Abstract image of a woman sitting on books and studying on a laptop

DHT Handbook full

J
Julie Bissett

Fiona Sandom introduces the 2015-2016 DH&T Handbook, noting key developments in the previous year including the NHS focus on preventative care and skill mix teams. She discusses the role of dental therapists in improving access to care and oral health statistics. As BADT president, her goals are to raise the profile of dental therapy through outreach, media exposure, and education to empower patients. The handbook provides perspectives and evidence to inspire readers to advance their profession.

1 of 117
Downloaded 30 times
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
HandbookThe perfectly informed companion for dental hygenists and therapists 2015-2016 2015-2016Handbook
3 Introduction Foreword by BADT President Fiona Sandom Fiona Sandom says be inspired to raise your voice to the benefit of all I suspect the answer lies in a multitude of topics and new developments, not least of which is the drive by NHS England to harness a skill mix to deliver dentistry within an environment of preventive care. The NHS contract places pressure on all NHS practices to offer care within a primary dental fter being invited to write a foreword for this handbook generously sponsored by Dental Protection, I considered what were the key oral health developments in 2015 that will make this handbook current and an essential read for dental hygienists and therapists. A www.dentistry.co.uk Introduction
4 Introduction Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists. healthcare setting that is accessible to all – whilst maintaining financial viability. As we are all acutely aware, the business of dentistry is not immune to the current economic turmoil and it is, therefore, a tricky balance to strike. The debate that the skills of a dental therapist are, therefore, a cheaper route to care for many – and so more financially viable for government – is only part of the story. Improving the current dental health statistics Despite the naysayers, I truly believe that allowing dental therapists to use their whole scope of practice in general dental practice can empower dental phobics and other reluctant patients to engage actively in preventive oral healthcare, and this will ultimately lead to improving the current dental health statistics. As healthcare workers, surely we all need to be singing from the same song sheet if we are to raise public awareness of the importance of good habits, whether we are GPs, nurses or fellow members of the dental team. How care is delivered and who delivers it is inevitably a region-specific conundrum – with care in the valleys of Wales (my particular patient base) differing greatly from my London colleagues, for example. Access remains a challenge in places, and I do see a future that welcomes with open arms the skills of dental hygienists and therapists – especially in remote and rural areas of the UK. The media focus on the nation’s health, what they put in their mouths and how this affects their overall well being does not look set to disappear – and I feel it is here where we need to seize an opportunity caused by ‘hooking’ our home care hygiene instruction on the much-publicised demise of the western world’s health status. When I took over the presidency of the BADT last year, I vowed that my main aim was to raise the profile of dental therapy. It’s been a tough enough call amongst fellow dental professionals, but the rest of council and I have cast our net further afield – to the general public. A two-pronged attack My modus operandi is a two-pronged attack. I have reached out to other dental associations, secured two chief dental officers of England to speak at our annual conference last month (September) and am currently in ongoing conversations with the BDA about how best to get the UK dentally fit. I have also pledged to work towards changing the ‘unfair’ status quo on prescribing rights for dental therapists and hygienists. Alongside this, our council is heavily committed to media exposure – not the unpleasant experience that dentistry usually gets, but of a more informative variety. Via blogs on national health websites and in local newspapers and online forums, we are trying to raise the profile of dental therapy in the hope that patients will wake up to their own health risks as well an alternative route to care. As a dental therapist in North Wales Community Dental Services, I am acutely aware of what needs to be done and how it can best be achieved. As a postgraduate tutor at Cardiff University, I am equally passionate about how the next generation must help to raise the profile of this profession. I see education as a key to driving forward the role of hygienists and therapists – within dentistry, amongst newly qualifieds and, especially, with our patients. With change comes opportunity, and this DH&T Handbook offers perspectives and evidence on both. So, read on and be inspired to raise your voice to the
6 Introduction ContentsIntroduction 3 Foreword - Fiona Sandom 8 Acknowledgements 10 How this handbook works - Julian English New beginnings 14 Career checklist 16 First tasks 18 Registration and standards 19 Scope of practice 22 Reflective learning 24 CPD 26 Direct access 28 Foundation Traning Career options 32 CV and interview techniques 34 Extended duties 36 Career pathways 40 Salaried services 42 Remuneration and charging Organisations and associations 44 BSDHT update 46 BADT update 50 Key associations Clinical protocols 56 BPE scoring 58 Periodontal disease 61 Tooth notation 62 Periodontal disease and systemic health 64 Implant maintenance 66 Developing dentition 68 Xerostomia - Charlotte Wake 70 Xerostomia - Bal Chana 72 Tooth whitening 75 BADT minimally invasive dentistry 76 Treating endodontically-exposed implant threads 78 Minimally invasive dentistry 80 Dentine hypersensitivity
7 Introduction General practice 83 Referral letter template 84 Caries risk from sports drinks 86 Prescription-only medicines 87 Caring for the orthodontic patient 88 Avoiding needlestick injuries 90 Bruxism 91 Recall interval guidelines 92 Radiography and radiation protection 96 Medical emergencies: resuscitation 100 Oral cancer - early detection 102 Working with the elderly 104 Photography 106 Eating less sugar 108 Educating patients on sugar consumption 110 Increasing access 112 Social inequalities Indemnity and governance 116 Indemnity partnerships 118 Handling complaints 122 Social media usage 124 Good communication practices Glossary 126 Abbreviations www.dentistry.co.uk
6 Introduction Acknowledgements November 2015 FMC, Hertford House, Farm Close, Shenley, Hertfordshire WD7 9AB Tel: 01923 851777 Fax: 01923 851778 Website: www.dentistry.co.uk/oral-health-dental-hygiene-news/ Editorial: Julian English, julian.english@fmc.co.uk Editorial: Charlotte Lloyd, charlotte.lloyd@fmc.co.uk Editorial: Sophie Bracken, sophie.bracken@fmc.co.uk Designer: Brendan Morrell, brendan.morrell@fmc.co.uk Designer: Corin Skeggs, corin.skeggs@fmc.co.uk Head of production: Laurent Cabache, laurent.cabache@fmc.co.uk Production manager: K-Marcelyne McCalla, k-marcelyne.mccalla@fmc.co.uk Advertising manager: Tim Molony, tim.molony@fmc.co.uk Authors and advisers Scott Froum, New York dentist Graham Hart, radiography and IRMER regulations expert Debbie McGovern, chair of the BADT Baldeesh Chana, past president of BADT Heather Richardson, Browns Locumlink Pat Popat, dental hygienist and winner of DH&T’s Best Treatment of Nervous Patients 2014 Christina Chatfield, Brighton hygienist and owner of Dental Health Spa and winner of DH&T’s Dental Hygienist of the Year 2012 Charlotte Wake, dental hygienist and therapist Leon Bassi, dental hygienist at Bridge Dental, London Leanne Barwick, winner of DH&T’s Best Young Hygienist 2014 Julie Rosse, president of BSDHT Melanie Joyce, dental therapist Gareth Grimes, sales development manager, Astek Innovations Amanda Gallie, dental therapist, president-elect of the BADT Robiha Nazir, dental hygienist Damien Walmsley, specialist in prosthodontics Leigh Hunter, dental therapist and hygienist Fiona Sandom, dental therapist, president of the BADT Juliette Reeves, an expanded-duties hygienist and nutritionist Diane Rochford, dental hygienist and clinical coach for Jameson Management Mhari Coxon, registered dental hygienist and dental and senior professional marketing and relations manager for Philips Oral Healthcare, UK & Ireland Sheila Scott, consultant for dental business and dental practice management Henry Clover, former general dental practitioner and deputy chief dental officer for Denplan Kirstie Thwaites, dental hygienist and therapist Joe Ingham, Dental Protection Katrina Matthews, primary care dental therapist and manager
7 Introduction dentalhygienetherapy.co.uk Email subscriptions@fmc.co.uk to request a copy: £20 each. Printed by: Headley Bros, Kent ISSN: 2044-1436 The DH&T Handbook is an annual publication available to a controlled circulation of subscribers to Dental Hygiene & Therapy magazine. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form, including photocopies and information retrieval systems. The DH&T Handbook makes every effort to report clinical information and manufacturer’s product news accurately but cannot assume responsibility for the validity of product claims or for typographical errors. The publishers also do not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of the DH&T Handbook. Without the support of our sponsor, we could not have produced this publication. The DH&T Handbook would like to thank the team at Dental Protection and, in particular, communications manager David Croser, for an ongoing commitment to excellence in dental hygiene and therapy. We would also like to thank: Dental Hygiene & Therapy magazine British Society of Periodontology British Society for Dental Hygiene & Therapy British Association of Dental Therapy Ivoclar Vivadent Tepe Information contained in this handbook is believed to be correct at the time of going to press. The publishers also do not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of the DH&T Handbook or Dental Protection.
10 Introduction A guiding handJulian English welcomes you to the DH&T Handbook 2015 – an essential reference guide designed to help you with all aspects of dental therapy and dental hygiene reading, covering all aspects of dental hygiene and therapy. A quick scan of the handbook’s contents and sections should confirm its intentions. It is our aim and genuine belief that a dental therapist and hygienist can read this publication and find useful information within, and have genuine cause to retain it as an essential reference guide. The handbook contains the most up-to-date guidance, rules, regulations and best practice for dental therapists and dental hygienists. Enthusiasm, hard work and dedication have been poured into the production of the DH&T Handbook from the editorial team at FMC and all the contributors and sponsor Dental Protection. Nothing less than 100% dedication is required to produce a publication like this. I hope you enjoy it and find it of benefit and use. H&T magazine welcomes you to its guide to professional life. The intention of this guide is to produce a concise and entirely relevant handbook of practical information and advice to assist undergraduates, new graduates, and even the experienced dental therapist and dental hygienist practising in this professional landscape. This handbook has been compiled by the editorial team of DH&T magazine, with input from some of the opinion leaders in the profession. This includes the significant input from the dentolegal experts at Dental Protection, one of the leading UK defence organisations supporting therapists and hygienists throughout their career. There are more than 100 pages of essential D
13 Newbeginnings New Beginnings
14 Newbeginnings Set sailBal Chana’s top tips on cruising into the uncharted waters of dentistry ndergraduate training provides the basic skills required to gain qualification. Through experience and continuing professional development one develops and enhances one’s skills. Dentistry is a career that involves lifelong learning. The first stage of the journey is to identify needs, define goals and have a basic route towards a successful career in dentistry that will lead to great opportunities. U
15 Newbeginnings Career checklist 1 Work within a team environment and communicate. Look through your patient list and plan how you wish to work through the day. Do not struggle – ask for help if required. Have aide memoires (crib sheets) to help with treatment protocols, eg, history taking, treatment planning, etc. Use the skills of your dental nurse; an experienced dental nurse will literally hold your hand and guide you through the day. 2 Have a professional development plan (PDP). A PDP is defined as ‘a structured and supported process undertaken by an individual to reflect upon their own learning, performance and/or achievement and to plan for their personal, educational and career development’. • What would you like to achieve in the next five years, where do you see yourself in five years? A PDP will give you greater confidence in the skills, qualities and attributes that are required. 3 Work within your scope of practice and competency. If you feel treatment is beyond your competency, liaise with the prescribing dentist and either refer back, ideally if within your scope of practice, then get the dentist to guide you through the treatment. This will help you gain confidence and enhance your skills. 4 Join your professional associations. The benefits are: • An association supports members in all matters relative to their chosen profession, ranging from education, clinical techniques, employment and personal development • Members receive a professional journal and newsletters throughout the year • Reduced fees at national conferences and regional study days • Dedicated phone line and email address for advice and help from an experienced team • Forums for advice and discussion on the website • Networking opportunities with fellow professional • Tax relief on membership fees. 5 Continual professional development (CPD) – Patient safety is paramount. As a registrant of the GDC, one has to meet certain standards. The GDC expects professionals to: • Uphold and follow the required standards and any additional guidance (the standards guidance is a code of behaviour that registrants are required to abide by in order to safeguard the patient) • Maintain CPD – it is vital to keep your skills and knowledge up-to-date. 150 hours of CPD must be completed over a five-year cycle, with a minimum of 50 hours must be verifiable. You are also recommended to complete three core subjects which are: medical emergencies, infection control and decontamination and radiography and radiation protection • You are also expected to keep up to date in areas such as legal and ethical issues and handling complaints. Only CPD carried out within your cycle can be counted. www.dentistry.co.uk Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006.
16 Newbeginnings Plain sailing: first tasks You’re qualified and now raring to meet your first patients. There are some essential steps you need to take o, you’re now qualified and ready to jump headfirst into the exciting world of dentistry, but there are a few crucial steps you need to take first. They might seem like boring admin issues that you can push to one side, but it’s worth doing them straight away because, of course, it’s all just plain sailing after that… General Dental Council The General Dental Council (GDC) regulates dental professionals in the UK. By law, you must register with the council in order to legally practise in this country. The GDC protects patients and the profession S alike, dealing with standards of care, complaints, fitness to practise hearings and quality assurance through continuing professional development. Indemnity/defence organisations Dental Protection looks after the interests of dental hygienists and therapists in the UK. Its services You’re now qualified and ready to jump headfirst into the exciting world of dentistry...
17 Newbeginnings Essential steps 1 Register with the General Dental Council 2 Sickness insurance is optional, but recommended 3 Joining the BSDHT or the BADT is recommended 4 Joining the British Dental Health Foundation is recommended 5 Plan your career right now and take action. www.dentistry.co.uk include: • Access to defence and indemnity against claims for clinical negligence • Safeguarding professional reputation • Assisting in complaints and replying to them • Representing the clinician in court and at committees of investigation • Advising in matters affecting the DCP’s professional career • Representing the dental team’s interests in matters affecting the profession in general. Sickness insurance Sickness insurance providers to the UK’s dental profession include Dentists & General. Dentists & General is a friendly society and, as such, is a non-profit making organisation that enables a lump sum to be paid on retirement. The fund for this sum grows yearly by appointment of company profit and interest. The BSDHT The British Society of Dental Hygiene and Therapy welcomes members who are dental hygienists, dental hygienist-therapists and students. The BSDHT is a major organisation within dentistry that exists to represent your interests. The BADT The British Association of Dental Therapists promotes the advancement of dental therapy within the dental profession. Membership is available to all qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership). The BDHF The British Dental Health Foundation is a charity aimed at promoting oral health to the public. It provides a range of resources including leaflets, posters, stickers, books, DVDs and dental motivators to help educate and motivate patients.
18 Newbeginnings Registration and standardsJulian English presents the nine standards expected of a dental professional Registration with the GDC depends upon certain criteria – namely those with a recognised UK qualification. If you do not have a recognised UK qualification, please check the following points to see if you can have your qualification and/or experience assessed. If the assessment is successful, your name will be entered onto the DCP’s register. Assessment is available for those with a formal qualification from an EEA Member State or overseas. Those that are unsure should fill out the ‘route to registration’ questionnaire. You can find out if you are able to apply for registration, if your qualifications may need to be assessed, or if you need to pass the overseas registration exam before you can register. Standards The GDC, which holds the register of hygienists, also provides guidance to its registrants on a number of topics, including advertising, indemnity, prescribing medicines, using social media, child protection and GDC standards. The document sets out the standards of conduct, performance and ethics that govern you as a dental professional. It With more than 20 years’ experience at the helm of multi-award-winning Dentistry magazine and numerous other dental journals, editorial director of FMC, Julian, is a well-known face in the dental publishing industry. He is also a member of the editorial committee of the British Dental Industry Association. Julian attends many events at home and overseas throughout the year. specifies the principles, standards and guidance that apply to dental hygienists and therapists. There are nine standards, which set out what is expected and what patients expect. The principles must be kept at all times. They are: 1. Put patients’ interests first 2. Communicate effectively with patients 3. Obtain valid consent 4. Maintain and protect patients’ information 5. Have a clear and effective complaints procedure 6. Work with colleagues in a way that is in patients’ best interests 7. Maintain, develop and work within your professional knowledge and skills 8. Raise concerns if patients are at risk 9. Make sure your personal behaviour maintains patients’ confidence in you and the profession. You have an individual responsibility to behave professionally and follow these principles at all times. Reference www.gdc-uk.org/Dentalprofessionals/ Applyforregistration/Pages/default.aspx retrieved 13/10/15
19 Newbeginnings Scope of Practice he scope of your practice is a way of describing what you are trained and competent to do. It describes the areas in which you have the knowledge, skills and experience to practise safely and effectively in the best interests of patients. Orthodontic therapists Orthodontic therapists are registered dental professionals who carry out certain aspects of orthodontic treatment under prescription from a dentist. As an orthodontic therapist, you can undertake the following if you are trained, competent and indemnified: • Clean and prepare tooth surfaces ready for orthodontic treatment • Identify, select, use and maintain appropriate instruments • Insert passive removable orthodontic appliances • Insert removable appliances activated or adjusted by a dentist • Remove fixed appliances, orthodontic adhesives and cement • Identify, select, prepare and place auxiliaries • Take impressions • Pour, cast and trim study models • Make a patient’s orthodontic appliance safe in the www.dentistry.co.uk T absence of a dentist • Fit orthodontic headgear • Fit orthodontic facebows that have been adjusted by a dentist • Take occlusal records including orthognathic facebow readings • Take intraoral and extraoral photographs • Place brackets and bands • Prepare, insert, adjust and remove archwires previously prescribed or, where necessary, activated by a dentist • Give advice on appliance care and oral health instruction • Fit tooth separators and bonded retainers • Carry out Index of Orthodontic Treatment Need (IOTN) screening either under the direction of a dentist or direct to patients • Make appropriate referrals to other healthcare professionals • Keep full, accurate and contemporaneous patient records • Give appropriate patient advice. Additional skills that orthodontic therapists could develop include: With more than 20 years’ experience at the helm of multi-award-winning Dentistry magazine and numerous other dental journals, editorial director of FMC, Julian, is a well-known face in the dental publishing industry. He is also a member of the editorial committee of the British Dental Industry Association. Julian attends many events at home and overseas throughout the year. Julian English discusses the scope of practice for orthodontic therapists, dental hygienitsts and dental therapists
20 Newbeginnings • Applying fluoride varnish to the prescription of a dentist • Repairing the acrylic component part of orthodontic appliances • Measuring and recording plaque indices • Removing sutures after the wound has been checked by a dentist. Orthodontic therapists do not: • Modify prescribed archwires • Give local analgesia • Remove sub-gingival deposits • Re-cement crowns • Place temporary dressings • Diagnose disease • Treatment plan as these tasks are reserved to dental hygienists, dental therapists or dentists. Orthodontic therapists do not carry out lab work other than that listed above as that is reserved to dental technicians and clinical dental technicians. Dental hygienists Dental hygienists are registered dental professionals who help patients maintain their oral health by preventing and treating periodontal disease and promoting good oral health practices. They carry out treatment direct to patients (direct access) or under prescription from a dentist. As a hygienist, you can undertake the following if you are trained, competent and indemnified: • Provide dental hygiene care to a range of patients • Obtain a detailed dental history from patients and evaluate their medical history • Carry out a clinical examination within their competence • Complete periodontal examination and charting and use indices to screen and monitor periodontal disease • Diagnose and treatment plan within their competence • Prescribe radiographs • Take, process and interpret various film views used in general dental practice • Plan the delivery of care for patients • Give appropriate patient advice • Provide preventive oral care to patients and liaise with dentists over the treatment of caries, periodontal disease and tooth wear • Undertake supragingival and subgingival scaling and root surface debridement using manual and powered instruments • Use appropriate antimicrobial therapy to manage plaque-related diseases • Adjust restored surfaces in relation to periodontal treatment • Apply topical treatments and fissure sealants • Give patients advice on how to stop smoking • Take intraoral and extraoral photographs • Give infiltration and inferior dental block analgesia • Place temporary dressings and re-cement crowns with temporary cement • Place rubber dam and take impressions • Care of implants and treatment of peri-implant
21 Newbeginnings www.dentistry.co.uk tissues • Identify anatomical features, recognise abnormalities and interpret common pathology • Carry out oral cancer screening • If necessary, refer patients to other healthcare professionals • Keep full, accurate and contemporaneous patient records • If working on prescription, vary the detail but not the direction of the prescription according to patient needs. Additional skills that dental hygienists might develop include: • Tooth whitening to the prescription of a dentist • Administering inhalation sedation • Removing sutures after the wound has been checked by a dentist. Dental hygienists do not: • Restore or extract teeth • Carry out pulp treatments • Adjust unrestored surfaces. Other skills are reserved to orthodontic therapists, dental technicians, clinical dental technicians or dentists. Dental therapists Dental therapists are registered dental professionals who carry out certain items of dental treatment direct to patients or under prescription from a dentist. As a dental therapist, you can undertake the following if you are trained, competent and indemnified: • Obtain a detailed dental history from patients and evaluate their medical history • Carry out a clinical examination within their competence • Complete periodontal examination and charting and use indices to screen and monitor periodontal disease • Diagnose and treatment plan within their competence • Prescribe radiographs • Take, process and interpret various film views used in general denal practice • Plan the delivery of care for patients • Give appropriate patient advice • Provide preventive oral care to patients and liaise with dentists over the treatment of caries, periodontal disease and tooth wear • Undertake supragingival and subgingival scaling and root surface debridement using manual and powered instruments • Use appropriate antimicrobial therapy to manage plaque-related diseases • Adjust restored surfaces in relation to periodontal treatment • Apply topical treatments and fissure sealants • Give patients advice on how to stop smoking • Take intraoral and extraoral photographs • Give infiltration and inferior dental block analgesia • Place temporary dressings and re-cement crowns with temporary cement • Place rubber dam and take impressions • Care of implants and treatment of peri-implant tissues • Carry out direct restorations on primary and secondary teeth • Carry out pulpotomies on, and extract, primary teeth • Place pre-formed crowns on primary teeth • Identify anatomical features, recognise abnormalities and interpret common pathology • Carry out oral cancer screening • If necessary, refer patients to other healthcare professionals • Keep full, accurate and contemporaneous patient records • If working on prescription, vary the detail but not the direction of the prescription according to patient needs. Additional skills that dental therapists could develop include: • Carrying out tooth whitening to the prescription of a dentist • Administering inhalation sedation • Removing sutures after the wound has been checked by a dentist All other skills are reserved to orthodontic therapists, dental technicians, clinical dental technicians or dentists.
