnostic role.

Health and Wellbeing of Clinical Dental Care Professionals: A Systematic Review

BACKGROUND

There has been much research relating to stressors in the dental environment and concerns over dentists' health and wellbeing. The determinants of dentists' health and wellbeing within the UK include macro-factors, such as healthcare systems and regulation; meso-factors, such as job specification and workplace characteristics; and micro-factors, such as personal aspects, professional career level, and personal and professional relationships. Given the challenges in dentistry, research is needed to investigate the key determinants relating to the health and wellbeing of clinical dental care professionals (DCPs) nationally.

AIM

To review the literature on the key determinants of health and wellbeing among dental hygienists, dental therapists, clinical dental technicians, and orthodontic therapists in the UK.

MATERIALS AND METHODS

A systematic review of the literature was conducted across seven databases. The records were screened by title, abstract and full text based on the study inclusion criteria. Extraction of data and a qualitative synthesis of the included studies was performed. A mixed methods appraisal tool was used to quality assess for risk of bias.

RESULTS

Twelve studies were included in this review, eleven of which were medium to high quality (5*, 4*) and one low quality (2*). Ten studies focused on dental therapists, and/or hygienists, with only one each on orthodontic therapists and clinical dental technicians. Job satisfaction and professional careers were the primary factors explored in the included studies and clearly identified as determinants of health and wellbeing. However, there was evidence of these being associated and linked with a range of determinants at macro-, meso-, and micro-levels, with a general lack of evidence on the overall health and wellbeing.

CONCLUSION

There is currently very limited evidence on the key determinants of health and wellbeing of clinical DCPs within the UK, but the available evidence maps to the same domains as dentists. Further well conducted research examining the overall health and wellbeing is required, with consideration of the full matrix of possible factors.

What are the possible barriers and benefits to the use of dental therapists within the UK Military Dental Service?

Introduction All dental service delivery organisations and their workforce need to adopt more efficient and effective delivery models including increased skill-mix.Aim The aim of this study was to investigate the possible barriers/benefits to the utilisation of dental therapists (DTs) in the UK Military Dental Service.Method An explanatory mixed-methods study of sequential design was conducted using purposive sampling of dentists and DTs in the Defence Military Service. Electronic questionnaires (25) were sent to dentists and DTs with an overall response rate of 80% (15/18 dentists and 6/7 DTs). Following analysis of the questionnaires, seven semi-structured interviews (four dentists, three DTs) were thematically analysed.Results All dentists and DTs agreed that DTs could play a positive role within the Defence Military Service, but the barriers and benefits of their use centred on the six main themes of: leadership, delegation, new ways of working, scope of practice, skill-mix and utilisation.Conclusions To address the barriers and maximise the benefits of using DTs, effective leadership at the organisational, dental centre and individual levels is required. This leadership is key to unlocking the benefits of improved teamwork, increased skill-mix and maximised use of all dental care professionals within the Defence Military Service.

The dental therapist's role in a 'shared care' approach to optimise clinical outcomes

Introduction Dental therapists have a key role to play in the provision of dentistry in the UK. The Dental Workforce Advisory Group has reported this is relevant in multiple areas, including prevention and care in young children, and to support dentists in providing advanced and routine treatment for complex adult patients within the wider collaborative dental team. There remain diverse and multiple barriers and challenges to utilising the optimal scope of the dental therapist in general practice. In 2013, the General Dental Council introduced direct access (DA) legislation in the UK. By utilising the potential of dental therapists, some of the above challenges could be overcome and the DA approach optimised.Aims The purpose of this article through presenting clinical cases is to demonstrate the full scope of practice of the dental therapist and highlight how clinical outcomes can be optimised for patients when a 'shared care' approach is followed.Conclusions Notwithstanding the complexities of the financial implications practice owners face, through knowledge and understanding of the role and scope of the dental therapist within the wider dental team, optimal treatment of dental patients in the UK can be encouraged.