22 Newbeginnings Back to basicsThroughout your professional career, it is important to have a structured approach to your learning. Here, BADT president Fiona Sandom reflects on how best to shape your future safely and successfully uring your time as a student, your education is supported by lecturers within a carefully monitored environment. They provide feedback and guidance in order that you develop clinically. On qualification, there is then an expectation upon you to continue this process using different platforms, and a requirement to formulate and demonstrate by the GDC. Keeping abreast of new skills and knowledge is at the heart of dentistry and a commitment to the regulatory continuing professional development (CPD) is only a part of this. Keep a log A reflective log is a way of thinking in a critical D and analytical way about your work in progress. Self-evaluation is a key part of learning and keeping written reflective logs each time you take a new step is an essential part of your personal development activity. There is no standard format for a reflective log – but there are many templates available. Genuinely identifying areas for development means a clinician needs: • Focus – to pinpoint key areas for improvement • Courage – to recognise when something is wrong, however uncomfortable this may be • Honesty – to address the problem and, if needs be, share this with a mentor or trusted colleague and find a solution together. Reflective learning is an ongoing process, but
23 Newbeginnings www.dentistry.co.uk there are key moments when this may prove fruitful. • In times of innovation. Before offering new treatments, ask yourself why you should do so, what this will achieve for you and your patient and whether it is realistically achievable. So, if you are considering offering tooth whitening, for example, fully consider the skills you need to do so safely, which courses you will attend (and when and why) and how you will implement them in practice • When with colleagues. Making time to reflect with others on what you have learned, what you will do the same or differently as a result and whether your learning needs have changed, is essential. As well as developing your performance, it also fosters a confident, safe and competent dental team • When considering your next step. There is a propensity by many of us to learn what we already know and sit tight in our comfort zone. A reflective log is useful in identifying strengths and weaknesses and highlights the clinical skills with which we are less familiar or use less often. Seeking courses in these latent skills will only serve to develop you as a clinician • During research. The internet has opened up our access to knowledge – not always for the good. Auditing what you have read is an important part of the learning process and a reflective log aids in our assimilation of clinical information. Just like information accessed in books and journals, be sure to dispense with anything found online that does not have its roots in current scientific thinking as is therefore not evidence based. Increasingly, regulators are expecting the dental team to use a personal development plan (PDP). A PDP can identify goals for the forthcoming year and methods for achieving these goals and can work in tandem with a reflective log. Although not currently a requirement of the GDC (unless the registrant has had conditions placed upon them following a GDC inquiry), it is nevertheless a recommendation. The GDC maintains: ‘You are highly recommended to use a personal development plan (PDP), to help you make good CPD decisions, and review it regularly, ideally with an appropriate colleague. ‘Holding and maintaining a PDP will also enable you to identify your learning needs and consider them in a structured way.’ Confidence It’s the aim of the dental team to provide high quality oral healthcare to patients who are confident in their standards and are acting in their best interests at all times. A programme of CPD – together with comprehensive reflective practice and a well- considered (but flexible) PDP – supports this. Aims 1. To identify strengths and weaknesses 2. To improve and/or learn new skills 3. To consolidate these skills 4. To encourage a self-awareness 5. To improve performance and knowledge 6. To reflect on pathways 7. To offer respite from – and an outlet for – the stresses of a demanding workplace 8. To share with others in order to build a culture of openness and improvement. Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists.
24 Newbeginnings Love to learn As a registered dental care professional, you have a duty to keep your skills and knowledge up to date in order to give patients the best possible treatment and care. CPD is compulsory, but it should simply set out a formal framework for what you are already doing. What is CPD? CPD is an activity that contributes to your professional development. There are two kinds of CPD – general and verifiable. What is verifiable CPD? To count as verifiable CPD, an activity must have: • Concise educational aims and objectives • Clear anticipated outcomes • Quality controls • Documentary proof. A look at the many ways you can gain that all-essential CPD In other words, you should know what the activity is about and what you will learn, how it’s going to benefit your patients, whether you can provide feedback on the activity and that you will be given documentary proof (such as a certificate) that you carried out the activity. The certificate should come from the provider or organiser, and should show the number of hours you spent on the activity, your name and registration number, as well as the subject of the activity. How much CPD should I do? You must complete at least 150 hours of CPD over your five-year cycle. A minimum of 50 of these hours must be verifiable CPD. You must keep your CPD records for at least five years after the end of the cycle
25 Newbeginnings www.dentistry.co.uk in which they were completed. Which subjects should CPD cover? CPD is any activity that could reasonably be said to have benefitted you professionally, so you should use your own judgement when choosing subjects and activities. We recommend that you create a personal development plan, which will help you to meet your CPD requirement over your cycle. As well as your chosen areas there are three core subjects that we strongly recommend you complete as part of your verifiable CPD. The suggested minimum number of hours for dental care professionals in each subject are: • Medical emergencies - 10 hours per CPD cycle • Disinfection and decontamination - five hours per CPD cycle • Radiography and radiation protection - five hours per CPD cycle. We also recommend that you keep up to date by doing CPD in the following areas (verifiable or general, no suggested minimum number of hours): • Legal and ethical issues • Complaints handling • Oral cancer: improving early detection • Vulnerable children and adults. When do I start my CPD? Your CPD cycle is determined by your date of first registration. Your CPD cycle is always five years long, and this is the period in which you must complete your compulsory number of hours. You can break down your CPD each year in a way that works for you, but you should spread it out across your cycle as evenly as possible. Only CPD carried out within your cycle can be counted. Any activities you do before your cycle starts, or after it has ended, cannot be included. As a dental care professional, your first CPD cycle will start on 1 August after you register. Activities that count as CPD: • Courses and lectures • Distance learning • Private study • Journal reading • Multimedia learning • Training or study days • Educational elements of professional and specialist society meetings • Peer review and clinical audit • Background research. Information provided in this article comes directly from General Dental Council literature, by kind permission. If you have any questions about CPD, call 020 7167 6000, email information@gdc-uk.org or visit www.gdc-uk.org.
26 Newbeginnings Direct Access Charlotte Wake looks at the barriers and advantages of Direct Access ay 2013 saw a big shift to a new era in the world of dentistry with the introduction of Direct Access (DA). Direct Access is a term that reflects the exact meaning – it is the time when dental therapists and dental hygienists are able to work without a prescription and see a patient ‘directly’ without having seen the dentist first. As with any change there were, and are, people in agreement and disagreement. There were concerns about how patients would accept this and concern from within the profession about competency, workload and indeed whether this would be compulsory in daily work. The GDC provided some clarity with this statement: ‘Dental hygienists and dental therapists can carry out their full scope of practice without prescription and without the patient having to see a dentist first. The only exception to this is tooth whitening, which must still be carried out on prescription from a dentist. ‘Dental hygienists and dental therapists must be confident that they have the skills and competences to treat patients directly. A period of practice working to a dentist’s prescription is a good way to assess this. ‘Hygienists and therapists who qualified since 2002 should have covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything. However, many of these registrants will have addressed this via top-up training, CPD and experience. ‘Registrants who are unsure whether there are any gaps in their training should contact the dental school where they received their Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapists’ council, and is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice. M qualification, and check their indemnity arrangements before undertaking any new duties.’ It has been some time now since this new pathway was introduced and there are still some barriers in place that restrict the use of DA. More difficult to use in an NHS environment Currently it is only possible for a dentist who has a performer number to open and close a course of treatment. This means it is not possible for a dental hygienist or therapist to see a patient directly under the NHS. Prescription needed for local anaesthetic DA does not change the need to have a prescription to use local anaesthetic. This written prescription may come as a Patient Group Directive (PGD) or directly from the dentist. Tooth whitening and prescription only medication (POM) Again the introduction of DA does not change the need for a prescription if using any item labelled
27 Newbeginnings www.dentistry.co.uk as ‘POM’ or tooth whitening. This includes antibiotics, Duraphat toothpaste, topical fluoride and Ledermix. This prescription should be in writing. Advantages Direct Access would not have been introduced if it did not have advantages: Optional This is imperative. Use of Direct Access is optional. It is for each clinician to decide, if and when they will use DA. It is not compulsory. Promotes utilisation of skill mix DA allows you to undertake what is clinically necessary within your scope of practice. This encourages a therapist and hygienist to use all their skills. Increased access to dental care More patients are able to get appointments sooner as more clinical time is available. The importance of this must not be under emphasised. Able to see patient in an event of staff absence We have all been there when the dentist is not able to work, due to holiday or sickness and prior to DA if a new patient to the practice was booked then both those appointments would need to be re-scheduled. Now the patient is able to attend, for example, their hygiene treatment and return at a later date for their consultation with the dentist. Practice builder Offering DA can help build a practice and can become a unique selling point, certainly in situations where a hygiene appointment is requested prior to a major event such as a wedding. There are some key points that need to be acknowledged if you work with DA: • Make sure the patients know you are not a dentist and that there is a robust practice referral procedure in place should it be needed • Never work outside of your scope of practice or outside of your competency
28 Newbeginnings Dental foundation trainingA dental therapist foundation training programme provides a safe and secure transition from dental school to dental practice, highlights the BADT he purpose of dental foundation training for dentists is the first phase of continuing postgraduate education after graduation and is recognised as a part of career pathways in all sections of the dental profession. The purpose of dental therapist foundation training is similar and provides a structured introduction to working in dental general practice for dental therapists. There are two main strands of the programme, working in a protected environment within an approved practice that has been selected to provide training and mentoring. This is backed by a programme of study days, lectures and conferences organised by the Dental Postgraduate Education Department and tutorial/feedback sessions once a month with the practice trainer. The dental therapists who complete dental therapist foundation training are equipped with the necessary training and education required to continue to develop and expand the clinical and personal skills learnt as a student, and to gain the skills required to work successfully in a general dental practice environment. The positions in practice are usually part time and can be combined with split jobs in other practices or full time if the training practice T has the capacity. The BADT also support the development of a dental therapist foundation training programme, which provides a safe and secure transition from dental school to dental practice and the additional responsibilities that the NHS contract reform will give to dental therapists. Therapist Foundation Training Thames Valley and Wessex The Dental Therapist Foundation Training Scheme (TFT) is primarily aimed at newly qualified therapists to provide the initial stage of training and education required to practice in a general dental practice environment. Emphasis is placed on continuing professional development throughout the course. The therapist is encouraged to develop and expand the clinical and personal skills learned as a student. The scheme covers the Thames Valley and Wessex area (Berkshire, Buckinghamshire, Oxfordshire, Milton Keynes, Hampshire and the Isle of Wight). The programme, which will last for an academic year commences in September and is open to recently qualified therapists. Therapists will be employed within training practices, be allocated an approved trainer and attend the day-release
29 Newbeginnings www.dentistry.co.uk More information on the Dental Therapist Foundation Training Thames Valley and West Sussex scheme can be found at www.oxforddeanery.nhs.uk/dental_school/ therapist_foundation_training.aspx. For more information on the Welsh Dental Therapist Foundation Training Scheme, contact Kath Liddington at LiddingtonKE@cardiff.ac.uk, or telephone 02920 687 498. For further information regaring the West Midlands Foundation Training Scheme for Dental Therapists, contact Dr Steve Clements, programme director for Foundation Training Dental Therapy, HEWM Dental Team, St Chad’s Court, Hagley Road, Edgbaston, Birmingham, B16 9RG, or phone 0121 695 2587. For more general information contact Jane Ford, regional lifelong learning advisor. Contact via Judith Hunter at Judith.hunter@ne.hee.nhs.uk, or phone 0191 275 4714. educational programme organised by Oxford & Wessex Deaneries’ Dental School. Training Programme for Dental Therapists West Midlands Deanery The West Midlands Foundation Training Scheme for Dental Therapists was established in 2009 and is based on the Foundation Training Scheme for Dental Graduates. It is a structured introduction to NHS general dental practice for recently qualified dental therapists. The scheme is looking for suitable dentists and practices to provide a supportive environment for dental therapists. It is looking for recently qualified (or soon to be qualified) dental therapists who wish to pursue a career in NHS dentistry. Therapists will be based in practices around the West Midlands and attend monthly study days. Welsh Dental Therapist Foundation Training Scheme This programme provides a structured introduction to working in general practice for dental therapists. The two main strands of the programme are working in a protected environment within an approved practice that has been selected to provide training and mentoring. This is backed by a programme of study days, lectures and conferences organised by the department and tutorial/feedback sessions once a month with the practice trainer. The positions in practice are for two days a week so they can be combined with split jobs in other practices, or full time if the training practice has the capacity.
31 Careeroptions Career Options
32 Careeroptions The job of dreams Need a fresh challenge? Heather Richardson of Browns Locumlink offers some key tips to those of you seeking pastures new f a new challenge is required then what should you be bearing in mind if you wish to get the job of your dreams? Let’s start at the beginning… Your CV This may seem an obvious thing to say but it needs to be said because so many professionals still get it wrong. Do your best to avoid any gaps in your employment history. If there are gaps, make sure you can adequately explain them. People often tell me that they have taken information out to shorten the CV to one page – this is not always best. It is important that we see all relevant experience and skills, even if this goes on for a couple of pages. You do not, however, need to add every single detail. How far will you travel? It is wise to be realistic. Enure you have researched a journey before applying for a position; there is nothing worse than pulling out at the point you are asked for an interview, or worse if the job is offered and you decide the journey is too far to travel on a regular basis. DBS checks and GDC credentials As you would expect, these all need to be in order and up to date. I
33 Careeroptions Browns Locumlink is one of the UK’s leading recruitment agencies specialising in finding locum and permanent work for dental, pharmacy and most recently GP professionals. With over 30 years of experience, the company has worked with thousands of professionals across the UK. For those looking for cover, Browns Locumlink has a database consisting of hundreds of registered dental professionals (both clinical and non-clinical) and pharmacists looking for work. This means that the team can find the most suitable candidate for the position. Whether it is short notice, a sick day for example, holiday cover, simply high demand, or something longer term such as maternity leave, or permanent such as unexpected staff shortage, the team will try their hardest to ensure you are covered. Contact the team today to put them to the test! Visit www.brownslocumlink.com for more information. www.dentistry.co.uk References Do you have good, solid references? A potential employer will quite frequently wish to see at least two clinical references before offering a position to you. Ensure you have more than two referees that are reliable and that will respond quickly to a request. Current referees are preferable and it would always be questionable if you cannot supply these. Flexibility What type of role is it that you are looking for? A degree flexibility is key – always attend an interview with an open mind. Many opportunities arise at this point – the more flexible that you can be, the more posts will be open and available to you. Remuneration Quite possibly number one on your list. It is of course a vital part of the process and one of the most important reasons for choosing or not choosing a role. Your expectations need to be realistic, however. It is tough out there and many dental professionals can have an overvalued opinion of what they are worth. Depending on the role, are you looking for a salaried position or a day/hourly rate? Have in your mind the minimum that you will consider and be open and honest about the numbers with any potential employer. There is no point in accepting an offer that you feel is too low; a frank dialogue is in everyone’s best interests. Discuss periodic pay reviews or bonus/ target incentives. Conditions and benefits These can be somewhat overlooked as many push for the salary above all else. Pension provision, holidays and flexible working hours can make a ‘maybe’ job become a ‘definitely’. Even if you are on a paid by day rate, take a step back and look around. Are the team happy and upbeat? Do the patients seem comfortable and relaxed? Does the role offer longevity? Above all, could you be happy here? Appropriate dress and appearance for interviews This may come as somewhat of a surprise in a recruitment article for dental professionals. In our experience though, it is not uncommon for candidates to get it spectacularly wrong when attending an interview. All we suggest is that you give this some consideration – no matter the role, who you are meeting or what level of seniority you are looking to hold, professional, clean and well presented applies to all. Register with agencies you can trust It generally doesn’t cost anything to join an agency but choose with care and ideally a name that has been associated specifically with the healthcare profession for some time. Ensure you find out how the agency takes their fee if you are looking to take up locum work; could they take a percentage of your invoice? Browns will not charge you to receive notifications of work or any fee to arrange this. It is entirely free to be registered and work through us, all we ask for in return is loyalty and some compliance documents.
34 Careeroptions The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership). • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. ental hygienists and therapists may develop additional skills in line with the GDC Scope of Practice guidance. These extended duties are: • Carrying out tooth whitening to the prescription of a dentist • Administering inhalation sedation • Removing sutures after the wound has been checked by a dentist. Additional training Dental hygienists and therapists that qualified before 2002 may also need to undertake additional training in the following areas: • Prescribing radiographs • Impression taking • Local anaesthetics. Dental therapists that qualified before 2002 may D
35 Careeroptions Another string to your bowFiona Sandom considers your potential extended duties Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists. For more about the BADT, visit badt.org.uk. www.dentistry.co.uk also need to undertake additional training in: • Prescribing radiographs • Impression taking • Administering inferior dental block anaesthetic • Pulpotomies in deciduous teeth • Stainless steel crowns for deciduous teeth. It is important to remember that a dental hygienist or dental therapist should only carry out a task or treatment about a patient’s care if they have the necessary skills.
36 Careeroptions Voyage of discoveryWhat routes to new horizons will you consider in the future? Kirstie Thwaites offers a road map to some key destinations patients and will raise our profile. Here are a few options you may wish to consider... Perfect therapy The pilots currently testing the NHS dental contract reforms are rooted in the principle that the skill mix of the whole team is the best way to e have an important role in promoting good oral health and, with our GDC Scope of Practice ever expanding and NHS dentistry looking towards a team approach to care, our options are increasing. We should all have a desire to develop our skill set; it prevents clinical complacency, offers more treatment options to W
37 Careeroptions www.dentistry.co.uk deliver dentistry – suiting clinical outcomes, the changing needs of a population and government purse strings. There have been claims that the increasing use of dental therapists in NHS general practice is simply a government ploy to deliver dentistry on a budget. But, many forward-thinking practices are realising that the more holistic approach we offer is better suited to a patient base that’s living longer and remaining dentate. Dental therapists can
38 Careeroptions treat these patients while dentists can focus on delivering the more complex (and more lucrative) treatments that are going to be in demand. There are a number of training options for hygienists wishing to extend their skill set to expand their scope of practice as a dental therapist. The University of Bristol, for example, offers a two- year part-time course and the University of Essex offers a one-year full-time course whilst remaining in practice. State of independence There have been many developments in dentistry over the years and being able to work without the dentist on the premises has been a massive change for the hygienist and therapist. To date, very few of us have monopolised on direct access in this way, coinciding as it did with a long period of global economic turmoil. For those of you who braved it and now practise independently, I salute you for it will be your blood, sweat and tears on which other hygiene practices will be built. The challenges are many – having the capital to invest, securing support from dental dealers and ensuring there is a solid referral arrangement in place are among the few obvious ones. But, the rewards are many and it offers patients a different path to care. Brace yourself For those wishing to extend their scope of practice in orthodontic care, the Royal College of Surgeons, among others, offers a diploma in orthodontic therapy. An orthodontic therapist can carry out a limited range of orthodontic procedures such as the placement of brackets and changing of orthodontic arch wires. The GDC requires all orthodontic students to train for a minimum of 45 weeks full time but training on a part-time basis is also available. Visit www.gdc-uk.org/dentalprofessionals/ education/pages/orthodontic-therapist- qualifications.aspx for a full list of course providers. Periodontally yours Do you have the enhanced skills in advanced care needed in the new dental contract? Dental practices that do are likely to be commissioned Kirstie Thwaites qualified in 2006 from the University of Leeds as a dental hygienist and dental therapist. Since qualifying she has completed a PG Certificate in Medical & Clinical Education at the University of Essex and a two year postgraduate programme in Enhanced Skills in Clinical Periodontology at King’s College Hospital. At the 2012 DH&T Awards Kirstie was the recipient of the Young Hygienist/Therapist award. 
She has previously worked in NHS practice and as a clinical educator teaching student dental hygienists from the University of Essex, she now divides her working week between private general & specialist practice and lecturing at the University of Essex. Kirstie is the Editorial Council member for BADT. to provide specialised services. Periodontology is just one of those specialised services you could be commissioned to do. The University of Essex offers a MSc advanced periodontal practice course that provides an educational route for you to acquire valuable skills and knowledge in periodontology. For more information, visit www.essex.ac.uk/coursefinder/course_details. aspx?course=MSC+A40136. Go public! Public health experts help shape decisions made by government policy makers and develop national public health programmes. An understanding of oral health strategy – based on evidence- based research – forms a key part of a clinician’s understanding and should be the foundation on which we all develop our clinical skills. Equally, a masters degree in dental public health may also set you on a more academic pathway. Research Branching out into the field of research is an exciting path to tread. Continuing your education long after qualification can spark renewed interest in – and give you a fresh pair of eyes on – the complexities of our chosen profession. We all know that preventing and controlling dental disease requires an evidence-based approach,
39 Careeroptions www.dentistry.co.uk but conducting research provides the scientific understanding of what we offer patients and why. You also learn new skills when coordinating or collaborating in clinical trials. Some faculties offer opportunities, as do dental companies that are keen to road test new dental products. University teaching Inspired by your course tutor? Enjoy the role of mentor? You may wish to consider academia. BADT president, Fiona Sandom, says of her role: ‘I have taught dental nurses in north Wales since 1994 and still do as part of my CDS role. I enjoy it a great deal. Once I qualified as a dental therapist from Liverpool, I was offered a tutor post. A few years later, in 2004, the Wales Deanery created the DCP postgraduate education department, which at the time was very forward thinking. I enjoy the variety and opportunities that my tutor’s role brings me and last year I gained my MSc in medical education from Cardiff University.’ Hungry for nutrition Increasingly, the evidence that links nutrition, dental health and overall wellbeing is taking dental hygienists and therapists into other areas of healthcare. Hygienists are now developing skills as nutritionists in order to understand and educate patients in the systemic links and treat them with a ‘whole body’ approach. Teaching patients proper nutrition and guiding them to an improved quality of life is a vital part of your role. Elderly care A population with a higher number of older people will require dental care to be provided in different settings – in their own home or in residential care homes, for example. We will be required to collaborate a lot more with other health and social care professionals. Challenges such as increased prevalence of dementia within society will also need to be considered. The ageing population is one that will need careful nurturing. Their mental health and dexterity may be compromised but they may remain dentally fit. Hygiene protocols will have to be adapted in order to meet their needs and capabilities and, only with the proper training, will successful outcomes be achieved.
40 Careeroptions Be dynamic Salaried services – have DH&Ts forgotten about this vital role? Dental therapist Leon Bassi reviews this all- encompassing role challenging and dynamic. It provides you the opportunity to use your full skill set. The team is led by a consultant paediatric dentist. The dental y dental therapy career started at Bart’s and the London School of Medicine and Dentistry. Most graduates are lured towards the sparkle of private practice but, just before I graduated, a post of staff therapist was advertised. The post would be working on the paediatric department at the London Dental Institute with Bart’s Health Trust. Working as a staff therapist, on a children’s department, is M Leon Bassi is a dental therapist whose dental therapy career started at Bart’s and the London school of medicine and dentistry.
41 Careeroptions Rewardingly different I would urge any new graduate to seriously consider a position within salaried services if there is an opportunity. The salaried service will always struggle to lure new graduates to the service due to restraints on pay scales, in particular compared to that of private hygiene or therapy services, but the rewards is being able to use our full scope of practice. Dental nurses and dentists both have postgraduate qualifications in special care; dentists have a clear pathway for postgraduate training within paediatric dentistry and dental therapists should work towards more specialised postgraduate training. www.dentistry.co.uk hospital provides you with the chance to work within a multi-disciplinary team. The patient base is far reaching and broad. Paint a picture To give you an idea of a typical child patient referred to a dental therapist, imagine a picture of early childhood rampant caries. Most of the children we see have high treatment needs with DMFTS 10 and above, will be from a large family with several siblings, and will speak English as an additional language. Communication between the patient, parent and the dental team can be problematic so we often use health advocates to interpret; learning a few words of several different languages is extremely helpful. Acclimatising children into the dental surgery setting can take time, especially as they have experienced episodes of pain relating to their teeth; we have toys and models to help with this and use a passport system to encourage progress. With such a high caries rate in young children, methods such as the Hall’s technique is very useful; we have found it a successful way of treating carious second primary molar teeth. Many of these patients require teeth to be extracted, and this can be done in a surgery setting using inhalation sedation, which helps make the experience easier. However, if the treatment is not suitable or too extensive, a referral is made for general anaesthetic. State of transition Salaried services are currently undergoing dynamic and far-reaching changes. The NHS is in a state of transition, which has impacted on community dental services. There has been a spilt between commissioners who are funding the services and Many patients have complex medical histories: • Bleeding disorders • Global developmental delay • Cleft lip and palate • Severe learning difficulties • Heart problems • Conditions only seen in very rare circumstances. providers who are supplying the service. This means that community dental services can be tendered for, and bid on, by interested parties. A contract is then agreed on. Hospital services are having to deliver services with tighter budgets as dental hospital services are in increasing demand. The way healthcare services are being delivered is changing; hopefully there will be a continued role for dental therapists working in salaried service settings, even if this not under the umbrella of the NHS. As clinicians, we represent good economic value for providing patient care. Because of the way NHS dentistry is funded, it is very hard to conduct cost-benefit analysis as all UDAs generated by dental therapists are submitted under a dentist’s performance number. Hospital services are paid differently to that of the CDS, but we still need recognition of the role the therapist plays in reducing waiting lists and having a positive affect on a child’s dental health. As salaried services are increasingly being target driven, I hope dental therapists continue to be used to provide care for patients and, as a group, we should push for greater recognition of our role among the commissioners who are funding the service and hospital boards.
42 Careeroptions Fee setting and pay scales Julian English presents a guide to the highs and lows in fees charging and remuneration there are four basic payment methods. A hygienist’s salary is paid as either: 1. A fixed annual salary 2. Straight commission 3. A combination of salary and commission 4. Daily/hourly rates. Each method has advantages and disadvantages. With a straight salary, paid vacations and sick leave usually are included. This can provide financial security. However, it may not be as rewarding. There may be less incentive to fill broken appointments and to maintain a good patient-return rate. Straight commission is usually paid at 30-40% of a hygienist’s daily production. Some dentists pay more. References Boyer EM (1990) Methods of charging and the fees charged for dental hygiene services in traditional and non-traditional settings. J Dent Hyg 64(3):144-9 www.payscale.com/research/uk/Job=Dental_ Hygienist/Hourly_Rate Retrieved 13/10/15 everal studies have been conducted regarding fee setting, such as that by Boyer (1990). This survey found that the methods of charging for services and the fees charged were similar. Although most hygienists provided many services, only one fee for those services was changed in most settings. The most recent data has been collected by publisher FMC, but not yet released at the time of going to press. However, the survey of dental fees suggests that the average hygienist’s hourly fee charged in the UK is £105, ranging from £70-£240 per hour for hygienist services. Salary setting Salary is one of the most important questions to think about. After all, would you work for free? Would you leave a job you love for more money? How much money would it take to get you to stay at a job you hate? Market demand ultimately determines the going hygienist pay rate. Cities have more dentists, which means that more hygienists will be needed, and, therefore, the dentists in big cities are going to pay far more to get the hygienists into the cities. To be compensated for your productivity, the dentist must see you as a great asset to the practice. And thinking is definitely changing, but even in countries like the US, still a whopping 40% of dentists do not employ a hygienist. There are two ways a dental hygienist can be classified: independent contractor or employee. And S Julian English is the editorial director at FMC.
43 Organisationsand associations Organisations & Associations
44 Organisationsand associations Introducing the BSDHT British Society of Dental Hygiene and Therapy The main organisation for dental hygienists in a nutshell the interests of their profession. The mission of the BSDHT is to represent the interests of members and to provide a consultative body for public and private organisations on all matters relating to dental hygiene and therapy. It aims to work with other professional and regulatory groups to provide the highest level of information to its members as well as to the ith over 3,600 members, the British Society of Dental Hygiene and Therapy (BSDHT) is the primary UK organisation for hygienists and dental therapists. The BSDHT (formerly British Dental Hygienists’ Association, BDHA) was set up in 1949 by a group of 12 dental hygienists who felt the time was right to organise a professional association to represent W Incumbent president Michaela ONeill Ex-president Marina Harris
45 Organisationsand associations general public. The BSDHT directs the decision-making processes within the society and provides mechanisms to monitor progress and success. The plan is all-embracing and affects all aspects of the society’s business. The society seeks to increase the range of benefits offered to members by: • Representing members at national level, www.dentistry.co.uk particularly in the political arena • Providing services to members • Supporting members on issues that affect their working lives • Producing a publication that educates, updates and inspires • Providing CPD opportunities, both locally and nationally • Helping members to find employment and provide guidance on contractual matters, as well as salaries, and access to a 24/7 legal helpline • Listening to members and responding accordingly. All dental hygienists and therapists, and students thereof, should be members of the society. Ex-president Sally Simpson Ex-president Julie Rosse
46 Organisationsand associations The BADT – opening doors Katrina Matthews pays tribute to her ‘dental therapist family’ concept of dental therapy began to take seed. The early role of the dental auxiliary evolved into the dental therapist we know today, with a slow shift It was way back in 1950, when the state of children’s dental health was at a low and there was a shortage of dentists in the school services that the
47 Organisationsand associations www.dentistry.co.uk towards the doors opening for them to practise in a primary care environment. Along the way, there were expectations placed upon them that required patient management skills, an ability to educate patients in oral health care and above all, an affinity with patients and fellow dental professionals alike. Bridge the gap Slowly, the training developed into what we now know today – with much tenacious persuasion by those who cared passionately about the role. These ‘gentle persuaders’ blossomed along the way and, today, the British Association of Dental Therapists (BADT) still has that tenacity and staying power of their predecessors some six decades earlier. I qualified in 1974 and immediately joined the BADT and have been a member ever since. It was the only association for dental therapists until very recently, and I always felt it was my ‘dental therapist family’; so many people didn’t know (and perhaps are still learning!) about our profession. For many years, we were a very rare occupation. The support and friendship has been invaluable. The achievements of the BADT over the years has been amazing – working in practice and extended duties and raising our profile within the dental profession among them. We were always that person bridging the gap between dental nurse and dentist so we learnt excellent negotiating skills and quickly became a solid, valued member of the team. Our special clinician/patient dynamic and the long-standing and close association with the education, care and treatment of children’s teeth puts us at an advantage when it comes to a full understanding of the implications of poor oral hygiene, as well as the impact this has on their overall health and wellbeing. Once again, children’s dental health is in the spotlight and the lifted restrictions by the regulators, which allows us direct access, and underpins all that the BADT stands and fought for. Advise, support and protect Today, more than 500 members rely on us to advise, support and protect their interests. In this new dawn in dentistry, how you practise and what you can do may seem daunting and it is a role that requires careful navigation. For this reason, members are encouraged to look to us for assistance and we offer students and newly qualifieds reduced membership fees and access to some of the leading clinicians within dental therapy. This deep vault of knowledge held by experienced dental therapists – working in all areas of dentistry – is a hidden gem in the membership benefits. The council recently secured the help of patient membership scheme experts, Privilege Plan, to make it easier for its members to pay their fees by now accepting Direct Debit payments. Membership includes a quarterly peer-reviewed journal that includes two hours of non-verifiable CPD, accredited by Colgate. Online access is also available to previous issues of Dental Therapy Update. The journal aims to inform members of new clinical protocols and theory, keep them abreast of relevant news and views and highlight key courses and conferences, as well as offer insight into the working lives of therapist colleagues. Katrina Matthews works for Central London Community Health Care NHS Trust as manager for dental therapy and oral health promotion in the Specialist and Community Dental Services. Katrina qualified in 1974 and spent years as a tutor. She manages a team of dental therapists working across central and west London and a team of oral health promoters over four Trust areas. Katrina has spent the last 15 years working clinically in the specialist service, alongside a wide range of specialities and combine this with her interests in a range of dental public health programmes in the community, including fluoride varnish, adults with learning difficulty, early years settings, homeless and training of health, local authority and educational professionals.
48 Organisationsand associations The BADT has a vibrant social media presence, too, both on Twitter and Facebook and encourages members to share thoughts, comments and discuss common challenges in its own online forum at www.badt.org. There is a monthly e-newsletter to complement this, and to make it easy for our busy members to navigate their way directly to what they need to know. Heart So, although our association took root slowly, the heart of it remains the same. In her short time as president, Fiona Sandom has displayed the same passion as those who went before her, having For more information, visit www.badt.org. secured commitment from all four chief dental officers to understand and work towards solving issues affecting dental therapists. Some barriers to care remain within NHS regulations and prescribing rights and, although we aware that time frames to resolving these issues are lengthy, the BADT is in it for the long haul – much as it has ever been. Council is working towards understanding these barriers so we can use our full scope of practice directly with patients and therefore increasing their access to dental care.
50 Organisationsand associations Who’s whoA guide to the people and groups in the world of dentistry Month and Mouth Cancer Action Month. As a self- funded charity, the Foundation is very grateful to the support of its members, which enables it to provide such a wide range of important services. National Smile Month is the Foundation’s pro- active campaign designed to raise awareness of dental and oral health over one month. The campaign has now been running for 35 years and is one of the best established worldwide public awareness campaigns dedicated to the promotion of oral health. It encourages dentists, dental hygienists and therapists, and other dental professionals to get involved and spread good oral health messages to the public. Over the years, National Smile Month has been a great way for dental practices to organise themed events and publicise their business, as well as spreading a good oral health message to the public. It is also an excellent way for practices to encourage patients to maintain regular dental visits. A full range of patient awareness literature covering a wide range of dental topics is available as a resource to members and non-members of the British Dental Health Foundation to help educate and motivate patients. The range of resources includes leaflets, posters, stickers, books, DVDs and lots of fun dental motivators. The core of this material is the 50 titles in the ‘Tell me about…’ series, giving patients information on virtually every aspect of dental care. The BDHF also runs a dental advice line, the National Dental Helpline. For more, email sarah@dentalhealth.org. British Dental Industry Association Members of the British Dental Industry Association (BDIA) do more than just sell products and services to dentists and laboratories. Working with the profession, they help dentists deliver quality care to their patients. It is a partnership that can be rewarding to all concerned, including patients. Suppliers are constantly researching new products B is for. . . British Association of Dental Therapists The BADT promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome • Payment is available online, taken securely via Worldpay. For more, visit www.badt.o rg.uk. British Dental Health Foundation The British Dental Health Foundation is a national charity dedicated to promoting the benefits of oral healthcare to the public. It aims to serve the public interest by improving awareness of, and access to, the means of maintaining better oral health. As well as aiming to bring about improved standards of oral health care in the UK, the Foundation has a vastly growing overseas market, under the arm of the International Dental Health Foundation. The Foundation keeps in close communication with its members, who can benefit from direct involvement in its activities and campaigns, such as National Smile
51 Organisationsand associations www.dentistry.co.uk and services as well as developing established ones. Members of the dental team who work with BDIA members can be assured of a reliable service and continued support. They can be sure that the products and services they buy are of high quality and conform to all regulations and requirements of both UK and EU legislation, which is particularly important when investing in capital equipment. The BDIA also works in harmony with other dental associations to make sure that the products offered are what the dentist or dental care professional needs. The BDIA ensures the staff of its member companies are able to provide a good service to the dental team, who in turn can give the best to the patient. The BDIA runs courses every year to familiarise those new to dentistry with the basic knowledge they need. Most companies also offer training to dental teams to make the transition to a new product as smooth as possible. So, BDIA members are committed to providing the same high standards of quality as you are, giving you peace of mind when delivering dentistry to patients and clients. In summary, they: • Comply with a strict code of practice, meaning they are committed to providing the highest quality products and exceptional levels of customer service, minimising downtime and giving you the confidence to run a busy practice or laboratory • Research and develop new materials, equipment and technologies, providing you with more choice and the ability to work more efficiently and effectively • Provide courses and seminars to support you with the adoption of these innovations within the dental practice or laboratory • Are actively encouraged to train their staff, ensuring they have the relevant knowledge to understand the ever changing needs of the dental team. The BDIA is a primary source of information on dental suppliers and brands. When you are trying to source a particular product or replace a piece of equipment, rather than searching aimlessly through the internet, you may find it useful to search the online product and brand locators on the BDIA website, www.bdia.org.uk. British Society of Dental Hygiene & Therapy The BSDHT welcomes members who are dental hygienists, dental hygienist-therapists and students. The BSDHT is a major organisation within dentistry that exists to represent your interests. For example, representatives of the BSDHT maintain an ongoing dialogue with the General Dental Council (GDC), the Departments of Health and all the main groups representing dental care professionals. The BSDHT attends meetings of the dental All Party Parliamentary Group (APPG), bringing dental hygiene and therapy to the attention of government ministers and MPs. The BSDHT (formerly British Dental Hygienists’ Association, BDHA) was set up in 1949 by a group of 12 dental hygienists who felt the time was right to organise a professional association to represent the interests of their profession. Over 60 years later, the BSDHT is a nationally recognised body that represents around 3,600 members across the UK and beyond. There is 50% discount for newly qualified people for their first year of membership. The mission • Promote the study of oral health and to provide a consultative body to whom reference may be made by public or private bodies for guidance in connection with the dental hygienist/dental therapist profession • Maintain the honour and interests of the dental hygienist/dental therapist profession • Represent and safeguard the common interests of members • Provide opportunities for post qualification education. The aim • Represent members at national level, particularly in the political arena • Provide services to members • Support members on issues that affect their
52 Organisationsand associations working lives • Produce a publication that educates, updates and inspires • Provide CPD opportunities, both locally and nationally • Help members to find employment and provide guidance on contractual matters, as well as salaries, and access to a 24/7 legal helpline • Listen to members and respond accordingly. For more information, visit www.bsdht.org.uk. British Society of Periodontology The BSP exists to promote the art and science of periodontology. Membership includes specialist practitioners, periodontists, general dentists, consultants and trainees in restorative dentistry, clinical academics, DH&Ts, specialist trainees in periodontology and many others. For more information, visit www.bsperio.org.uk. C is for. . . Care Quality Commission CQC compliance inspectors started their visits to dental providers at the end of 2010. Wherever possible, inspectors give advance notice of an intended visit, as they do not want patient appointments to be disrupted or cancelled. So far, CQC visits have been planned reviews of compliance where, on the whole, there no concerns about the provider beforehand. However, the CQC may make an unannounced visit when a primary care trust, ‘whistleblower’, or another agency alerts of a possible major concern. Compliance inspectors come from a wide range of backgrounds. They are trained to ‘regulate whether providers are complying with the regulations’ and use a number of methods to review compliance. Having structures and processes in place are obviously necessary, but the CQC will look to make sure that all members of staff understand them when they check that a dental provider complies with these outcomes. Visits will last for about three hours and, in certain situations, a second visit may be necessary, with or without a dental specialist to check more details or actions required. Although CQC inspectors are not registered dentists, they can access these dental specialists who are spread throughout the country, and have vast experience in appraising, regulating and running both NHS and private dental practices. After leaving the practice, the inspector will compile a report, which will be sent, in draft, to the dental provider for any comments on factual accuracy, before it is finalised for publishing on the CQC website. D is for. . . Department of Health The Department of Health (DH) is responsible for numerous initiatives to improve oral health for the nation’s population. It manages the public dental workforce and reviews the capability and capacity of it. An increased focus on oral health improvement will reduce the need for treatment and improve the efficient use of financial resources. The chief dental officer (CDO) is the government’s most senior dental adviser for England and the professional head of dental staff in England. The holder of the role has close links with the profession and other staff across government, both to provide expert advice and to ensure a coherent input to policy across government. The CDO is the government’s senior adviser on all issues related to dental services and dental public health. The current CDO is Sara Hurley, she: • Provides professional leadership to the dental profession • Provides advice to ministers and other senior civil servants on improving oral health, reducing inequalities and developing high quality services for patients • Works closely with the professional regulatory body, the NHS and dental educators. For more information contact 0207 210 4850 or visit www.dh.gov.uk. Dental Protection Dental Protection Limited is a member of The Medical Protection Society Limited group of companies, the world’s leading defence organisation helping doctors, dentists and other healthcare
53 Organisationsand associations professionals to meet their professional obligation to make suitable indemnity arrangements. It offers members a first-class service combined with a wealth of educational information and risk management material. Key services • Protecting the professional integrity of its members • Advice and assistance, including legal advice and assistance in all matters that challenge a member’s professional registration • Indemnity against costs and damages in dental negligence claims. Neither Dental Protection or The Medical Protection Society are insurance companies; the benefits of membership are discretionary • More than 70 dento-legal advisers, who are all experienced dentists with legal expertise, provide expert guidance and support to members of the dental team in difficulty, including emergency advice available 24 hours a day, seven days a week. In addition, locally-based teams of dentists and lawyers with a specialised knowledge of dento- legal matters support the in-house advisers in all the nations where there are dental members • An independent and confidential counselling service specifically to assist members suffering from stress as a result of dento-legal issues. Educational services Dental Protection provides risk management publications, seminars and other educational resources, with the aim of preventing avoidable harm to patients and reducing risk to members. These are provided for members either free of charge on request, or at preferential rates. For more information, visit www.dentalprotection. org/uk. G is for. . . General Dental Council The GDC is the organisation that regulates dental professionals in the UK. By law, all dentists, dental nurses, dental technicians, clinical dental technicians, dental hygienists, dental therapists and orthodontic therapists must be registered with the GDC to work in the UK. The GDC’s purpose is to protect the public by regulating the dental team. It does that by: • Registering qualified professionals • Setting standards of dental practice and conduct • Assuring the quality of dental education • Ensuring professionals keep their skills up to date • Investigating allegations and complaints about dentists or dental care professionals and taking appropriate action • Working to strengthen patient protection. Registration The GDC has two registers; the Dentists Register and the Dental Care Professionals Register. These are updated daily and are publicly available on the GDC’s website, www.gdc-uk.org. The GDC can prosecute people who practise dentistry, but who aren’t registered. A list of dental specialists is also held. Any registered dentist can work in a particular branch of dentistry but only those on the 13 Specialist Lists can call themselves a specialist. Standards All dental patients are entitled to high standards of professional and personal behaviour from those providing their care. Every registrant is expected to meet the GDC’s Standards for the Dental Team, which sets out nine key principles of ethical practice. In addition, there are supplementary guidance sheets on topics such as advertising and prescribing medicines. Action can be taken against registrants who do not follow these principles. Education and quality assurance Currently, the aim of the GDC’s quality assurance process is to check whether courses for dentists and dental care professionals meet its training requirements, which are outlined in Preparing for practice – Dental team learning outcomes for registration. Dental professionals are required to keep their skills and knowledge up to date by carrying out continuing professional development (CPD). Complaints Most dental professionals are competent, www.dentistry.co.uk
54 Organisationsand associations conscientious people who patients can have complete confidence in. But there are times when the behaviour or health of a dental professional may cause concern. The GDC can act on complaints from patients or information received from other organisations (for example, the police or the NHS), which questions whether a registered dental professional should be practising. Action can be taken if a registrant’s fitness to practise may be impaired due to their health, conduct – including convictions and cautions – and performance. Fitness to practise hearings As part of its duty to protect the public, the GDC holds formal hearings into cases about dental professionals. The fitness to practise process begins when the complaint is assigned to a caseworker, who starts by comparing the complaint to the GDC Standards for the Dental Team to assess what should happen next. If a committee decides to erase or suspend a dental professional, they have 28 days to lodge an appeal with the High Court on the basis that the decision was too harsh. If the court agrees, it can substitute a different decision or send the case back to the Conduct Committee to dispose of the case according to the court’s directions. The Professional Standards Authority for Health and Social Care (PSA) has the power to appeal a Practice Committee decision if they consider that the outcome was unduly lenient. For more details on any of these issues, please log on to www.gdc-uk.org or call the customer advice and information team on 020 7167 6000. H is for. . . Hygienist Direct A website that allows registered dental hygienists and therapists to advertise their services to the public while complying with GDC guidance. Twenty-five per cent of funds raised from membership fees will go towards a new DH&T Benevolent Fund For more information, visit www.hygienistdirect. co.uk. I is for. . . International Federation of Dental Hygienists The IFDH was officially formed on June 28 1986 in Oslo, Norway. The forerunner was The International Liaison Committee on Dental Hygiene, established in 1973, by some European countries, the USA, Canada and Japan. The IFDH is an international, non-governmental, non-profit organisation. It unites dental hygiene associations from around the world in their common cause of promoting dental health. The stated purposes of the federation are to: • Safeguard and defend the interests of the profession of dental hygiene, represent and advance the profession of dental hygiene • Promote professional alliances with its association members as well as with other associations, federations and organisations whose objectives are similar • Promote and coordinate the exchange of knowledge and information about the profession, its education, and its practice • Promote access to quality preventive oral health services • Increase public awareness that oral disease can be prevented through proven regimens • Provide a forum for the understanding and discussion of issues pertaining to dental hygiene. T is for. . . Tooth Whitening Information Group TWIG was formed to unite people with a common purpose. Its mission statement is to work together to provide: • Clear guidance and supporting material for professionals on tooth whitening • Clear information for the public • Support to the official bodes who tackle illegal sales and illegal whitening.