A global review of the education and career pathways of dental therapists, dental hygienists and oral health therapists

Introduction With ongoing needs in oral healthcare being unmet, dental therapists, dental hygienists and oral health therapists have the potential to assume greater roles and responsibilities in the provision of care. This review provides a global overview of the education and career opportunities of these professions, contributing to the discussion on the future trajectories of all three professions.Methods A scoping review was conducted to collate and summarise the current available evidence from peer-reviewed journal articles, published reports and books, and websites of professional associations and government agencies.Results Of the 145 sources identified and reviewed, 53 were included in the qualitative synthesis. The themes were categorised into domains: 1) dental therapy; 2) dental hygiene; and 3) oral health therapy.Conclusion The results of this review indicated that, although there has been continuous advocacy for dental therapists, dental hygienists and oral health therapists to assume roles beyond the traditional clinical practice, the majority of the professionals still mainly practise as clinicians. Many dental therapists, dental hygienists and oral health therapists felt limited by their scope of practice and were dissatisfied with the lack of career pathways. Additional research is needed to examine the influences behind career development for all three professions.

Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

Background

Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.

Objectives

The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.

Design

A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.

Setting

The setting was NHS dental practices in North West England.

Participants

A total of 217 low-risk patients in eight high-street dental practices participated.

Interventions

The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).

Main outcome measure

The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.

Results

No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.

Limitations

The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.

Conclusions

Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.

Future work

Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.

Trial registration

Current Controlled Trials ISRCTN70032696.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances

INTRODUCTION

In the United Kingdom, policy and guidance changes regarding the role of dental therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive-focussed, teamwork approach. However, success in the adoption of this model of working has been varied.

AIMS

Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances.

MATERIALS AND METHODS

The research comprised two stages. (a) A structured literature search, dual-coding papers for high-level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill-mix operates in the general dental service. (b) Six case studies of general dental practices (three with a dental therapist/three without a dental therapist) employing a range of skill-mix models incorporating semi-structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature.

RESULTS

Eighty-four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories.

CONCLUSION

Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice.

Feasibility study: assessing the efficacy and social acceptability of using dental hygienist-therapists as front-line clinicians

Background The oral health of the adult population has been improving in the United Kingdom decade upon decade. Over half of dental service activity in the National Health Service (NHS) is limited to a check-up without any further treatment. This raises a question as to whether check-ups could be provided by dental hygienist-therapists, rather than general dental practitioners. The aim of this study was to assess the feasibility of a definitive trial to evaluate the costs and effects of using dental hygienist-therapists to undertake the check-up.Methods/design Adult NHS patients were randomised into three arms in two dental practices: patients who only saw dental hygienist-therapists for a check-up, those that saw the general dental practitioner and dental hygienist-therapist alternatively and a control, where patients only saw the general dental practitioner for their check-up. The study ran for 15 months. The primary outcome measures of the study were patient recruitment, retention and fidelity. A parallel and embedded qualitative study was undertaken which recorded the views of participating patients to determine the social acceptability of the intervention.Results Sixty patients participated in the study. The initial recruitment rate for the study was 33.7%. This figure increased to over 82.1% when telephone calls or face-to-face recruitment was utilised. The retention rates were 60% for both the dental hygienist-therapist only group and the alternate general dental practitioner and dental hygienist-therapist group, compared to 70% for the general dental practitioner only group. Fifteen patients were interviewed in the qualitative study and supported a team approach to the provision of check-ups in the NHS. Conclusion This study demonstrates the feasibility of a definitive trial to evaluate the costs and effects of using dental-hygienist-therapists to undertake the check-up.

A Markov model assessing the impact on primary care practice revenues and patient's health when using mid-level providers, lesson learned from the United Kingdom

OBJECTIVE

To evaluate the cost-effectiveness of using mid-level providers for dental "check-up" examinations and the treatment of caries in different NHS settings in the United Kingdom. Mid-level providers are a broad category that describes non-dentist members of dental teams. This study focused on the potential use of Dental Hygiene Therapists undertaking dental "check-up" examinations and simple restorative treatment, instead of dentists.