Keyclinical protocols 56 The proper way to scoreThe British Society of Periodontology’s guide to periodontal assessment thorough assessment and a consistent protocol from the practice team. But just why is it so important we involve our patients in determining the level of their periodontal health? 1. Because they have a right to know 2. It is our ethical duty to assess, diagnose and educate patients 3. Defence organisations have noted that their highest litigation costs are due to an increase in undiagnosed periodontal disease. Supervised neglect and failure to refer results in the ongoing existence of disease is a threat to systemic health and increased litigation within the profession atients’ understanding of periodontal disease is evolving, largely as a result of media coverage and also because of marketing by consumer healthcare companies (Balanoff and Duvall, 2010). However, despite the increasing emphasis on periodontal health and the oral systemic link, periodontal disease remains prevalent. As shown in the Adult Dental Health Survey, ‘83% of people show signs of gum disease’ (Office for National Statistics, 2009). Patient awareness and treatment acceptance, especially in the early stages of disease (when it is often asymptomatic) can be encouraged through P Code Definition Treatment required 0 No pockets >3.5mm, no calculus/ overhangs, no bleeding after probing (black band completely visible) No need for periodontal treatment 1 No pockets >3.5mm, no calculus/ overhangs, but bleeding after probing (black band completely visible) Oral hygiene instruction (OHI) 2 No pockets >3.5mm, but supra- or subgingival calculus/overhangs (black band completely visible) OHI, removal of plaque retentive factors, including all supra- and subgingival calculus 3 Probing depth 3.5-5.5mm (black band partially visible, indicating pocket of 4-5mm) OHI, root surface debridement (RSD) 4 Probing depth >5.5mm (black band entirely within the pocket, indicating pocket of 6mm or more) OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated * Furcation involvement OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.
Keyclinical protocols 57 www.dentistry.co.uk (Mitchell, 2010) 4. It affords the opportunity for the practice to provide optimal patient care while enhancing practice-building opportunities. Many clinicians feel uncomfortable mentioning profit and ethics in the same sentence but, the fact is, dental practices are businesses that must generate revenue and profit while providing excellent care (Balanoff and Duvall, 2010) 5. It is important to assess the periodontal condition before commencing restorative treatment as there is evidence to suggest that, once the foundation of the periodontium is stable and a good level of plaque control is achieved, the restorative treatment will have better long-term prognosis (preshaw, 2008/9) 6. In line with Care Quality Commission regulations, all patients should have ‘a full examination of both the hard and soft tissues and supporting structures of the oral cavity using diagnostic aids such as radiographs as and when necessary’. This includes diagnostic and screening procedures for periodontal disease (Care Quality Commission, 2010). All new patients must be screened and evaluated for periodontal disease and it should be routine practice to probe every patient each time he or she is seen at recall. Periodontal protocol It is important to make a clear distinction between preventive care and periodontal therapy. The ‘routine scale and polish trap’ can induce a false sense of security in our patients for it communicates that all is well (Mitchell, 2010). In a well-defined periodontal protocol, patients are graded by their disease and risk level and the definition of disease is made clear. A good example of such a protocol is the Basic Periodontal Examination (BPE), which was developed by the British Society of Periodontology from the Community Periodontal Index of Treatment Needs (CPITN) (British Society of Periodontology, 2011). It is essentially a method of screening patients to estimate the level of disease present and the treatment required for each level. The BPE examination and scoring system divides the mouth into sextants. All the teeth in a sextant are examined and scored accordingly. The scores are detailed in the table on the opposite page. It is important to remember that in addition to BPE scores, a periodontal data chart is needed to determine the severity of disease, and provide a baseline for later comparison to assess the effects of the treatment (British Society of Periodontology, 2011). Communicating with patients Encourage patients to assume some responsibility for their role in controlling the disease. • When chatting to patients about their perio score it helps to have a typodont of the periodontium and a BPE probe to hand, as these can be used to illustrate various aspects of the disease • Technology can help patients ‘own’ their disease and diagnosis. Responsive software systems generate verbal feedback during probing and charting, which helps keep patients involved because they can hear the message generated by an ‘objective third party’ (the computer). You can provide the patient with a print-out of your findings • In the absence of technology, talk patients through examinations by using personal diagnosis. Disclose teeth and show them any areas of plaque accumulation. With a BPE probe point out any ‘hot spots’ (where there is bleeding on probing), demonstrate the depth of periodontal pockets and reinforce the message with radiographic evidence • Always back up any information you have given with educational literature. Younger patients In 2012, the British Society of Periodontology (BSP) and The British Society of Paediatric Dentistry collaborated to produce Guidelines for Periodontal Screening and Management of Children and Adolescents Under 18 Years of Age as it had been realised that there is a need to identify early signs of disease in younger patients. All clinicians should make themselves aware of this advice, which is available from the BSP website. For references, contact Julian@dentistry.co.uk.
Keyclinical protocols 58 Periodontal disease and systemic health Charlotte Wake says that patients need to be educated about how their mouth can reflect on their overall health role as a profession to make sure we do all we can to get the message heard and understood. Risk factors Diabetes is an area well documented in its relationship with periodontitis. We have known atients are often aware that gum disease means that they can lose their teeth; in my experience they are less aware of the effect it can have on their overall health. In contrast they are not always educated on how systemic illness can affect their mouth, teeth and gums. It is our P
Keyclinical protocols 59 for some time that diabetes is a risk factor in periodontal disease and the link is now considered two-way. If a patient is able to stabilise their diabetes this helps control their periodontitis; if their periodontal disease is controlled this can help stabilise their blood sugar level. With diabetes diagnosis on the rise I think this is going to become a bigger factor in our working life. An area that is slightly less understood is periodontal health and heart disease. The issue is a little bit like the chicken and egg. There are theories that relate to inflammation caused by periodontal disease increasing the buildup of fatty plaque, thus leading to swelling of the artery (www. perio.org, 2015). Another is that oral bacteria attach to the fatty plaques in the arteries, leading to clot formation and cardiovascular disease (www. perio.org, 2015). We know oral bacteria have been found in cardiovascular specimens and that smoking is a contributing factor to both diseases. Whether periodontal disease causes cardiovascular disease or indeed the other way around is still contested. Time may show they are not causative agents but risk factors to each other. We do however know that the two are linked, we know that they share risk factors and that ongoing research will help to shed light on the exact relationship between the two. The American Academy of Periodontology states on its website that as well as heart disease an additional study indicates a relationship between periodontal disease and strokes. It says that ‘people diagnosed with acute cerebrovascular ischemia [sic] were found more likely to have an oral infection when compared to those in the control group’. If this continues to prove to be the case then controlling periodontal disease can help to prevent our patients having a stroke. We understand that osteoporosis is a risk factor to periodontal disease. The bone density can be lost and this in turn can lead to premature tooth loss. Other areas of research have indicated a link of periodontal disease, pancreatic and kidney cancer. Pneumonia can be linked to periodontitis as the oral bacteria can be aspirated into the lungs. The possible illnesses continue as research is looking into a possible link between Porphyromonas gingivalis, periodontitis and rheumatoid arthritis. Research The risk of periodontitis to premature birth and low birth weight is well documented. We know that non-surgical periodontal therapy in mothers with periodontal disease can help reduce the risk of premature births (Tarannum and Faizuddin, 2007). Research in 2013 stated ‘a significant association between periodontitis (but not with gingivitis) and adverse pregnancy outcomes. Maternal periodontitis is associated with an increased risk of pre-eclampsia, intrauterine growth restriction, preterm delivery and low birth weight infants’ (Kumar et al, 2013). For men, their prostate health might be affected by periodontal health. The American Association of Periodontology explains: ‘Research has shown that men with indicators of periodontal disease such as red, swollen or tender gums as well as prostatitis (inflammation of the prostate) have higher levels of PSA [prostate-specific antigens] than men with only one of the conditions. This means that prostate health may be associated with periodontal health, and vice versa.’ Even in the last 10 years that I have been practising we have learnt so many more relationships; risk factors, be they solo or shared, and two-way links between not just periodontal disease and systemic health but for the oral cavity itself. It is important research continues and equally important the general public understands www.dentistry.co.uk Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapists’ council, and is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice.
Keyclinical protocols 60 that looking after your teeth is not just about stopping tooth loss, decay and bad breath. They need to be educated about how their mouth can reflect on their overall health and well being. References Kumar A, Basra M, Begum N, Rani V, Prasad S, Lamba AK, Verma M, Agarwal S, Sharma S (2013). Association of maternal periodontal health with adverse pregnancy outcome. J Obstet Gynaecol Res 39(1): 40-5 Tarannum F Faizuddin M (2007). Effect of periodontal therapy on pregnancy outcome in women affected by periodontitis. J Periodontol 78(11): 2095-103 www.perio.org retrieved 29/9/15
Keyclinical protocols 55 Key Clinical Protocols
Keyclinical protocols 61 Tooth notation differentiations A comprehensive guide to the different formats in tooth notation European, Scandinavian or Haderup system Permanent teeth 8+ 7+ 6+ 5+ 4+ 3+ 2+ 1+ +1 +2 +3 +4 +5 +6 +7 +8 R L 8- 7- 6- 5- 4- 3- 2- 1- -1 -2 -3 -4 -5 -6 -7 -8 Primary teeth 05+ 04+ 03+ 02+ 01+ +01 +02 +03 +04 +05 R L 05- 04- 03- 02- 01- -01 -02 -03 -04 -05 American system Permanent teeth 1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16 R L 32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17 Primary teeth A B C D E F G H I J R L T S R Q P O N M L K FDI two-digit system of tooth designation Permanent teeth upper right upper left 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 lower right lower left Primary teeth upper right upper left 55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75 lower right lower left Zsigmondy-Palmer, ‘Chevron’ or Set-Square system Permanent teeth 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 R L 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Primary teeth e d c b a a b c d e R L e d c b a a b c d e
Keyclinical protocols 62 Periodontal disease and systemic health Oral-systemic connections are now widely accepted. Melonie Prebble looks at the evidence so far systemic link, it is more likely caused by diet. Acidic foods and drinks are well known sources of the problem; conditions such bulimia or anorexia nervosa can be, too. It’s our role to look for the signs and provide guidance and understanding of the effects on the oral cavity • Cancer - Researchers found that men with gum disease were 49% more likely to develop kidney cancer, 54% more likely to develop pancreatic cancer and 30% more likely to develop blood cancers. The most significant contributory factors to oral cancer are smoking and heavy drinking • Childbirth - Several studies have suggested that women with periodontal disease may be more likely to deliver babies prematurely or with low- birth weight than mothers with healthy gums. Additionally, babies with a birth weight of less than 5.5lbs may be at risk of long-term health problems such as delayed motor skills, Melonie is an experienced dental hygienist and therapist, having worked in the dental industry for over 20 years. She graduated from The London Hospital in 1995 and has been enhancing her skills and contributing to the industry ever since. Melonie currently offers her services at Abbey Road Dental, in north west London, and the clinic at The Luke Barnett Centre, Watford, Hertfordshire. ith more and more concrete evidence emerging, it is hoped that scientists will one day clarify the ‘whole body’ relationship. In the meantime, adding value to a patient’s visit continues to be an essential part of our everyday practice and this includes their overall health and well being. The GDC’s Standards for the Dental Team maintains that all aspects of patients’ health and well being should be considered and there is an expectation upon us all to inform and advise patients about any behavioural risks. At the frontline We are at the frontline of oral healthcare and regular dental examinations gives us the opportunity to detect early predictors of systemic and dental disease. In fact, we are perfectly placed to address the lifestyle choices patients make and if they are detrimental, to look after their mouths – and the rest of their bodies, too. An oral examination reveals a lot more than just the health of the oral cavity. Equally, recording a patient’s medical history can highlight these risks and we should review their habits jointly in order to address them. Lifestyle risks • Bulimia or anorexia nervosa - Although tooth surface loss through erosion may have a W
Keyclinical protocols 63 The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. For more about the BADT, visit badt.org.uk. www.dentistry.co.uk social growth, or learning disabilities. Similar complications are true for babies born at least three weeks earlier than its due date • Diabetes and heart disease - It is important to help diabetic patients manage their diets, to control any negative impact it may have on their periodontal status. Public Health England’s Delivering Better Oral Health acknowledges that lowering the intake of sugars will have wider health benefits, by preventing weight gain, which in turn could reduce the risk of heart disease, type II diabetes and some cancers. Many cases of diabetes in the UK are undiagnosed and so have a useful role to identifying those who are, so far, unaware. Conversely, patients with diabetes also have a greater level of periodontitis and therefore, there are some important factors to consider in assessing the periodontal status of patients with diabetes, such as their degree of metabolic control, the presence of concurrent risk factors and their general level of well being (www. colgateprofessional.com, 2009) • Hypertension risk – Researchers recently found that oral hygiene may be considered an independent risk factor for hypertension and that maintaining good periodontal health habits may prevent and control the condition. The study, published in the July 2015 issue of the Journal of Periodontology, suggests periodontitis and hypertension may be linked by way of inflammation and blood pressure elevation • Osteoporosis - Researchers have suggested that a link between osteoporosis and bone loss in the jaw. Studies suggest that osteoporosis may lead to tooth loss because the density of the bone that supports the teeth may be decreased, which means the teeth no longer have a solid foundation • Respiratory disease - Research has found that bacteria that grow in the oral cavity can be aspirated into the lungs to cause respiratory diseases such as pneumonia, especially in people with periodontal disease. Treatment, therefore, should focus on the prevention of disease and oral inflammation, which is essential in controlling the oral complications associated with other diseases. Equally, control of periodontal infection and inflammation will improve the oral health of patients, decrease the systemic chronic inflammation burden caused by oral inflammation, improve general health, and may ultimately contribute to the reduction of disease elsewhere. References www.colgateprofessional.com/patient-education/ articles/periodontal-disease-and-diabetes www.colgateprofessional.com/Professional/v1/en/ us/locale-assets/docs/OSH-Cardiovascular Health-InflammationCardiovascularDisease.pdf Retrieved 13/10/15
Keyclinical protocols 64 Peri-implantitis – the ‘time bomb’Peri-implantitis has been described as a ‘time bomb’ with many patients unaware of the consequences of poor care. Dental therapist Amanda Gallie offers some tips Amanda Gallie has 20 years’ experience as a hygienist and became a therapist in 2012 on a tutor conversion course at KCH. She is a BADT representaive and works in practice in Stamford. ental implants are an increasingly mainstream part of dental care – their popularity has grown rapidly in the UK in the last few years – and are now considered the treatment of choice for replacing missing D
Keyclinical protocols 65 Diet and lifestyle To avoid the risk of peri-implantitis – and to help limit inflammation as a whole – advise patients to: • Drink lots of water • Eat plenty of green vegetables • Include olive oil and fish oil in their diet • Quit smoking • Keep to the recommended units of alcohol • Exercise regularly. The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. For more about the BADT, visit badt.org.uk. www.dentistry.co.uk teeth. According to the latest Adult Dental Health Survey, half a million adults have at least one dental implant. But, implants require long-term care and regular dental check ups as these are crucial in identifying disease. Like natural teeth, poor oral hygiene can cause plaque and bacteria accumulation but bone loss around implants tends to be far more rapid around an implants versus a natural tooth. Eventually, if left untreated, the implant may become loose and may have to be removed. Loss of an implant Studies have suggested that one third of implant patients may be affected by peri-implantitis. Amanda Gallie explains: ‘The scar tissue around the implant is less forgiving, more fragile and prone to breakdown in the presence of plaque. It can become inflamed and ulcerated – implant mucositis. The condition can progress to peri- implantitis and, if untreated, can lead to bone loss and eventual loss of the implant. ‘Symptoms may include soreness, redness, tender to touch, pus and bleeding, and there can be halitosis but, often, because bone loss is painless, many patients fail to realise they have the condition. So, good oral hygiene and regular hygiene appointments after an implant is fitted are essential.’ ‘We need to assess an implant – probing and palpate for signs of peri-implantitis, assess for calculus and visually assess soft tissue for mobility or pain. Home care is an essential part of prevention, as is biofilm disruption and recall appointment intervals should be set relevant to the patient. If inflammation is present, then biofilm disruption may be required more frequently.’ Supportive periodontal therapy Dental teams may also offer patients supportive periodontal therapy (SPT). Amanda explains: ‘This is usually a treatment phase to detoxify a patient’s gum and supporting tissues. Once this has been deemed successful, a patient goes into a maintenance phase of three-month appointments to keep the bacterial load at a minimum, so that the body can work in conjunction with good home care to keep the tissues healthy. The treatment is gentle and well tolerated but local anaesthetic can be used if needed or requested.’ And although peri-implantitis is not just an age-related disease – as Amanda explains, ‘it’s all about how your body reacts to the plaque bacteria’ – the maintenance of dental implants can prove a challenge in older, less dexterous patients. In these cases, Amanda advises using an electric toothbrush to remove the plaque efficiently. She says: ‘Hygienists and therapists can train family members and/or carers in how best to brush the teeth if that is agreed by the patient. More frequent professional cleaning may be advised, so every one to three months in some cases.’
Keyclinical protocols 66 Developing dentitionFrom birth to permanent dentition, see below for a vital reference on all stages of tooth eruption 3-4 months Eruption begins. Parents will notice signs including irritation, redness, sleeplessness and teething. 6-12 months First tooth will erupt, usually an incisor. Usually in the mandible. The other incisors will follow close behind. Primary dentition Table 2: A = central or first incisor; B = lateral or second incisor; C = canine; D = first molar; E = second molar. Note: The lower incisors tent to erupt shortly before the upper incisors. Primary teeth Erupt Lost Central incisor 8-12 months 6-7 years Lateral incisor 9-13 months 7-8 years Canine 16-22 months 10-12 years First molar 13-19 months 9-11 years Second molar 25-33 months 10-12 years Tooth Commences to calcify (months before birth) Eruption (months) Crown calcification complete (months) Root calcification complete (months) Absorption commences (years) A 3-4 5-7 4 18-24 4 B 4-5 7-8 5 18-24 5 C 5 16-20 9 30-36 7 D 5 12-16 6 24-30 6 E 7-9 20-30 12 36 6
Keyclinical protocols 67 www.dentistry.co.uk Table 3: 1 = central or first incisor; 2 = lateral or second incisor; 3 = canine; 4 = first premolar; 5 = second premolar; 6 = first molar; 7 = second molar; 8 = third molar or wisdom tooth. Note: The lower incisors and canine tend to erupt one year earlier than the upper incisors. They also complete their calcification one year earlier. Permanent dentition Tooth Commences to calcify Crown calcification eruption (years) Root calcification eruption (years) Complete (years) 1 3-4 months 6-7 4-5 10 2 10-12 months 7-8 4-5 11 3 4-5 months 10-12 6-7 12-13 4 1.5-2 years 9-11 5-6 12-13 5 2-2.5 years 10-11 6-7 12-14 6 Just before birth 5-7 3 10 7 3-4 years 12-13 8 15 8 8 years When sufficient. Usually 18-24 12-16 18-25 12-18 months The remainder of the incisors will erupt. The first molars often then come through before the canines, so that when you look into a baby’s mouth you might see four teeth anterior, then a space and then some more teeth in the posterior of the oral cavity. 12-24 months Canine and pre-molar primary teeth will erupt, as well as the molars all deciduous teeth have erupted by the end of this period. 3-5 years All primary teeth should have come in. Permanent teeth are preparing to erupt. 5+ years The child will lose primary teeth, and permanent teeth begin to come in, starting with molars.
Keyclinical protocols 68 XerostomiaCharlotte Wake highlights the effects of xerostomia and discusses The Challacombe Scale of clinical oral dryness disrupted as there is already a reduction in natural saliva flow overnight. Taste may also be affected and some patients may not experience the usual increased flow when hungry or smelling food. Effects Patients suffering from xerostomia may complain of a sore throat or a burning sensation and an increase in oral candidiasis is more likely. Denture wearers might struggle with poor denture retention or present with more cheilitis. So as a condition oral dryness is clinically significant for us but it is often life changing for the patient. For some years there have been options for the management of xerostomia. These can be obtained on prescription and have primarily been salivary substitutes or stimulants. Substitutes are suited to patients who have impaired saliva flow due to the removal of a salivary gland for example. These efined as a dry mouth, xerostomia is a common condition and it is important we do not underestimate its discomfort for the patient. As clinicians we know saliva is an important aid for oral health – it has a great buffering capacity helping to maintain a neutral pH in the mouth. The enzyme ptyalin is present aiding digestion and saliva contains lysozyme that helps control bacterial growth. Our patients may be unaware of the clinical benefits but they know saliva helps them to speak, to eat and gives oral comfort, so when there is a reduction in the amount produced there will be both signs and symptoms present. Xerostomia leads to a rise in the risk of caries and periodontal disease and patients can produce a more rapid deposition of plaque. For the patient they may find mastication more difficult and oral clearance is likely to be impaired. Sleep may be D
Keyclinical protocols 69 Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapist’s council, and is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice. www.dentistry.co.uk substitutes mimic natural saliva and are available in various forms such as sprays, tablets and liquids. The other option is a saliva stimulant – these are intended to help stimulate the salivary glands into increased production. Since 2011 we have had a tool to help us clinically identify and quantify whether our patient has a dry mouth. The Challacombe Scale of Clinical Oral Dryness was developed from research under the supervision of Professor Stephen Challacombe at King’s College London. The scale is free to download from the Challacombe Scale website (www.challacombescale.co.uk). There is also a patient review form for an individual patient that can be kept as a record in their notes. This scale allows us to monitor xerostomia and leads us to the appropriate advice for our patient. For patients presenting with oral dryness dentists may choose to include the use of fluoride in their treatment plans, more regular attendance to help monitor oral disease or may even refer for specialist intervention. With the help of this scale it is easier to monitor, it’s universal and is useful for future reference when continuing your patient’s dental care.
Keyclinical protocols 70 XerostomiaBal Chana presents the causes and symptoms of xerostomia along with some effective management • Radiotherapy - The salivary glands can be damaged if they are exposed to radiation during cancer treatment • Chemotherapy - Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry. Approximately 500ml of saliva is secreted daily. However, the rate can vary amongst individuals. Salivary flow peaks in the afternoon and decreases at night when the major salivary glands are less active. Less than 2ml in 10 minutes unstimulated salivary flow is considered to indicate xerostomia. Salivary flow can be measured by asking the patient to tilt their head forward, allowing their saliva to flow into a container for 10 minutes. Symptoms of xerostomia Symptoms of xerostomia include the following: • Soreness or burning of the mouth, lips or tongue • Sleep disturbance due to thirst or oral discomfort • Difficulty chewing, speaking, swallowing and wearing dentures • Difficulty clearing oral debris • Complaint of dryness • Altered taste. Management strategies Advise the patient to: • Stay well hydrated • Suck ice chips • Sip liquids while eating • Rinse the oral cavity immediately after meals • Use a soft bristled toothbrush • Use interdental brushing aids such as Tepe’s • Use a fluoridated toothpaste and mouthwashes • Recommend saliva substitutes or atients presenting with xerostomia are frequently seen in the dental practice, especially the ageing population. Clinically, the mucosa will appear glazed and translucent. Plaque often is thicker and more tenacious and debris can be seen adhering to the tooth surface. The tongue is usually lobulated and fissured. On examination the mouth will feel dry and the mirror will adhere to the mucosa, making the examination very uncomfortable. There will be no saliva pooling in the floor of the mouth. The Challacombe Scale was developed by Professor Stephen Challacombe. It is a Clinical Oral Dryness Score and uses a simple numeric system that enables the clinician to quantify the severity of the xerostomia and to decide if the condition needs treatment or not. It lists 10 key features of dry mouth, accompanied by example images and allocates one point for each feature. The patient’s additive score indicates whether the dry mouth is mild (a score of 1-3), moderate (4-6) or severe (7-10). The patient score should be document in their clinical notes. A.S. Pharma has produced the scale in poster form, which is available for the dental team. Causes of xerostomia Xerostomia is caused by the salivary glands not functioning properly; this could be due to a number of reasons: • Side effects of medication - More than 500 medicines can cause the salivary glands to produce less saliva. For example, medicines for high blood pressure and depression often cause dry mouth • Disease - Some diseases affect the salivary glands such as, Sjögren’s syndrome P
Keyclinical protocols 71 Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006. www.dentistry.co.uk saliva stimulants • Have regular dental examinations. Advise patients to avoid the use of: • Sugary, acidic, spicy and salty foods and drinks • Caffeine • Tobacco • Mouthwash with alcohol • Alcoholic drinks • Toothpastes containing sodium lauryl sulphate. Early recognition and management of xerostomia will prevent dental disease and will help improve the quality of life for these patients. Management of xerostomia should be a multidisciplinary approach due to the medical problems and pharmaceutical complications associated with this condition.
Keyclinical protocols 72 White or wrong? Dental Protection puts hygienists and therapists in the picture on how best to approach tooth whitening he GDC states: ‘Dental hygienists and dental therapists can carry out tooth whitening on the prescription of a dentist, if they have the necessary additional skills. Taking impressions to a dentist’s prescription, and making bleaching trays to a dentist’s prescription, are within the scope of additional skills for dental nurses.’ Under the new law introduced by The Cosmetic Products (Safety) (Amendment) Regulations 2012 (The ‘regulations’), dental hygienists and therapists (DHTs) may provide tooth whitening using products containing or releasing up to 6% hydrogen peroxide under the direct supervision of a dentist, if an equivalent level of safety is ensured. This regulation is not altered by the announcement that direct access to DHTs was announced by the GDC with effect from May 2013. The tooth whitening treatment will still need to be provided under the direct supervision of a dentist. Dental Protection has sought legal advice on the meaning of direct supervision. The legal opinion advises that a dentist’s physical presence on the practice premises when the first use of the tooth-whitening product is provided to the patient is likely to be required. Therefore, Dental Protection advises members it is appropriate that the dentist is on the premises when the first use of the tooth whitening product is provided to the patient by a dental therapist or hygienist. An examination by the dentist prior to the cycle of tooth whitening is also required. The regulations prohibit the supply of the tooth whitening products containing or releasing up to 6% hydrogen peroxide to anyone other than a dentist. This means that a dental hygienist or therapist cannot legally purchase these tooth whitening products to use on patients. Cycle of use There is a risk that a patient who has not had appropriate instruction on loading a home tooth whitening tray with the tooth whitening product and who has not received instruction on fitting the tray in the mouth could be at risk of swallowing excess material. The requirement that the first use of each cycle is by a dental practitioner (or under their direct supervision) helps to allay these concerns as it allows the dental professional to demonstrate the amount of material to be used and how to load and seat the tray. Direct supervision Before undertaking any procedure, a registrant must ensure that they are trained and competent. The regulations do set out that the treatment is under the ‘direct supervision’ of the dentist but do not define ‘direct supervision’. In Maintaining Standards the GDC used the term ‘direct personal supervision’ to indicate when the dentist was to be on the premises. T
Keyclinical protocols 73 Worth noting! • Tooth whitening is the practice of dentistry • GDC-registered dentists can carry out tooth whitening. GDC-registered DHTs can also carry out tooth whitening on the prescription of a dentist • To only be sold to dental practitioners • For each cycle of use, first use by a dental practitioner; or • Under their direct supervision, if an equivalent level of safety is ensured • Afterwards to be provided to the consumer to complete the cycle of use • Not to be used on a person under 18 years of age, but there are certain clinical situations where bleaching may be part of a comprehensive treatment plan for a child. Even though the GDC has indicated that is will not prosecute in cases where the consent is valid and such treatment would be in the best interest of the child, the law has not changed and it remains technically illegal to treat a person under the age of 18. www.dentistry.co.uk Afterwards After the first in-surgery application, the patient can be provided with the tooth whitening product for home use. The dentist’s duty extends to continuing to monitor the provision of top-up gels and ensuring that this is in accordance with his/her treatment plan. If the patient requires additional product for that course of treatment, assuming the patient had not been provided with the full amount of product required for the entire cycle of use from the outset, then it is the dentist’s duty to provide access to these. The dentist does not necessarily have to be physically present when the top-up gel is handed out, but the duty is to have a system that ensures what is handed out is in accordance with the specified treatment plan (ie, cycle of use). Under 18s The regulations and EU Directive specifically state the product should not be used on patients aged under 18. This means that it is only possible to use products containing or releasing up to 0.1% hydrogen peroxide on patients who are under 18. It has been suggested by some practitioners that tooth-whitening products could be classified as medical devices and as such The Cosmetic Products (Safety) (Amendment) Regulations 2012 do not apply. However, even where a product is marked with a CE mark the regulations do apply. A dental practitioner (or indeed anyone else acting in the course of their business) would be in breach of the regulations by using a tooth whitening product with a concentration higher than 0.1% on a patient under the age of 18, and so be potentially liable to prosecution and disciplinary action by the GDC. This may create a legal and ethical dilemma for members who consider, for example, that it would be in the best interests of a particular patient under 18 years of age, to provide tooth whitening to an isolated non-vital tooth. The member may consider that other treatments, for example crowns or veneers, would be unnecessarily destructive to the tooth/teeth. Dental Protection understands the ethical dilemma that the regulations may cause. Over 6% The use of products containing or releasing more than 6% hydrogen peroxide is a breach of the regulations. Dental Protection would expect members to comply with the law. If a member considers that it is in a patient’s best interests to use a product containing or releasing more than 6% hydrogen peroxide and a clinican chooses to use this product, they may be challenged on the use of the product by Trading Standards Officers or the GDC. Dental Protection appreciates that in a limited number of cases this may present an ethical dilemma. Dental Protection is a member of the Medical Protection Society. For more information or for dento-legal advice, visit www.dentalprotection.org/uk, or call 0800 561 1010.
Keyclinical protocols 75 Keep it conservativeThe BADT presents fast facts on minimally invasive (MI) dentistry 5. Diagnosis and management of stained and sometimes early carious fissures can be difficult. MI dentistry aims to prevent the historical restorative cycle of traditional caries removal, and there are a wide range of diagnostic tools and interventions available. For more about the BADT, visit badt.org.uk. The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. istorically, dentistry has used a surgical approach to dealing with caries, with tooth removal once the only solution offered to patients. However, over time, the profession has found a more conservative approach to treatment in a bid to ensure the maximum preservation of healthy tooth structure. Fast facts 1. Thirty-one per cent of adults in the UK have tooth decay. Although levels of tooth decay have decreased over the last few decades, it is still one of the most widespread health problems in the country 2. Minimally invasive dental therapy has a simple goal – to preserve tissue 3. The concept of MI dentistry can embrace all aspects of the profession. Changes in how best to manage dental disease has developed rapidly in the last few decades – now is the time for these changes to be implemented in practice 4. Air abrasion is more conservative than a traditional drill, only removing desired material and suffering no chipping or stress fracturing. It greatly improves patient comfort and may not require anaesthesia. It resembles microscopic sandblasting and uses a stream of air combined with a super-fine abrasive powder www.dentistry.co.uk H
Keyclinical protocols 76 Implants exposed Melanie Joyce explains how to treat exposed implant threads side motion, one thread at a time gently, like stairs (Wingrove, 2013). Chemical treatment Following mechanical debridement of the implant threads, an antimicrobial agent should be applied to the exposed threads to prevent recolonisation of the bacteria (Besimo et al, 1999). Many microorganisms such as S. aureus, are capable of overcoming the gap between the crown and implant and to proliferate in that area. The colonisation of an implant with S. aureus may result in peri-implantitis, which in turn may jeopardise the survival of the implant. Studies have shown that Cervitec Plus varnish is ‘capable of protecting implants from bacterial colonisation and reducing the risk of peri-implantitis’ (Besimo et al, 2000), therefore placing Cervitec Plus varnish on exposed implant threads following mechanical debridement could be an effective measure to help treat and prevent peri implant disease. Susan Wingrove (author of Peri implant therapy for the dental hygienist, 2013) recommends the patient continues to apply antimicrobial solutions to the exposed threads twice daily as part of their home oral health care. Ivoclar Vivadent produces two professional care products that meet this need in the form of Cervitec Liquid and Cervitec Gel, both of which contain chlorhexidine as their active ingredient. Conclusion Though implants are generally successful, failure can occur. Failure can be caused by peri- implant disease, which can lead to bone loss and subsequently exposure of the implant threads. Exposed implant threads can pose a significant dental implant is now commonly placed to restore spaces in the dentition. Titanium implants osseointegrate creating a bond between living bone tissue and the surface of the titanium implant. The typical basic implant structure we see placed today comprises of a screw-retained titanium implant that is implanted into the bone, then a transmucosal abutment is screwed into the implant providing an anchor for the coronal restoration. What causes an exposed implant thread? The literature varies but the success rate for implants is generally quite high, with over 90% success. One major reason for implant failure is peri-implant disease, which is caused by inflammation of the implant surrounding tissues due to bacterial colonisation. Peri-implant disease starts with peri-mucocitis and can progress to peri- implantitis, which – according to the PIMI scale – is characterised by bleeding on probing, generalised erythema around implant, presence of exudate, radiographic evidence of bone loss and the exposure of three or more threads (Wingrove, 2013). The screw threads of an implant becoming exposed can pose a significant issue when it comes to preventing bacterial colonisation and calculus build up. Mechanical treatment Exposed implant threads have a greater risk of bacterial colonisation and are prone to calculus build up. To remove the calculus and disrupt the biofilm it is recommended to scale using a shorter radius blade tip of an implant scaler, such as a Wingrove L5 mini to clean horizontally in a side to A
Keyclinical protocols 77 Melanie Joyce started out as a dental nurse and in more recent years qualified with merit as a dental hygienist and therapist, she also holds qualifications in management and teaching in addition to her dental qualifications. She plays a role in the north east region for the BADT. She is currently working in a fully private and a mixed general practice as a dental therapist and is completing further advanced studies in her field. Her main interests lie in prevention and education particularly with regards to the periodontal-restorative interface and the maintenance of dental implants. dentalhygienetherapy.co.uk challenge when preventing bacterial colonisation and calculus build up. Mechanical debridement of the exposed threads is necessary to remove any calculus deposits and disrupt the biofilm. To prevent further colonisation, an antimicrobial varnish such as Cervitec Plus could be placed and a home care routine using Cervitec Liquid and Cervitec Gel advised. References Wingrove S (2013). Peri-Implant Therapy for the Dental Hygienist: Clinical Guide to Maintenance and Disease Complications. Ames:Wiley-Blackwell Besimo CE, Guindy JS, Lewetag D, Meyer J (1999). Prevention of bacterial leakage into and from prefabricated screw-retained crowns on implants in vitro. Int J Oral maxillofac Implants 14(5): 654-660 Besimo CHE, Guindy JS, Lewetag D, Besimo RH, Meyer J (2000). Marginale Passgenauigkeit und Bakteriendichtigkeit von verschraubten implantatgetragenen Suprastrukturen. Parodontologie 3: 217
Keyclinical protocols 78 Minimum intervention – surely the only way is prevention Bal Chana believes an understanding of human behaviour is essential for successful preventive outcomes that is ultimately the patient’s own responsibility to control with the aid of the dental profession.’ The importance of oral health Oral health is important to general health and well being; poor oral health has a major impact on quality of life. Dental caries and periodontal disease are the most common dental problems in the UK. These preventable diseases can be painful, expensive to treat and can seriously damage health if left unchecked. Public Health England produced the 3rd edition of Delivering better oral health: An evidence-based toolkit for prevention, in June 2014. The document was developed by a number of well-known experts who have provided evidence-based oral health prevention and promotion guidelines. The entistry in the past has been treatment orientated, but we are now moving to a prevention-focused philosophy. It is far better to prevent the disease in the first place, than treat it once it has happened. The aim of preventive dentistry is to avoid disease altogether, in which the dental profession has a key role to play. Minimal intervention dentistry (MID) is a modern approach to the management of caries, which emphasises prevention and early interception of disease. Professor Avijit Banerjee from King’s College London states: ‘Changes in the outlook on management of oral health and dental disease have developed over decades. Minimum intervention is preventing disease rather than restoring teeth. We know dental caries is a lifestyle-related disease D
Keyclinical protocols 79 Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006. www.dentistry.co.uk document identifies key areas and comments on how the main problem areas can be addressed, by providing clear and simple messages to improve the oral health of individuals. As dental professionals we recognise the importance of oral health but do we really understand what it means and how to do it? More importantly, do our efforts result in patients improving their oral health? Improving patients’ oral health Effective plaque control is necessary to maintain oral health, as dental plaque is the main aetiological factors in both periodontal disease and dental caries. There are so many oral care products available on the market that it is easy for consumers to feel overwhelmed by the choice on offer and not select the most appropriate product for their own needs. It is important for dental professionals to consider manual dexterity, motivation and financial abilities of the individual, along with the available research supporting the product. A successful outcome Humans are complex individuals; an understanding of human behaviour is essential for a successful patient outcome. To help us achieve this we need to ask ourselves the following questions: • What are the key messages when managing our patients and how should they be addressed to make an impact? • What are the needs of the patient? • What are the patient’s expectations – are they the same as our expectations? • Have we been successful in meeting their needs and expectations? It is vital for dental professionals to communicate the key messages in a manner that patients can easily understand, remember and act upon. Communication takes place at two levels: 1. Cognitive (understanding) – getting the message across 2. Emotional (related to feelings) – how the message is conveyed. Effective communication makes it easier for patients to discuss problems and devise solutions. Treat people as you would like to be treated. Patients should have trust and confidence in you as a dental professional. The use of skill mix can assist a practice to become more prevention orientated. Teamwork is crucial in dentistry; it is vital for the dental team to work together. All members of the team contribute to the patient’s experience – key preventive messages can be delivered by all members of a dental team.