METHODS

A Markov model was used to construct the natural history of caries development in adults that visit a dental practice every six months over a five-year period. Three cost perspectives are taken: those borne to dental healthcare providers in England and Wales, Northern Ireland and Scotland. These represent three separate forms of retrospective payment system that are currently in use in the United Kingdom. The cost outcome was the average amount of retained practice earnings required to provide healthcare per patient visit. The health outcome was the average length of time in a cavity-free state and the cost-effectiveness outcome was incremental cost for six months in a cavity-free state.

RESULTS

No statistical difference was found between dentists and mid-level providers in the length of time in a cavity-free state but the use of the latter saved money in all three NHS health system jurisdictions. This ranged from £7.85 (England and Wales) to £9.16 (Northern Ireland) per patient visit ($10.20 to $11.90, respectively) meaning the incremental cost for six month in a cavity-free state ranged from £261.67 ($339.93) in England and Wales to £305.33 ($369.68) in Northern Ireland. Further, changes in baseline assumptions and parameter values did not change mid-level providers being the dominant service intervention.

CONCLUSION

In a time of limited funds for dental services, these results suggest that resources in public funded systems could be saved using mid-level providers in dental practices, without any health risk to patients or capital investment.

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Background

Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.

Research questions

This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?

Design

Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.

Setting

NHS ‘high-street’ general dental practices.

Participants

121 practices across the north of England.

Interventions

No active interventions were undertaken.

Main outcome measures

Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.

Results

The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.

Conclusions

Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.

Study limitations

Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.

Future work

Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The efficacy of screening for common dental diseases by hygiene-therapists: a diagnostic test accuracy study

Regularly attending adult patients are increasingly asymptomatic and not in need of treatment when attending for their routine dental examinations. As oral health improves further, using the general dental practitioner to undertake the "checkup" on regular "low-risk" patients represents a substantial and potentially unnecessary cost for state-funded systems. Given recent regulatory changes in the United Kingdom, it is now theoretically possible to delegate a range of tasks to hygiene-therapists. This has the potential to release the general dental practitioner's time and increase the capacity to care. The aim of this study is to compare the diagnostic test accuracy of hygiene-therapists when screening for dental caries and periodontal disease in regularly attending asymptomatic adults who attend for their checkup. A visual screen by hygiene-therapists acted as the index test, and the general dental practitioner acted as the reference standard. Consenting asymptomatic adult patients, who were regularly attending patients at 10 practices across the Northwest of England, entered the study. Both sets of clinicians made an assessment of dental caries and periodontal disease. The primary outcomes measured were the sensitivity and specificity values for dental caries and periodontal disease. In total, 1899 patients were screened. The summary point for sensitivity of dental care professionals when screening for caries and periodontal disease was 0.81 (95% CI, 0.74 to 0.87) and 0.89 (0.86 to 0.92), respectively. The summary point for specificity of dental care professionals when screening for caries and periodontal disease was 0.87 (0.78 to 0.92) and 0.75 (0.66 to 0.82), respectively. The results suggest that hygiene-therapists could be used to screen for dental caries and periodontal disease. This has important ramifications for service design in public-funded health systems.

Extending dental nurses' duties: a national survey investigating skill-mix in Scotland's child oral health improvement programme (Childsmile)

Background

Childsmile is Scotland’s national child oral health improvement programme. To support the delivery of prevention in general dental practice in keeping with clinical guidelines, Childsmile sought accreditation for extended duty training for dental nurses to deliver clinical preventive care. This approach has allowed extended duty dental nurses (EDDNs) to take on roles traditionally undertaken by general dental practitioners (GDPs). While skill-mix approaches have been found to work well in general medicine, they have not been formally evaluated in dentistry. Understanding the factors which influence nurses’ ability to fully deliver their extended roles is necessary to ensure nurses’ potential is reached and that children receive preventive care in line with clinical guidance in a cost-effective way. This paper investigates the supplementation of GDPs’ roles by EDDNs, in general dental practice across Scotland.

Methods

A cross-sectional postal survey aiming to reach all EDDNs practising in general dental practice in Scotland was undertaken. The survey measured nurses’: role satisfaction, perceived utility of training, frequency, and potential behavioural mediators of, preventive delivery. Frequencies, correlations and multi-variable linear regression were used to analyse the data.