Keyclinical protocols 80 A sensitive subject Leigh Hunter offers an insight into how you can help patients suffering from dentine hypersensitivity factors, particularly dietary and oral hygiene habits associated with erosion and abrasion. The relevant differential diagnosis should be considered to exclude all other dental conditions with similar pain symptoms, eg cracked tooth, pulpitis and so on. A wide variety of factors can contribute to gingival recession and subsequent dentine exposure, eg, poor oral hygiene techniques, periodontal therapy, labial frenum attachment, disease such as necrotizing ulcerative gingivitis (NUG), orthodontic therapy, restorative or surgical procedures, or metal jewellery used in oral piercing. Often, loss of tooth structure is multi-factorial with attrition and abrasion, in combination with erosive exposures, contributing to dentine exposure and resulting DHS. Education DHS management includes patient education alongside appropriate treatment interventions, which should be reviewed to evaluate effectiveness. The aim of treatment is to relieve pain and control or eliminate the contributing factors. Based on Brannstrom’s theory, desensitisation agents disrupt pain transmission by either preventing nerve polarisation or by preventing a stimulus moving tubule fluid by occluding the tubule orifice or reducing its diameter. Patient education may involve modifying behaviour such as dietary changes – not just what entine hypersensitivity (DHS) is one of the most painful and chronic dental conditions presented in practice, often difficult to diagnose and treat satisfactorily. Older people retaining teeth, parafunctional habits and lifestyle choices may result in an increased demand for effective solutions to DHS. Clinicians must screen for DHS and diagnose by exclusion, determine appropriate management, and provide treatment and preventive recommendations. While many theories exist to explain DHS, Brannstrom’s hydrodynamic theory is the most widely accepted. DHS was once described as an enigma frequently encountered yet poorly understood, but recently a more widely accepted definition is available in the literature. Patients complain of experiencing a short, sharp pain from exposed dentine often following some type of external stimuli that cannot be ascribed to any other form of dental pathology, defect or disease. Its definitive characteristic is that the pain is elicited by a stimulus and alleviated on its removal. Common causes Cold is the most common stimulus for DHS pain and is often related to cervical dentine exposure, but it may occur elsewhere. Correct diagnosis and recording of DHS includes the patient’s history and clinical examination, in combination with the identification of aetiologic and predisposing D
Keyclinical protocols 81 TEETOC – an aid memoire • Thermal – from hot and cold food, drink or air • Evaporative – dehydration of oral fluids, eg, high speed suction or air drying from three-in-one syringe • Electrical – use of pulp tester • Tactile – from toothbrush or other oral hygiene aids, instruments, prosthetic clasps, etc • Osmotic – altering pressure in the dentinal tubules, eg, sugar or salt solutions, vital tooth bleaching materials • Chemical – eg, acids in foods and drinks, acidogenic bacteria and/or from gastric regurgitation, acid, etc. www.dentistry.co.uk is ingested but also how and when. Patterns such as brushing immediately after an acidic challenge can accelerate tooth structure loss (TSL). An alcohol-free, neutral pH mouthrinse or even water can help to neutralise an acid environment. Dental biofilm can increase the size of the tubule opening so effective control is a key factor in patient education – aim for gentle and effective. A soft toothbrush and/or the non-dominant hand can help to reduce the pressure on exposed dentine surfaces. Consider a power toothbrush, as these typically exert less pressure than a manual brush. Management Dental professionals must be knowledgeable about the wide range of desensitising agents available for home and surgery use. Home care products generally take two to four weeks to reduce DHS. These can be applied via toothbrushing, rinsing or burnishing directly onto affected surfaces. The most common agents include potassium salts, fluorides, oxalates, amorphous calcium phosphate (ACP), calcium sodium phosphosilicate (CSP – Novamin), casein phosphopeptide- amorphous calcium phosphate (Recaldent) and arginine and calcium carbonate. Professional measures include tray delivered fluoride agents, fluoride varnishes, oxalates, resins, hydroxyapatite agents, dentine bonding agents, bioglass particles, arginine and calcium carbonate paste, glass ionomers and soft tissue grafts. There are many causes and treatments for DHS. For every 20 patients, between two and seven will suffer from DHS. It is incumbent on dental professionals to investigate and offer effective and timely solutions for this ever-growing condition. Leigh H Hunter MSc, PGCFHE, Dip DT, Dip DH, Dip DHE (RSH), Cert HEd has more than 30 years’ experience in the UK and abroad, and has extensive experience in teaching hospital and community dentistry. She presently splits her time between general practice, education and training. Leigh lectures widely throughout the UK and Ireland to all dental team members. She is an active member of a number of professional organisations including the British Society of Periodontology and the British Society of Paediatric Dentistry.
82 Generalpractice General Practice
Keyclinical protocols 83 ReferralsDental Protection with the nuts and bolts of what to include in a referral letter form via their website. This can be completed by you and emailed back to the referral practice so that an appointment can be sent to your patient. Don’t forget to keep a note of the referral in the patient’s record. It is a good idea to follow up with the patient to see that they have attended the referral appointment. If they decline to attend, you should remind them of the outstanding treatment and warn them of the consequences. A note of the conversation should also be included in the patient’s record. Don’t forget to include: 1. The name, address and contact details of the patient, (phone, fax, email) 2. The correct date 3. The request for treatment, advice or information, including a working diagnosis if you have made one. 4. The background to the referral, including 5. The patient history, summarised from the records 6. The findings of your own examination 7. The summarised results of any tests (eg, periodontal charting or plaque scores) 8. Relevant medical history, including current medication and any known allergies 9. The level of urgency 10. The availability of the patient 11. Any relevant radiographs, in order to avoid taking duplicates 12. Proposal for future participation in the patient’s ongoing care. he referral letter to a colleague should be legible, on headed paper, with a clearly identified writer and contact details showing any non-working days in case the dentist being referred to needs to contact you. Some practices offer a downloadable referral www.dentistry.co.uk T
84 Generalpractice The caries risk of sport supplements The BADT says the dental team needs to identify those patients at an increased risk of developing dental caries and provide tailored advice on how to better manage the risk the numbers of people spending their hard-earned cash on related products such as gym wear and bodybuilding supplements that are increasingly becoming popular among gym goers. To get ‘ripped’ and build lean muscles, many body builders opt for supplements that can improve their physique and enhance their muscle growth. Not surprising then that, according to market analyst firm Euromonitor, the retail value of sales of sports nutrition products grew by 14% in 2010 to reach £200 million in the UK. Health food shops and pharmacies are the most popular sales outlets, but 6% of sales are now made via the internet. However, f obesity is now a national epidemic, with figures ballooning to the current figure of one in four UK adults being obese, then it is somewhat of an anomaly that, along that same timeline, we have become a nation of body image obsessives. The ‘fat shaming’ of celebrities, social media and the ubiquitous ’selfie’ all demonstrate a population fascinated by the ‘body beautiful’, and fuels the desire for the idealised perfect muscle-toned torso to which we are all we meant to strive. Bodybuilding For some, bodybuilding is a lifestyle trend, making a huge dent in their wallets as the industry spend has grown to match. Research conducted in the summer (on behalf of Alpha Man magazine) found that 82% of more than 1,200 men polled ‘feel more stressed about not having an impressive physique than they did five years ago’. Figures published by market researcher Mintel in September showed that the consumer spend on gyms had increased too, driven primarily by the trend for budget gyms that carry no contract fees. Additionally, with the growth of wearable tech, it suggested that almost four-fifths of UK adults now set themselves at least one health or fitness goal. This inevitably has a knock-on effect with The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. I
85 Generalpractice www.dentistry.co.uk For more information about the BADT, visit badt.org.uk. what is now beginning to filter through is that these supplements often have a high sugar content and hygienists and therapists need to be aware – and make patients aware – of the drawbacks. Dental caries The dental team will need to identify those patients who are at an increased risk of developing dental caries and provide tailored advice on how to better manage the risk. In a study published online in July 2015 the BDJ entitled, Bodybuilding supplementation and tooth decay (www.nature.com, 2015), the authors suggested there is a very real need to raise awareness of the increasing consumption of bodybuilding supplements amongst fitness enthusiasts and amateur competitors. Acknowledging that supplementation is a ‘key component in bodybuilding and is increasingly being used by amateur weight lifters and enthusiasts to build their ideal bodies’, they said that ‘bodybuilding supplements are advertised to provide nutrients needed to help optimise muscle building but they can contain high amounts of sugar. Supplement users are consuming these products, while not being aware of their high sugar content, putting them at a higher risk of developing dental caries.’ The researchers based their comments on the discovery that 76% had gum disease while 55% had evidence of cavities, with 45% of the study participants having tooth erosion. Increased risk As frontline clinicians, it is important that hygienists and therapists recognise the increased risk for supplement users and raise awareness, providing appropriate preventative advice. The authors also suggest that dental professionals need to be knowledgeable of alternative products to help bodybuilders reach their goals, without increasing the risk of dental caries. Dental therapist and BADT chair, Debbie McGovern, says: ‘In all this, the patient’s history is a fundamental part of the investigative phase of dental care. The social history should include details of interests, hobbies, sports etc, as well as the other social and family-related information. By taking a detailed patient history – that includes pastimes and health habits – as dental therapists, we can tailor our advice and offer a more holistic approach to care.’ Tops tips for patients • Enlighten them. Evidence suggests that for most athletes and individuals engaged in physical activity, the use of sports drinks does not provide a benefit over water • Therefore, suggest water as a healthier drink to quench thirst • Tell them to avoid brushing immediately after drinking acidic drinks to avoid tooth erosion • Suggest they drink with a straw or in one sitting • Advise they chew sugar-free gum or rinse the mouth with water following consumption of sports drinks. Reference www.nature.com/bdj/journal/v219/n1/full/ sj.bdj.2015.521.html retrieved 13/10/15
Keyclinical protocols 86 POMs – the right direction A look at the use of prescriptions by DHTs direction applies • The clinical conditions covered by the direction • A description of those patients excluded from treatment under the direction • A description of the circumstances under which further advice should be sought from a doctor (or dentist, as appropriate) and arrangements for referral made • Appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period over which the medicine should be administered • Relevant warnings and potential adverse reactions • Details of follow-up action and the circumstances • A statement of the records to be kept for audits. The Human Medicines Regulations 2012 allow independent hospitals, clinics and medical agencies to authorise their own PGDs. The regulations also allow dental practices and clinics registered with the CQC (or the HIW in Wales or the RQIA NI equivalent) for the treatment of disease, disorder or injury and/or diagnostic and screening procedures to authorise PGDs. This applies to both private and NHS treatments. Preparing a PGD Patient group directions are specific to individually named DHTs working in a particular practice. Consequently, it will be necessary to generate a new document every time a new DHT comes to work in that practice. This has implications for new staff members as well as locum and agency staff who will be providing treatment under an NHS contract. An injection of local anaesthetic or the provision of high-concentration fluoride products are procedures that are controlled by the Medicines Act 1968 (as amended by the Human Regulations 2012) because they involve the use of prescription-only medicines (POMs). This means they can only be prescribed by a qualified prescriber. The GDC has no influence over this legislation. Traditionally, this prescriber would be a doctor or a dentist. Legislation was introduced throughout the UK in 2000 that allows certain other healthcare professionals to administer POMs in specific circumstances. A POM may then be administered by dental hygeinist and therapists (DHTs) in one of two ways: 1. An approved prescriber may provide a documented, patient-specific direction that allows the healthcare professional to administer a POM to a specific patient 2. Patient Group Directions (PGD) This is a legal framework that allows a listed group of healthcare professionals to administer named medicines to a group of patients (that fulfils certain predefined criteria), without the need for a written patient-specific prescription or instruction from the approved prescriber. The guidance states that PGDs must legally include the following information: • The name of the body to which the direction applies • The date the direction comes into force and expires • A description of the medicine(s) to which the
Keyclinical protocols 87 Hygiene for ortho patientsRobiha Nazir explains the importance of a strict oral health regime for orthodontic patients individuals • For Invisalign patients, the same regime as above is shown in detail with some being able to use floss and/or floss picks • Patients with an Incognito/lingual brace may find this appliance harder to keep clean. For those that have the P&G Oral-B electric toothbrush, the interspace brush head can be used for cleaning between and around brackets. Best results Patients enjoy the cleanliness of their mouth, from removal of plaque and calculus in hard to reach areas as well as the benefits of stain removal. The dentist and I work closely at these appointments to ensure that we get best access to teeth by removing the wires before a hygiene appointment. Every patient has different needs; motivating them to obtain the best oral health with a good oral health regime is a major part of my job satisfaction. rthodontic patients are usually the ones who will benefit from regular hygiene appointments the most. These patients have more accumulation of debris around brackets and are more prone to gingivitis, halitosis and tooth pathology. With orthodontic work it is in their best interest to see a hygienist every three months to help maintain optimal oral health. Patients who are embarking on any orthodontic treatment should have a hygiene session prior to an appliance being fitted. During this appointment the hygienist is able to go through an appropriate regime suited to the individual and advise the best interval period between future appointments. Regimental An oral health regime for a fitted orthodontic appliance is where my patients have shown great orthodontic care. The regime is to be carried out after meals and in the evenings. We go through the following implements to ensure optimal results: • The use of interdental aids for interdental cleaning, as well as cleaning between the wire and brackets before the use of a toothbrush • One can use an alcohol-free fluoride mouthwash alongside the use of an electric or manual toothbrush with care. Disclosing tablets can also use a helpful visual aid for younger O Your patients’ armamentarium: • Interdental brushes • Superfloss • Rubber stemmed brushes • An Airfloss or a Waterpik • Floss/floss picks for Invisalign patients • P&G Oral-B electric toothbrush for Incognito patients Robiha Nazir qualified from Newcastle University in 2004. She has a particular interest in dealing with nervous patients. www.dentistry.co.uk
88 Generalpractice How sharp are you?Dental Protection asks, are you up to date with the ‘safe sharps’ regulations? Dental Protection, the international leader in dental risk management, suggests all teams should frequently revisit regulations and check that their practice safety procedures are up to date, meet the necessary requirements and, just as importantly, are adhered to by the whole dental team. Following the introduction of The Health & Safety (Sharps Instruments in Healthcare) Regulations 2013, all healthcare facilities must ensure that they: • Implement safe procedures for using and disposing of sharp medical instruments and contaminated waste • Eliminate the unnecessary use of sharps by rimary dental care is – on the whole – delivered by relatively small teams, working closely together. It is this close involvement of practice principals in the day-to-day delivery of dental healthcare that often serves to ensure that employee safety, in matters of infection control and decontamination, is placed high on the agenda. However, with an increasing number of practices based across several sites, sometimes it can be difficult for employers and practice owners to ensure risks are being managed consistently. Equally, as a dental hygienist or therapist, you may work in several practices so it is important you are up to scratch on all practice policies. P
89 Generalpractice www.dentistry.co.uk implementing changes in practice and through providing medical devices incorporating safety- engineered protection mechanisms • Provide sharps disposal equipment as close as possible to the assessed areas where sharps are being used or found • Ban the practice of recapping • Use personal protective equipment • Train their practice staff on the correct use of sharps devices and the disposal of sharps waste • Familiarise themselves with the post-exposure protocols for each practice in which you work. Minimising the risk of accidental injury In terms of monitoring compliance and enforcing this legislation and others, such as the HTM 01-05 (infection control) guidelines from the Dental Protection offers risk management education tools for members across a multitude of platforms, including online, in publications, workshops and seminars and events. For more information, visit dentalprotection.org. Points to remember • Employers must be able to show they have taken steps to ensure all team members have been trained in the management of sharps. This involves the provision of information (especially when introducing new team members), training in safe practice when using sharps, the responsibility of employees to make employers aware when a sharps injury has occurred, and the procedures to be followed when an inoculation injury has occurred. Every such occurrence should be investigated proportionately to the severity of the incident and associated risk to the person concerned, and any relevant learning opportunities should be acted upon • Prevent the re-capping (re-sheathing) of needles. This involves the manual replacing of the protective sheath over the tip and shaft of a needle after use, and is a technique well known to have been associated with needlestick injuries in the past. It has particular relevance for dentistry, because of the level of exposure, ie, the number of occasions each day when hypodermic needles are used. Many systems are available whereby this risk can be reduced or eliminated, even when re-sheathing is considered necessary or desirable • Ensure the provision and prominent labelling of suitable secure containers in close proximity to the point of use. This is designed for the safe disposal and storage of sharps • Do not presume, or accept without question, the level of knowledge of a new team member • Ensure thorough induction training is carried out by an experienced and knowledgeable staff member, along with an assessment of the level of knowledge of the incoming person and also their practical ability to manage sharps safely and effectively • Keep a record of any training, and the subsequent appraisal of a new team member’s ability • Be aware of the risks when any third party is present in clinical/treatment area, such as parents and others accompanying patients • Assess the risks when using sharps away from the normal workplace for any reason eg, domiciliary visits. Department of Health, safe and effective sharps management remains an important feature of every dental practice inspection regime. The Regulations describe a ‘safer sharp’ as one that ‘is designed and constructed to incorporate a feature or mechanism which prevents or minimises the risk of accidental injury from cutting or pricking the skin’. This places an onus on employers – and those involved in the supplies procurement process – to demonstrate they have given thought to these options.