Results

Seventy-three percent of practices responded with 174 eligible nurses returning questionnaires. Respondents reported a very high level of role satisfaction and the majority found their training helpful in preparing them for their extended role. While a high level of preventive delivery was reported, fluoride vanish (FV) was delivered less frequently than dietary advice (DA), or oral hygiene advice (OHA). Delivering FV more frequently was associated with higher role satisfaction (p < 0.001). Those nurses who had been practising longer reported delivering FV less frequently than those more recently qualified (p < 0.001). Perceived difficulty of delivering preventive care (skills) and motivation to do so were most strongly associated with frequency of delivery (p < 0.001 for delivery of FV, DA and OHA).

Conclusions

This study has provided insight into EDDNs’ experiences and demonstrates that with appropriate training and support, EDDNs can supplement GDPs’ roles in general dental practice in Scotland. However, some barriers to delivery were identified with delivery of FV showing scope for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6831-14-137) contains supplementary material, which is available to authorized users.

Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England

BACKGROUND

Research suggests that health professionals who have trained together have a better understanding of one another's scope of practice and are thus equipped for teamwork during their professional careers. Dental hygiene-therapists (DHTs) are mid-level providers that can deliver routine care working alongside dentists. This study examines patterns of delegation (selected tasks and patients) by dental students to DHT students training together in an integrated team.

METHODS

A retrospective sample of patient data (n = 2,063) was extracted from a patient management system showing the treatment activities of two student cohorts (dental and DHT) involved in team training in a primary care setting in the South of England over two academic years. The data extracted included key procedures delegated by dental students to DHT students coded by skill-mix of operator (e.g., fissure sealants, restorations, paediatric extractions) and patient demography. χ2 tests were conducted to investigate the relationship between delegation and patient age group, gender, smoking status, payment-exemption status, and social deprivation.

RESULTS

A total of 2,063 patients managed during this period received treatments that could be undertaken by either student type; in total, they received 14,996 treatment procedures. The treatments most commonly delegated were fissure sealants (90%) and restorations (51%); whilst the least delegated were paediatric extractions (2%). Over half of these patients (55%) had at least one instance of delegation from a dental to a DHT student. Associations were found between delegation and patient age group and smoking status (P <0.001). Children under 18 years old had a higher level of delegation (86%) compared with adults of working age (50%) and patients aged 65 years and over (56%). A higher proportion of smokers had been delegated compared with non-smokers (45% cf. 26%; P <0.001).

CONCLUSIONS

The findings suggest that delegation of care to DHT students training as a team with dental students, involved significantly greater experience in treating children and adult smokers, and providing preventive rather than invasive care in this integrated educational and primary care setting. The implications for their contribution to dentistry and the dental team are discussed, along with recommendations for primary care data recording.

Dental therapists/hygienists working in remote-rural primary care: a structured review of effectiveness, efficiency, sustainability, acceptability and affordability

AIM

To examine the use of dental therapist/hygienists to provide primary dental treatment in remote-rural areas with regard to their effectiveness, efficiency, sustainability, acceptability and costs (affordability).

METHOD

The structured literature review of studies indexed in Medline, Embase and CinAHL was conducted using search terms relevant to 'dental therapists' and 'remote-rural'. Remote-rural was defined as 'those (individuals) with a greater than 30-minute drive time to the nearest settlement with a population of greater than 10,000'.

RESULTS

From 1,175 publications screened, 21 studies from 19 publications were initially included. Only seven studies were included that explicitly focused on remote-rural areas. Four were surveys and three were qualitative studies. All of the included studies were reported within the last 7 years. The methodological quality of the surveys varied, particularly with regard to their response rates. All three of the qualitative studies were assessed as potentially weak methodologies. Regarding the research question, none of the studies included provided data relevant to understanding efficiency, cost issues or the acceptability of dental therapists. The available empirical evidence contained only indirect indicators about the sustainability of dental therapy in rural areas.

CONCLUSIONS

The available data indicates that dental therapist/hygienists have suitable skills and could constitute a valuable asset to meet the dental demands in remote-rural areas. However, the evidence base is limited and of a poor quality. There is a need to put in place 'well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce'.