Keyclinical protocols 90 The daily grind What to do if your patients show signs of bruxism any of the mouth guard systems on the market through your regular dental dealer to protect patients against night time teeth grinding by cushioning the patient’s teeth and keeping them apart, with the least material possible, in the most natural position. By preventing the upper and lower jaw from touching, a dental guard will help prevent damage to teeth, prevent noise associated with grinding, and associated symptoms like jaw pain, headaches and sleepless nights. eeth grinding affects more than 10% of the population, so it’s likely you will meet patients complaining of unexplained jaw pain and worn tooth enamel without most of them even realising that they are grinding their teeth. If the patient has any of the following symptoms: severe headaches, jaw pain, toothache, tooth wear (usually in the form of flattening and breakage and in some cases injury to the jaw), and indentations on their tongue, it is likely they have bruxism, putting their jaw under extreme pressure. Chill out One of the most common causes for teeth grinding is stress, so find out if the patient has undergone a particularly stressful event or is about to go through something they consider stressful, then you are more likely to get to the root of the problem. Even if a patient feels like they are getting a good handle on their stress, their subconscious may still incite their jaw to clench. Relaxing the jaw throughout the day and make facial relaxation a habit should be advised. Get the patient to set their watch or phone to beep every hour to check their facial tension and practice loosening the jaw. Nocturnal habit The onset of teeth grinding and clenching can happen at anytime but night time grinders have biting force six times greater than during the daytime, meaning that they can cause more damage throughout the night without being aware of it. Recommend a dental guard for night time. Try www.dentistry.co.uk T Symptoms: • Severe headaches • Toothache • Tooth wear • Indentations in the tongue
91 Generalpractice Recall intervals between routine dental examinations Recall guidelines that should be should be interpreted with individual patient needs For adults, the interval should be between three and 24 months. The guidelines also recommend • During a check up, the dental team should ensure that comprehensive histories are taken, examinations are conducted and preventive advice is given. This will allow the team and the patient to discuss, where appropriate: – The effects of oral hygiene, diet, fluoride use, tobacco and alcohol on oral health – The risk factors that may influence the patient’s oral health and their implications for deciding the appropriate recall interval – The outcome of previous care episodes and the suitability of previously recommended intervals – The patient’s ability or desire to visit the dentist at the recommended interval – The financial costs to the patient of having the check up and any subsequent treatments. • The interval before the next check up should be chosen, either at the end of a check up or on completion of specific treatment • The clincian should discuss the recommended recall interval with the patient and record this in the patient’s records, along withthe patient’s agreement or disagreement. uidelines that set out recommendations for dentists and the public on the recall interval between dental check ups* were published by the National Institute for Health and Care Excellence (NICE) and the National Collaborating Centre for Acute Care several years ago. They are still current. Tailored The guidelines state that the recommended interval between dental check ups should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease. The guideline recommends that for under-18s the interval between check-ups should be between three and 12 months. www.dentistry.co.uk *At the time of going to press, outcomes from the NHS contract pilot practices suggest a different approach to dental ‘check ups’ with different care pathways emerging as the best practice when meeting the different levels of oral health need of patients. G
92 Generalpractice The role of quality assurance in dental radiation protection Graham Hart provides a comprehensive guide to radiation protection quality assurance is carried out when the equipment is installed, but will need to be repeated in the event of any relocation of the equipment, or following a major maintenance procedure that might affect the performance of the X-ray set. The critical examination is designed to ensure that equipment is electrically, mechanically and radiologically safe to use on patients, and that the environment in which the equipment is going to be used will keep radiation doses to staff and visitors ‘ALARP’ (as low as reasonably practicable). The critical examination is aptly named, since its importance cannot be underestimated. The Othea database of radiation incidents notes two separate occasions where intraoral dental X-ray equipment was not subject to a thorough pre-use test and where faults in the equipment gave rise to unintended radiation exposure (www.othea.net, 2012; www.othea.net, undated). An incident in 2012 was caused by a dentist who removed a wall- mounted X-ray unit himself to allow the surgery to be re-decorated but trapped a wire when he re-attached the X-ray set, causing it to expose continuously as soon as mains power was supplied to the set. here are many facets to dental radiation protection, but quality assurance (QA) plays a key role in avoiding unnecessary patient and staff radiation exposure, the key element in complying with the Ionising Radiation (Medical Exposure) Regulations (IRMER) (UK Government, 2000) and IRR99 – the Ionising Radiations Regulations 1999 (UK Government, 1999). There are four parts to the overall QA process: • X-ray equipment • Image formation system • Clinical image quality • Procedural audit. X-ray equipment All dental X-ray equipment needs to be subject to two kinds of performance test – the so-called ‘critical examination’ and routine testing. Both are requirements of IRR99. The critical examination T
93 Generalpractice www.dentistry.co.uk Thankfully, this incident did not give rise to significant radiation doses to anyone. This was unfortunately not the case in the other incident, where a mis-wired and hence continuously- operating set gave the right shoulder of the dentist concerned an estimated dose of 20 Sv – more than enough to cause major tissue damage. The second type of test is the routine QA test, and the UK’s Dental Guidance Notes to IRR99 and IRMER (Department of Health, 2001) recommends that this be done at least every three years on intraoral and panoramic sets, and more frequently if image quality deteriorates. Guidance published by what is now Public Health England (PHE) for the use of cone beam computed tomography (CBCT) equipment recommends that CBCT equipment be subject to annual routine QA testing (Health Protection Agency, 2010). Both the critical examination and the routine tests should include as a minimum: • kV accuracy, which should be within 10% of the set values • Beam filtration. This should be a minimum of 1.5mmAl for sets operating up to 70kV, and greater than 2.5mmAl for sets operating above 70kV • Beam size. Intraoral sets using circular collimators should have a beam diameter at the patient of no greater than 60mm. Nevertheless, rectangular collimators have been strongly recommended for more than 15 years. This is simply because they will save more than 40% of patient (and hence staff) radiation dose on geometric grounds alone, since film or digital image receptors are rectangular in shape. OPTs should have a beam size less than 5mm x 150mm • Patient radiation dose. For intraoral sets, this is usually measured as the ‘patient entrance dose’. The national reference dose for mandibular molar exposures are currently set at 1.7mGy for adults and 0.7mGy for a child exposure. Practices should aim to be well within this value. As an example, a modern digital set operating at 70kV can produce acceptable image quality for an adult mandibular molar exposure at a third of the national reference dose. Patient exposures from panoramic equipment are usually measured as the ‘dose area product’, and the national reference doses for a ‘standard jaw’ are currently set at 93mGy.cm2 for an adult and 67mGy.cm2 for a child. Again, practices should aim to be well within these figures. For CBCT sets, tests of kV accuracy and beam filtration are the same. Although there is no national reference dose for CBCT as yet, current guidance recommends that patient radiation dose normalised to an imaged volume of 4cm x 4cm should be within the PHE’s ‘achievable dose’ of 250mGy.cm2 (Health Protection Agency, 2010). Other tests of image quality and consistency are needed but are beyond the scope of this article, and should be discussed with the practice’s medical physics expert. Image formation system The image formation system may either use film or a digital imaging system. If digital imaging is being used then the image system will either be a phosphor plate put into a reader or a sensor plate where the image is transferred directly to a PC or laptop, usually through a connecting wire. For practices still using film-based imaging systems, there are two different ways of testing the imaging system. One method tests the film processor by developing pre-exposed strips in the processor to see whether each of the individual
94 Generalpractice segments can clearly be delineated. The other way is to use a step wedge to expose the film on a standard setting and then develop the film, looking to see that all the steps are clearly visible. Step wedges have traditionally been made of aluminium, but a simple step wedge can be made by overlapping pieces of the lead foil found behind dental film to achieve a perfectly usable QA test object (Martin, 2007). For practices using digital imaging systems, there are two aspects to the QA procedure. The first is that the imaging system itself is behaving consistently, and this can be adequately tested using either of the same step wedge systems just described. The second aspect is the image display system. In order to maintain the quality of images displayed on monitors or screens used for interpreting and reviewing, weekly QA should be undertaken to ensure that the monitor can adequately resolve the image contrast. This can be achieved using a test pattern such that produced by American Association of Physicists in Medicine (AAPM) – the ‘TG-18C’ pattern, or the one produced by the Society of Motion Picture & Television Engineers (SMPTE) for medical image screens – the ‘SMPTE-RP133’ pattern. They both follow essentially the same concept and both can be downloaded from the internet. Clinical image quality The quality of the clinical image is not only the endpoint of the imaging process, but is often the first point where problems with other aspects of the imaging system come to light. Therefore, a regular audit programme of clinical image quality is vitally important to ensure ongoing high quality imaging. The Dental Guidance Notes to IRR99 and IRMER (Department of Health, 2001) recommend a simple three-point rating system, with intraoral and panoramic imaging having a target of not less than 70% of images having ‘excellent’ quality; not more than 20% being only ‘diagnostically acceptable’; and not more than 10% being ‘unacceptable’. The criteria are based on whether the image has no errors of patient preparation, exposure, positioning, processing or film handling; some errors but still allowing the image to be clinically usable; or sufficient errors to render the radiograph diagnostically unacceptable. The image quality rating system for dental CBCT imaging recommended in the Health Protection Agency/PHE guidance document (Health Protection Agency, 2010) is simpler still, with a target of not less than 95% of images being ‘diagnostically acceptable’; and less than 5% of images being ‘diagnostically unacceptable’. Here again the criteria relate to whether the image has no errors or minimal errors in patient preparation, exposure, positioning, or image reconstruction and is of sufficient image quality to answer the clinical question; or whether the image is diagnostically unacceptable. Whether for intraoral, panoramic or CBCT imaging, the audits of patient image quality can either be carried out prospectively or retrospectively. Regardless of the dental imaging modality, guidance documents recommend that these audits should be carried out at intervals of not greater than six months (Department of Health, 2001; Health Protection Agency, 2010). Prospective audits are usually simpler to arrange, rating the quality of the next 100 intraoral exposures, or perhaps the next 50 exposures for less frequent examinations such as panoramic or CBCT radiographs, to make the calculation of percentages easier. If an audit reveals a higher percentage of diagnostically unacceptable images than the guidance suggests, the reasons need to be investigated. The practice’s medical physics expert is likely to be able to provide useful advice at this point. Procedural audit IRMER also includes a requirement for the regular audit of the various policies, procedures and protocols that govern the way the practice makes X-ray exposures and which will reside in the practice’s radiation protection file. A review of these documents should be triggered whenever there are changes to staff, equipment, techniques or working practices, but a simple
95 Generalpractice documented review should occur at least on an annual basis to ensure that they remain relevant to the dental practice. One example of a procedure that is likely to need regular review is the one identifying the individuals entitled to act as referrer, IRMER practitioner and operator. The list of those individuals will clearly change as members of staff are employed, or cease employment, at the practice. One of the practice’s dental nurses may also achieve the Certificate in Dental Radiography and thus be allowed to take radiographic exposures unsupervised, and their status would also need to be updated accordingly. Other examples of procedures likely to need regular review are those surrounding the criteria for the selection and justification of patient for radiography. Although both UK and European guidance (Department of Health, 2001; European Commission, 2004) make it clear that only those radiographs that are strictly clinically necessary to change patient management should be made. Practices may experience pressure to X-ray all new patients and/or all patients at regular intervals, perhaps to avoid the threat of medico- legal issues arising from undiagnosed conditions. The procedures in the practice’s radiation protection file need to accurately reflect what happens in the practice, and not just be a form of standardised wording. Conclusion Following the above elements of QA will ensure that dental radiography will be ‘optimised’ – producing a diagnostically useful image at the lowest achievable radiation dose – and this is a cornerstone of IRMER. Of course, using the lowest dose necessary to produce quality clinical images will also help to keep staff radiation doses ‘ALARP’ – one of the cornerstones of IRR99. For references contact Julian@dentistry.co.uk. Graham Hart worked as a medical physicist within the NHS at Bradford Royal Infirmary for 30 years, initially in ultrasound and nuclear medicine and latterly in radiological physics and radiation, laser and non-ionising radiation protection. Over 10 years ago, Graham left to set up YourRPA, acting as an independent radiation and laser protection adviser in the dental, medical, veterinary and academic sectors, and where appropriate as a medical physics expert in diagnostic radiology. During his career, Graham has been (at various times) a member of the Council of the British Nuclear Medicine Society, Chair of the Institute of Physics & Engineering in Medicine’s Radiation Protection Special Interest Group, Chair of the Society for Radiological Protection’s Non-Ionising Radiation Topic Group and member of their Medical Sectorial Committee. Graham has written almost 50 published scientific papers and book chapters, and given over 40 oral presentations at scientific meetings. For more information, visit www. dentalrpa.co.uk or email Graham at yourrpa@yahoo.co.uk. www.dentistry.co.uk
Keyclinical protocols 96 Resuscitation protocolsMedical emergencies are rare in a dental surgery, but you should still be familiar with the necessary procedures • There is a public expectation that dental practitioners and dental care professionals (DCPs) should be competent in managing common medical emergencies • All dental practices should have a process for medical risk assessment of their patients
Keyclinical protocols 97 www.dentistry.co.uk • All dental practitioners and DCPs should adopt the ‘ABCDE’ approach to assessing the acutely sick patient • Specific emergency drugs and items of emergency medical equipment should be immediately available in all dental surgery premises. These should be standardised throughout the UK • All clinical areas should have immediate access to an automated external defibrillator (AED) • Dental practitioners and DCPs should all undergo training in cardiopulmonary resuscitation (CPR), basic airway management and the use of an AED • There should be regular practice- and scenario- based exercises using simulated emergencies • Dental practices should have a plan in place for summoning medical assistance in an emergency. For most practices this will mean calling 999 • Staff should be updated annually • Audit of all medical emergencies should take place. Emergency drugs in general dental practice Specific emergency drugs should be immediately available in all dental surgery premises. These should be standardised throughout the UK. 1. To manage the more common medical emergencies encountered in general dental practice the following drugs are recommended: • Glyceryl trinitrate (GTN) spray (400mcg/dose) • Salbutamol aerosol inhaler (100mcg/actuation) • Adrenaline injection (1:1000, 1mg/ml) • Aspirin dispersable (300mg) • Glucagon injection 1mg • Oral glucose solution/tablets/gel/powder • Midazolam 10mg/ml (buccal or intranasal) • Oxygen. 2. Where possible, drugs in solution should be in a prefilled syringe 3. The use of intravenous drugs for medical emergencies in general dental practice is to be discouraged. Intramuscular, inhalational, sublingual, buccal and intranasal routes are all much quicker to administer drugs in an emergency 4. All drugs should be stored together in a purposely-designed ‘emergency drug’ storage container 5. Oxygen cylinders should be of sufficient size to be easily portable but also allow for adequate flow rates – eg, 10-15 litres per minute – until the arrival of an ambulance or the patient fully recovers. A full D size cylinder contains 340 litres of oxygen and should allow a flow rate of 10-15 litres per minute for between 20 and 30 minutes. Two such cylinders may be necessary
Keyclinical protocols 98 to ensure the supply of oxygen does not fail when it is used in a medical emergency. Medical emergency and resuscitation equipment The equipment used for any medical emergency or cardiopulmonary arrest should be standardised throughout general dental practices in the UK. All clinical areas should have immediate access to resuscitation drugs, equipment for airway management and an AED. Staff must be familiar with the location of all resuscitation equipment within their working area. The following is the minimum equipment recommended: • Portable oxygen cylinder (D size) with pressure reduction valve and flowmeter • Oxygen face mask with tubing • Basic set of oropharyngeal airways (sizes 1, 2, 3 and 4) • Pocket mask with oxygen port • Self-inflating bag and mask apparatus with oxygen reservoir and tubing • (1 litre size bag) where staff have been appropriately trained • Variety of well-fitting adult and child face masks for attaching to self-inflating bag • Portable suction with appropriate suction catheters and tubing eg, the Yankauer sucker • Single use sterile syringes and needles • ‘Spacer’ device for inhaled bronchodilators • Automated blood glucose measurement device • AED. The ‘ABCDE’ approach to the sick patient Dental practitioners, DCPs and their staff should be familiar with standard resuscitation procedures as recommended by the Resuscitation Council (UK). In all circumstances it is advisable to call for medical assistance as soon as possible by dialing 999. A systematic approach to recognising the acutely ill patient based on the ‘ABCDE’ principles is recommended. Accurate documentation of the patient’s medical history should further allow those ‘at risk’ of certain medical emergencies to be identified in advance Anaphylaxis treatment The UK incidence of anaphylactic reactions is increasing. Patients who have an anaphylactic reaction have life-threatening airway and/ or breathing and/or circulation problems usually associated with skin and mucosal changes. Patients having an anaphylactic reaction should be recognised and treated using the airway, breathing, circulation, disability, exposure (ABCDE) approach. of any proposed treatment. The elective nature of most dental practice allows time for discussion of medical problems with the patient’s general medical practitioner where necessary. In certain circumstances this may lead to a postponement of the treatment indicated or a recommendation that such treatment be undertaken in hospital. General principles 1. Follow the airway, breathing, circulation, disability, and exposure approach (ABCDE) to assess and treat the patient 2. Treat life-threatening problems as they are identified before moving to the next part of the assessment 3. Continually re-assess starting with airway if there is further deterioration 4. Assess the effects of any treatment given 5. Recognise when you need extra help and call for it early. This may mean dialling 999 for an ambulance 6. Use all members of your dental team. This will allow you to do several things at once, eg, collect emergency drugs and equipment, dial 999 7. Organise your team and communicate effectively 8. The aims of initial treatment are to keep the patient alive, achieve some clinical improvement and buy time for further treatment while waiting for help 9. Remember – it can take a few minutes for treatment to work 10. The ABCDE approach can be used
Keyclinical protocols 99 www.dentistry.co.uk • Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines • The exact treatment will depend on the patient’s location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction • Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction • Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline • Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use • All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy • Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions. This guideline replaces the previous guideline from the Resuscitation Council (UK): The emergency medical treatment of anaphylactic reactions for first medical responders and for community nurses (originally published July 1999, revised January 2002, May 2005) • The recognition and treatment of an anaphylactic reaction has been simplified • The use of an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to recognise and treat an anaphylactic reaction has been introduced • The early use of intramuscular adrenaline by most rescuers to treat an anaphylactic reaction is emphasised • The use of intravenous adrenaline to treat an anaphylactic reaction is clarified. It must only be used by those skilled and experienced in its use in certain specialist settings • The age ranges and doses for adrenaline, hydrocortisone and chlorphenamine have been simplified. irrespective of your training and experience in clinical assessment or treatment. Individual experience and measures such as laying the patient down or giving oxygen are needed. First steps • In an emergency, stay calm. Ensure that you and your staff are safe • Look at the patient generally to see if they look unwell • In an awake patient ask, ‘How are you?’ If the patient is unresponsive, shake him and ask, ‘Are you all right?’ If they respond normally, they have a clear airway, are breathing and have brain perfusion. If they speak only in short sentences, they may have breathing problems. Failure of the patient to respond suggests that they are unwell. If they are not breathing and have no pulse or signs of life, start CPR according to current resuscitation guidelines. The latest guidance about required training for the dental team is available from www.gdc-uk.org. For information about courses and educational resources, visit www.resus.org.uk. Material by kind permission from the Resuscitation Council (UK) and correct at the time of writing.
100 Generalpractice One minute can save a lifeScott Froum discusses the importance of early detection of oral cancer deaths per year. Studies show that successful treatment of oral cancer is highly dependent upon diagnosing and treating this disease in its early stages. Although there have been advances quamos cell carcinoma (similar to skin cancer) of the oral cavity and throat accounts for around 45,000 cases each year in the United States, resulting in around 8,000 S
101 Generalpractice www.dentistry.co.uk Dr Scott H Froum is a board-certified periodontist who received his BA from Amherst College in Amherst, Massachussetts, with a major in biology. He received his DDS from the State University of New York Stony Brook School of Dental Medicine where he graduated with honours. He continued his dental training in the postgraduate periodontal department at the State University of New York Stony Brook School of Dental Medicine and received his periodontal certificate. He currently is a clinical associate professor at New York University in the Department of Periodontology and Implantology. He is also a clinical associate professor at the SUNY Stony Brook School of Dental Medicine in the Department of Periodontics. He is co-editor of the website The Surgical-Restorative Resource. He has lectured on national and international levels on implant therapy and complications. He has a private practice in New York City, NY. in surgical, chemotherapy and radiotherapy, treatment for oral cancer five-year survival rates of patients with this moderate to advanced disease are less than 60%. In addition, those patients that do survive typically have trouble chewing, speaking, eating and smiling after treatment. It is therefore tremendously important to diagnose oral cancer before it becomes advanced, since treatment for early cancer is not as severe. Statistics Of all head and neck cancers, 75% begin in the mouth. The most common regions of oral cancer involvement are the back of the throat, the sides of the tongue and underneath the tongue. Historically, smoking and alcohol use are highly related to the development of oral cancer and would affect people over the age of 50. Unfortunately because of the increase in the incidence of human papilloma virus (HPV 16-18), head and neck cancers have been increasing in men and women in their 20s and 30s. One very general trend is that tobacco/alcohol lesions tend to favour arising in the anterior tongue and mouth while HPV-positive lesions favour arising in the back of the mouth. Detection The best way to detect oral cancer early is to screen every patient at every dental visit. A clinical and mirror exam is usually all that is needed. Visual identification results can be enhanced by the use of lights. I use a non-invasive blue light fluorescence technology that is not painful and takes one minute perform the examination. The light picks up pre-cancerous, cancerous and HPV lesions that normally could go undetected. One minute can save a patient’s life.
102 Generalpractice Swinging into their 60sMhari Coxon considers whether the UK dental profession is prepared to meet the healthcare needs of our ageing population he population of the UK is ageing. Over the last 25 years, the percentage of the population aged 65 and over increased from 15% in 1983 to 16% in 2008, an increase of 1.5 million people in this age group. Over the same period, the percentage of the population aged 16 and under decreased from 21% to 19%. This trend is projected to continue. The mid-year population estimates from the Office for National Statistics, General Register Office for Scotland and the Northern Ireland Statistics and Research Agency show that by 2033, 23% of the population will be aged 65 and over compared to 18% aged 16 or younger. This ageing population is not exclusive to the UK and most developed countries are facing the same statistics. Living longer Being 60 now is completely different to when our grandparents or even our parents turned 60. We are staying healthier, keeping youthful and, most pertinent to us, keeping our teeth for longer too. Think of Helen Mirren in her bikini at 60 still turning heads. And Harrison Ford is still making women weak at the knees. Sixty is the new 40. And 40? Well, that’s still young. People could be living not only longer, but to a better quality, according to doctors writing in The Lancet medical journal, who say that most T evidence shows the under-85s are tending to remain more capable and mobile than before. They have more chronic illnesses, such as cancers and heart conditions, but people survive them because they are diagnosed earlier and get better treatment. Healthcare is being provided more and more in a non-hospital environment to ease the burden on our overstretched wards. What is healthy? Patients’ perceptions and expectations have changed a lot in attitude to their health, healthcare professionals and their thoughts on ageing. There was a time when it was expected and accepted that you would lose your teeth as you got older. Now that we have a large proportion of the elderly population that are dentate, we need to look at how we care for these patients and the work they have in their mouths. Problems that we see and deal with regularly in an ageing patient group are: • Xerostomia
103 Generalpractice www.dentistry.co.uk • Recession • Acid erosion • Periodontal disease • A rapid change in oral health due to systemic health changes. Mental health issues Alzheimer’s is on the increase and there are around 820,000 people living with dementia in the UK today, a number forecast to rise rapidly as the population ages. One in three over 65s will die with some form of dementia and this will completely change the type of treatment that is appropriate and the care plan in the oral healthcare. Early-onset memory problems can affect a patient’s oral health as they can forget to brush. More advanced problems can lead to longer lapses in personal care, in some instances filled by family members. Again, oral health can deteriorate. More advanced stages of this illness usually lead to institutionalised care with very little personal care given. Carers in these homes are limited in oral healthcare knowledge and sometimes unable to get compliance from patients. Can we meet demand? If we think of the average lifespan of a piece of work, even very good work, being around 20 years then we see that replacement work and maintenance work will reach a high level. This could see demand for dental work increasing dramatically over the next few years. Root canals will need to be redone, fillings replaced and upgraded to crowns, and more implants will be placed as people become less accepting of being edentulous. There is also the previous trend for heavy cosmetic restorations. Although this type of invasive treatment is thankfully almost completely a thing of the past, there are still patients who will need this work maintained and replaced up to three times in their lifetime. Figures based on population censuses show there were more than 11 million people of state pension age and over in the UK in 2005. That will be significantly higher now. Utopian future More people of pensionable age than working age will mean less taxable income for spending on health services and services generally. As we stand now there is no long-term plan in place to deal with the increase of dentate elderly and demand for treatment. The question these facts pose is this: are we looking at a future where it will be impossible to provide adequate service as we will become financially lacking as a nation? The most obvious solution to me is an increase in affordable oral health education and treatment for all. Long term, I believe we need to have more registered professionals delivering low-level preventive care in non-dental environments to cope with the pressure the profession will face and reduce the burden on the dental surgeon. In an ideal world, I would see each care home having a small team of oral health educators, training and mentoring the carers in looking after the mouth. It would become part of the wellness plan in general medical practices. The deterioration that is seen regularly in care homes in dentate patients can be horrific. In fact, oral health educators and hygienists would become attached to many places where there could be a rapid downhill in the dental health of someone, for example, stroke units and cancer units (I know this is already in place in many, but it should be all). In my utopian future, dentists would be supported by teams with the freedom to work in the best interests of the long-term care of their patients. And GP practices would all have an oral health advisor attached to them in the same way as a practice nurse. Mhari Coxon has over 20 years’ experience in dentistry. At present, she works as a senior professional marketing and relations manager for Philips Oral Healthcare UK and Ireland. She was awarded the Outstanding Contribution award in 2015 at the DH&T awards.
104 Generalpractice especially if they have completed a long course of treatment. These images prevent any doubts about improvements that have been achieved. Indemnity providers say that complaints they handle are often due to poor communication. Using photographs and words together for case presentations reduces misunderstandings. Images to take The American and British Academy of Cosmetic Dentistry (AACD and BACD) provide guidelines of images that are taken for accreditation. This is a good place to start when deciding which images are required to complete a comprehensive evaluation or provide effective patient education. • Portrait       • Smile • Right smile     • Left smile • Anterior retracted   • Right lateral retracted • Left lateral retracted  • Anterior close up • Right Anterior close up • Left Anteror close up • Upper occlusal    • Lower occlusal. Give it a go! As dental hygienists and therapists, we are responsible for our patients’ care, even more so for ith the increased availability of digital point-and-press cameras, digital single lens reflex cameras (DSLR) and intra- oral cameras, dental photography can be easily intergrated into patient visits. With good training, any member of the dental team should be able to attain good quality, reproducible images. Reasons for taking photographs Good quality intra and extraoral images complete a comprehensive evaluation. They create a visual baseline prior to treatment. Long, written notes describing the clinical situation of the patient are traditionally used, images can save time and provide a more accurate account of the situation. Presenting patients with photographs of their own mouths during case presentations increases treatment acceptance and is more time efficient as visual explanations have a greater impact than long, detailed verbal descriptions. ‘Before, during and after’ images are extremely useful for tooth whitening, other aesthetic dental procedures and orthodontics. Patients sometimes forget what the situation was at the beginning, W Need for good photographyWith studies showing that 80% of the population learn in a visual capacity, Diane Rochford discusses the need for good photography in practice
105 Generalpractice www.dentistry.co.uk those practising direct access. Implementing the use of photography enhances the level of treatment we provide and patients deserve. Using a new skill requires training, practice and patience, it can also be enjoyable, so why not give it a go! You will need… Camera Cameras are easily accessible, easy to use and affordable. The quality of the image produced can depend on the type of camera used. The table below highlights the differences between DSLR and point-and-press cameras. Single Lens Reflector (SLR) Compact Lenses can be changed Fixed lens Varied zoom capacity Limited zoom Wide angle Wide angle Macro lenses are more efficient for close-up work Image can distort on a ‘macro’ setting Ring flash is less harsh = no shadows Harsh flash = extreme shadows Ring flash provides even illumination of the mouth Inadequate illumination of the mouth Large sensor = high resolution Small sensor = poorer resolution Easily produced consistent results Unable to produce consistent results Retractors There are various types of retractors available. Separate retractors are held by the patient, and available in various sizes. With direction the patient can assist, allowing for a good view of both anterior and posterior teeth. Contrasters Black backgrounds show off teeth well, the patient bites gently on a black paddle, or piece of black paper. These images are effective before and after tooth whitening or other aesthetic procedures. Mirrors Mirrors are used for taking occlusal images, this type of photography requires practice and patience. Mirrors can easily mist during use, air from the 3-in-1 keeps a clear field of vision. Background A white, black, grey or blue background provides a less distracting photograph and better contrast when viewing portrait images. Diane Rochford qualified as a hygienist from Guy’s Hospital in 1996. She joined Dr Linda Greenwall’s team in September 1996 where she assists with teaching on bleaching courses. Diane is also a clinical coach for Jameson Management.