The influence of population oral health on the dental team

This presentation focuses on the use of dental therapists as substitutes for dentists in the provision of some aspects of dental care. Our premise is that the use of therapists is a 'good thing' if it delivers a higher quality service. The care that may be provided by therapists is appropriate to population needs. They have been used to increase access to care in a number of countries by supplementing the volume and reach of services, which enhances equity. Therapists are socially acceptable where they are integrated into existing dental systems, but concerted work may be necessary to increase their acceptability if their use is to be introduced or expanded elsewhere. There is no reason to suspect that therapists offer less effective care than dentists, and available data are compatible with this view. More data may be required to lend political support for their greater use. The efficiency of teams is sensitive to the way in which they are organized and funded. Substitution of dentists by therapists within small dental teams creates complexities and costs that reduce efficiency. Conversely, where therapists can work with relative independence, diagnosing and treating patients without direct supervision, then efficiency may be high. Despite opportunities for improving the quality of care, the main barrier for increasing their use is the dental profession. Dental organizations tend to act as guilds, preventing or restricting the deployment of therapists. Dental public health practitioners therefore have a role as advocates for their greater use. At present, the use of therapists does not appear to be influenced by the health of the population.

Dental hygienists and therapists: how much professional autonomy do they have? How much do they want? Results from a UK survey

OBJECTIVES

To investigate autonomous working among singly and dually qualified dental hygienists and therapists in UK primary care. Earlier studies and policy papers suggest that greater autonomy for these groups may be a desirable workforce planning goal.

METHODS

UK-wide postal surveys of hygienists, hygienist-therapists and therapists. Respondents were asked whether they undertook 15 clinical activities on their own initiative, how comfortable they would feel undertaking such clinical activities if referral from a dentist were not required, and how they perceived dentists' reactions.

RESULTS

Overall response rate was 65% (n = 150 hygienists, 183 hygienist-therapists and 152 therapists). Over 80% of hygienists and hygienist-therapists reported undertaking BPEs, history-taking, pocket charting, mucosal examinations and recall interval planning autonomously. Similarly high proportions of hygienist-therapists and therapists reported giving local analgesia and choosing restorative materials autonomously. However, fewer than 50% of all three groups said they undertook dental charting, fissure sealing, resin restorations, taking radiographs, and tooth whitening autonomously. While confidence in undertaking such activities without a dentist's referral was generally high, it was lower in respect to mucosal examinations, identifying suspicious lesions, interpreting radiographs, tooth whitening, and (except for singly qualified dental therapists) diagnosing caries.

CONCLUSIONS

Results suggest high levels of experience and confidence in their ability to work autonomously across a wide range of investigative activities, treatment decision-making and treatment planning. The exceptions to this pattern are appropriate to the different clinical remit of these groups.

Is skill mix profitable in the current NHS dental contract in England?

The use of skill mix in medicine is now widespread, yet it appears that its use in dentistry is not as prominent. Unlike doctors, dentists are required to mitigate the financial risk produced by their capital investment and ensure an adequate cash flow to cover their annual running costs. Examining the financial incentives for employing dental care professionals is therefore an important step to understand why dentistry appears to lag behind medicine in skill mix. It is also apposite, given the announcement of the coalition government to develop a new contract, which could introduce incentives for the use of dental care professionals in this way. The purpose of this short paper is to examine whether skill mix is profitable for general dental practices under the existing NHS contract in England.

Examining whether dental therapists constitute a disruptive innovation in US dentistry

Dental therapists-midlevel dental providers who are roughly analogous to nurse practitioners in medicine-might constitute a disruptive innovation within US dentistry. Proponents tend to claim that dental therapists will provide more equitable access to dental care; opponents tend to view them from a perspective that focuses on retaining the current attributes of the dental profession. Therapists display traits similar to those of disruptive innovations: their attributes are different from dentists', they may not initially be valued by current dental patients, they may appeal to current dental underutilizers, and they may transform the dental delivery system. Whether dental therapists constitute a disruptive innovation will only be determined retrospectively.