106 Generalpractice Eating less sugar Bal Chana addresses the issue of sugar consumption and provides tips on eating less sugar school children were admitted to hospital due to dental caries, costing the NHS £30 million. Not only does sugar affect oral health, it also has a detrimental effect on general health; in the UK 25% of adults are obese, and high consumption of amie Oliver states: ’Important changes need to be made to address the UK’s deteriorating dental health from sugar consumption’. Dental caries is the main reason young children are admitted to hospital; last year, 26,000 primary J
107 Generalpractice dentalhygienetherapy.co.uk Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006. sugar can also lead to type II diabetes. In the UK there are currently 3.3 million people living with diabetes; shockingly, 7,000 amputations are carried out a year due to diabetes. Experts are saying that we should have no more than 30g of sugar per day, which is approximately seven teaspoons a day. A can of fizzy drink contains 35g (nine teaspoons) of sugar. Sugar Manifesto Jamie Oliver has launched a new campaign and is lobbying the Government. He is calling for the introduction of a sugary drink duty. Jamie has set out a Sugar Manifesto, which will make a serious difference to the dental health of the nation. The manifesto suggests that a range of measures are needed to tackle the issue. The measures outlined in the Sugar Manifesto are: • A 20pence levy per litre on every soft drink containing added sugar. This would be 7pence per 330ml can • Legislate The Responsibility Deal: The Responsibility Deal exists to improve public health in England • Ban all junk food marketing on TV before 9pm and create more robust digital marketing regulations to protect children on the internet • Make the ‘traffic light’ labelling system mandatory on the front of all food and drink pack packaging • Show sugar content in teaspoons on the front of packaging for all sugary drinks. Tips on eating less sugar Jamie Oliver is not the only person campaigning. Action on Sugar is a group formed by specialists concerned with sugar and its effects on health. Action on Sugar’s nutritionist, Kawther Hashem, provides some tips on eating less sugar: • Remove sugar (white and brown), syrup, honey and molasses from the breakfast table — out of sight, out of mind • Cut back on the amount of sugar added to things you eat or drink regularly like cereal, pancakes, coffee or tea. Try cutting the usual amount of sugar you add by half and wean down from there • Instead of adding sugar to cereal or porridge, add fresh fruit • Instead of having sweetened yoghurt, have plain yoghurt and add fresh or dried fruit • When baking cookies, brownies or cakes, cut the sugar in your recipe by one-third to one-half • Instead of adding sugar in recipes, use extracts such as almond, vanilla, orange or lemon • Enhance foods with spices instead of sugar; try ginger, allspice, cinnamon or nutmeg • Buy sugar-free or low-calorie drinks • Use Foodswitch UK, a free smartphone app, to help you find food and drink products with less sugar. Let’s all join forces and work together to address this issue.
108 Generalpractice The sweetest taboo Melonie Prebble welcomes the global attack on sugar he year of the big sugar debate has undoubtedly been 2015. An ever-increasing number of evidence-based studies is drawing a wide range of scientific conclusions. But there’s little doubt that: • It’s addictive • It’s bad for our health • It’s contributing to both a childhood obesity crisis and a surge in cases of Type II diabetes • Much of the western population needs to curb its intake. Even if we didn’t know the scale of its impact on general health, as dental professionals we do understand what it is doing to our nation’s oral health. In July, the Scientific Advisory Committee on Nutrition advised the Government to halve the recommended intake of free sugars – the effectively nutrient-free refined sugar added to products such as sweetened drinks – to help T Melonie Prebble is an experienced dental hygienist and therapist, having worked in the dental industry for over 20 years. She graduated from The London Hospital in 1995 and has been enhancing her skills and contributing to the industry ever since. Melonie currently offers her services at Abbey Road Dental, in north west London, and the clinic at The Luke Barnett Centre, Watford, Hertfordshire.
109 Generalpractice www.dentistry.co.uk address the growing obesity and diabetes crises and to reduce the risk of tooth decay. In response to this, the British Dental Association called on Government to take heed of this latest expert advice and its petition at change.org (2015) has, so far, been signed by over 2,000 people. Additionally, the British Association of Dental Therapists (BADT) pledged its support for the pressure group, Action on Sugar, which is also working towards reversing the nation’s addiction to the ‘sweet stuff’. The group is made up of across- the-board health experts, united in their concern about sugar and its effects on health. It leads with an unprecedented call to tackle and reverse the obesity and diabetes epidemic. Joined-up approach But BADT president, Fiona Sandom, argues that what’s needed is a joined-up approach by health professionals to successfully tackle dental decay and related health issues caused by a high sugar diet. She says: ‘There is a real appetite for change over the unnecessary and unhealthy amount of sugar in our diets and it is up to all health professionals to ensure we educate our patients of the full health benefits of cutting sugar out of diets. ‘There has been overwhelming scientific evidence that sugary drinks are linked to poor health. More importantly, however, the evidence regarding sugary drinks and their link to tooth decay is universal and this in itself can be a precursor to other serious health issues – and there is much research that shows how periodontal disease and systemic health are closely linked. She believes that dental therapists and dental hygienists are well placed to offer guidance from an oral health perspective and, in doing so, can also help to reverse the alarming obesity and diabetes epidemic. But there appears to be little desire by the food industry to be ‘on side’. To date, out of all the major supermarket chains, only Tesco has committed to reducing sugar (by 5%) across its own-label soft drinks range, despite the fact that Public Health England said other drinks brands should now follow its lead. Sugar Swaps campaign However, despite the criticism of the Government’s lack of action, at the start of this year, its health campaign, Change4life, launched ‘Sugar Swaps’, offering tips to parents so they can substitute high sugar meals with low sugar options – swapping sugary cereal with plain cereal, ice cream with low-fat yoghurt and so on. It’s an excellent resource for the dental team and supports the BADT’s thinking that, only by collaboration with other health professionals, can the tide of sugar addiction be turned. This addiction to sugar is placing a huge burden on the NHS. By taking the time to communicate the health risks to our patients when they are in the dental chair not only demonstrates our responsibility to them, but shows our commitment to the future health of our nation – and the future of healthcare, too. For references contact Julian@dentistry.co.uk. Alarming facts to share with patients 1. Brits eat around 700gm of sugar a week: that’s an average of 140 teaspoons per person 2. Tooth decay is the number one cause of hospital admissions among children. A total of 46,500 young people under 19 were admitted to have teeth removed under general anaesthetic in a single year, with hospitals forced to run extra operations in the evenings and at weekends to deal with demand 3. Across the UK, three in 10 five-year olds have visible signs of decay and by the time they reach 15, this increases to nearly one in two 4. A high-sugar diet can lead to an impairment of early learning for both long- and short-term memory 5. Sugar-sweetened drinks may give rise to nearly two million diabetes cases over 10 years in the US and 80,000 in the UK.
110 Generalpractice Increasing access to dental careCharlotte Wake believes that accessing dental care is a serious issue appointment.’ This shows that accessing NHS dental care is possible but there are numerous reasons, not just access itself, that will stop people making the appointment or proceeding with necessary treatment. The report also tells us that 26% of people had chosen a type of treatment due to cost. 19% of people said they had delayed dental treatment, citing cost as the reason. very 10 years the Adult Dental Health Survey is taken. The first was in 1968 and the most recent was produced in 2009. This contains information about dentate adults, oral hygiene trends and attitudes to oral care. This latest report tells us that ‘58% of adults said that they had tried to make an NHS dental appointment in the previous three years. Of these adults, 92% successfully received and attended an E
111 Generalpractice www.dentistry.co.uk Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapist’s council, is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice. Barriers We know that barriers include the cost of treatment, with another being dental anxiety. The survey explains that ‘12% of adults who had ever been to a dentist had a Modified Dental Anxiety Scale (MDAS) 2 score of 19 or more which suggests extreme dental anxiety.’ This anxiety was associated with the drill and with local anaesthetic injections. The number of adults that had a moderate level of dental anxiety was 36%. Regarding accessing care, the survey states that women are more likely to make the dental appointment and when patients had attended the feedback was generally positive, with 80% having no negative feedback at all about their dental visit. The general concerns when they were given, related to having time to discuss their oral health and worryingly not being involved as much as they would like in dental decisions and treatment. With this in mind, there are already procedures in place to help overcome some of these barriers to help improve access to care. The option of NHS treatment helps reduce costs and there are several types of dental plans available to help spread the cost of treatments within the private sector. The dental profession is aware of dental anxiety and we come into contact with this on a daily basis in varying degrees. Manufacturers make better dental materials than ever before and techniques continue to evolve to help provide a comfortable environment for treatment. Oral hygiene aids The introduction of fluoride toothpastes and the many oral hygiene aids available help people to care for their teeth at home better than ever before. Prevention is always better than cure and educating patients about their role in prevention with good lifestyle, diets and good oral hygiene regime helps prevent the need to have treatment and may indeed improve their systemic well being. The introduction of direct access in May 2013 has enabled more clinical time to be available. I acknowledge there are barriers to using direct access in an NHS environment without a performer number, but within the private sector patients no longer need to see a dentist prior to receiving treatment from a dental therapist or dental hygienist. Challenges the NHS faces In the summer of 2013, NHS England produced a document entitled: ‘Improving Dental Care and Oral Health – A Call to Action’. This, in part, sets out the challenges the NHS faces. It highlights the good progress made regarding accessing dental care in recent years. This says ‘1.4m more people having seen an NHS dentist in a 24-month period since 2010’. It claims the access can be improved and gives the example of extended hours to allow patients to attend after work or at weekends. It suggests that although care to those with special needs is often provided by community dental services, this could potentially change with dental practices seeing a wider range of patients. The report acknowledges routes to urgent care are too ‘variable and obscure’ to patients and advises this should be signposted. The fact that A&E departments continue to deal with dental pain that would be more appropriately treated by urgent dental services is also noted and further understanding of ‘eventual strategic framework’ is advised. Accessing dental care is a serious issue and although improvements have been made, we will see a bigger picture of its success or failure following the next adult dental health survey around 2019. Only then will we know what is left to be achieved.
112 Generalpractice Social and health inequalities BADT president Fiona Sandom considers the social gradient in healthcare decay, the inequality appears to be getting more profound and we won’t be able to treat away the difference’. Another frightening statement that he made was that: ‘Of the 15-year-olds that have caries, those that have free school meals are likely uge social and health inequalities in our society were highlighted by Professor Jimmy Steele in his BDJ/BDA anniversary lecture, who said that: ‘Although there has been a profound reduction in the prevalence of tooth H
113 Generalpractice www.dentistry.co.uk Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists. to have twice as much.’ Reducing health inequalities In November 2008, Professor Sir Michael Marmot was asked by the then Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010. Marmot reported that reducing health inequalities is a matter of fairness and social justice. In England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life. There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health. Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health. Actions must be universal Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. This is proportionate universalism. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs. That economic growth is not the most There is a social gradient in health – the lower a person’s social position, the worse his or her health important measure of our country’s success. The fair distribution of health, well being and sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together. Six policy objectives Sir Marmot concluded that reducing health inequalities will require action on six policy objectives: • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill-health prevention. Delivering these policy objectives will require action by central and local Government, the NHS, the public and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies. Effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities.
114 Indemnityand governance Indemnity & Governance
116 Indemnityand governance Protection through partnership he practice of dentistry is not without risk and there is an expectation upon you to have ‘appropriate arrangements in place for patients to seek compensation if they suffer harm’. The only types of cover recognised by the GDC are: • Dental defence organisation membership • Professional indemnity insurance held by you or your employer • NHS/Crown indemnity. As a dental defence organisation, Dental Protection offers professional protection, provided by world-class dentolegal experts, but this is only part of the story. In addition to defending members at the GDC, Dental Protection works tirelessly to help members create personal development plans and implement remediation where necessary. The team regularly offers the support of local dental advisers (who are also in practice like you) to reinforce the colleague-to- colleague support that members find so invaluable – there are even DCP-specific advisers who understand your role. Condition of registration The rules regarding indemnity have recently changed and dental professionals applying for registration or restoration, and those renewing There are changes afoot to your indemnity requirement and Dental Protection aims to help you with this – and more T their registration each year, will need to tell the GDC that they have access to indemnity – or will have by the time they start practising. So, when you renew your registration through EGDC, you must confirm you have access to indemnity. In order to renew your registration and make the declaration, you will need an EGDC account, so if you don’t already have one, now would be a good time to sign up. You can find instructions on how to do this at www.gdc-uk.org. As a result of changes in September 2015, anyone wishing to join the register for the first time, as well as restoring their name, now needs to declare that they have (or will have) access to indemnity in place during the application process. From the end of January 2016, those who are applying for restoration will be required to provide the GDC with evidence of their indemnity, or proposed indemnity, once they have restored to the register. If you are renewing your registration you should make this declaration during the annual retention fee collection period in summer
117 Indemnityand governance 2016. Dental care professionals will make their first indemnity declaration in July 2016 through the annual renewal process for the 12-month registration period that extends into 2017. Evidence that the GDC will accept include: • Copy of your Dental Protection membership certificate or the equivalent provided by any other arrangement • Copy of a cover letter addressed to you from a recognised dental defence organisation to confirm your application has been approved and you will have access to indemnity following registration with the GDC. Happily, Dental Protection’s promise of ‘more than just defence’ for its members will help meet these new requirements in a very simple and straightforward way in the form of a downloadable certificate of indemnity, which is available online via the member login area at www. dentalprotection.org. Genuine partner Like you, Dental Protection believes prevention is better than cure and is much more than a last line of defence, striving to be a ‘genuine partner’ throughout your career – to be by your side at every step, offering support, advice and world- class defence. As knowledge experts and international leaders in dentolegal advice, it understands the ever- changing world that today’s dental professionals work in. This means the team can adapt its service to your needs, actively protecting and helping you to develop, leaving you free to enjoy your career. www.dentistry.co.uk
118 Indemnityand governance Can you handle it? f a patient makes a complaint, it is usually around the following areas: • Their treatment – or lack of it, depending on the level of patient satisfaction • Adminastrative matters, ie, being kept waiting, treatment fee charges, staff behaviour • A clash of personalities or a breakdown in communication between the patient and dentist – this can sometimes involve the communication skills for tasks involving other member of the team. Whilst patients may not be able to judge ‘good dentistry’, they can certainly assess poor service or rude behaviour. So, here are some things to remember should you be faced with a complaint: It’s not personal There will always be patients who complain, no matter how professional you may be. The reaction to feel hurt and disappointment is inevitable when someone complains to – or about – you, especially early on in your career when it can also knock your confidence. Try to keep things in perspective – the real test of professionalism is how well you handle it. Invite feedback By having a proactive approach to feedback, you limit the potential damage wreaked by a broken relationship. By identifying disgruntled patients early on, you may reduce the risk of the matter developing into a formal complaint. Your interpersonal skills are important – and never more so when a patient rocks the boat with a complaint. Dental Protection offers some top tips I Quick steps to complaint handling Contact the complainant with an immediate acknowledgement, preferably in writing. Make sure it: • Offers an expression of sympathy or an apology • Gives clear explanations, avoids jargon and uses plain English • Suggests a way forward (if that is possible) • Informs the patient that you will provide an outline of option(s) after speaking to all the staff involved • Invites further comment. Provide a full written explanation of the treatment provided and instructions that were given, even if these had been delivered verbally. Good record keeping is always important. Further action could involve a conciliation meeting to which all parties should be invited to attend. Don’t do this over the telephone as the vital element of body language (non-verbal communication) is missing. Remember: • Don’t be afraid to say ‘I am sorry’ • Make eye contact • Don’t interrupt • Avoid statements or antagonistic questions • Ask open questions • Avoid leading questions • Avoid questions that give ‘yes’ ‘no’ answers – it closes things down.
119 Indemnityand governance Prevention is better than cure Prevention is better than cure. It’s well documented that a listening ear, a name remembered and a smile go a long way in retail – and this applies to dentistry, too. ‘Rapid response’ policy Adopt a ‘rapid response’ policy. By dealing with complaints swiftly, you should be able to prevent the complaint escalating from a local level to a higher authority or regulator. Be sure to speak to everyone involved in the matter before providing a definitive response to the patient. The root cause of the complaint What do they really want? It sounds simple enough, but getting to the root cause of the complaint is essential. To pursue a complaint takes both time and effort – but complainants can be surprisingly tenacious, so it is worth finding out what outcome they want. The internet is a ‘go-to’ source of information for many of us. We all go online to hunt for hotels, read reviews and look up facts and figures. As a nation, we are also becoming increasingly savvy about our rights as a consumer thanks to this plethora of information at our fingertips, which can make for an increase in the volume of challenges from patients. We can all learn from our mistakes. Taking time out for reflective learning is important as it offers a professional support mechanism that can develop a career safely and raise critical awareness. Sometimes your worst critic can become your biggest fan. If a complaint is efficiently handled – and amicably resolved – then the patient may well become a positive influence with friends and family. www.dentistry.co.uk Dental Protection offers a wealth of education tools and resources on the topic of complaints handling. Visit www.dentalprotection.org for more information.
122 Indemnityand governance Playing it safe with social media anning practice staff from using social media is not only impossible, but also undesirable. Indeed, the GDC acknowledges that social networking sites can be ‘an effective and entertaining way of communicating’. They can also be used exclusively for professional purposes by providing a platform for clinicians to share their thoughts on best practice, offering product tips and treatment successes. Additionally, patients and the NHS as a whole can benefit from more publicly accessible information and open discussion about public dental health and policy as well as when and how to access services. The dental profession also benefits from data and research shared across the globe. However, social media also brings with it many risks – and, these days, most workplaces will have a social media policy to which staff must adhere. If you practise across a number of workplaces, you need to be aware of the details within each policy. As well as adhering to any internet and social media policy set out by your employer, the main concerns regarding the use of social media by dental professionals are to: With Instagram, Twitter and Facebook an everyday part of life, dental professionals need to be mindful of their behaviour online, says Dental Protection B • Maintain and protect patients’ information by not publishing any information that could identify them on social media without their explicit consent • Maintain appropriate boundaries in the relationships you have with patients. Lost in translation Patient confidentiality will always be key, and you should ensure no patient details are unintentionally released to the public, via a professional or personal account. If this should happen, it will not only damage the reputation of the practice, it could unwittingly undermine your professional integrity, and even attract a complaint. Additionally, anything posted online that may be construed as bullying or harassment of colleagues should be avoided. The fact that you made a comment without malice is no defence – humour and sarcasm can get lost in translation within the virtual world of social media. You should also protect your personal information and it is wise to be well versed in the privacy settings of every social media site you use. However, do be mindful of the fact that this will not always guarantee complete protection
123 Indemnityand governance and it may be prudent to think along the lines of anything you put on the internet as potentially available for anyone to see – and that includes patients as well as employers! Those drunken ‘selfies’ taken in a bar in Spain in the summer may have seemed hilarious to post online at the time but, on reflection, they may be your downfall, perhaps putting paid to any new job opportunities you were hoping to secure. Self-censorship of uploads – whether images or opinions – is therefore essential and so too is the need to request friends to honour this. Remember, the GDC expects you to protect your professional name at all times and this includes online. As it states: ‘As a registrant, you have a responsibility to behave professionally and responsibly both online and offline. Your online image can impact on your professional life and you should not post any information, including photographs and videos, which could bring the profession into disrepute’. Maintaining the boundaries between personal and professional relationships is also important so be wary of accepting ‘friend’ or ‘follow’ requests from current or former patients – if in doubt, leave them out. www.dentistry.co.uk Dental Protection offers a wealth of education tools and resources on the topic of social media. Visit www.dentalprotection.org for more information.
124 Indemnityand governance More than just talking… he relationship with each patient is a very human and humane one that calls for understanding by both parties. At each stage of the professional relationship, the dental hygienist and dental therapist must ensure the patient understands the issues under discussion whether it is about: • Explaining histories • Agreeing treatment • Raising concerns over the outcome • The making of a complaint. Your skills must, therefore, include: • Maintaining control • Promoting the right body language • Listening • Clear articulation of information. Additional skills include: • Ability to generate a referral and to write to a patient • Accurate and complete record keeping. All have a role to play in communication and proper implementation should help control the situation for the benefit of the patient. Non-verbal skills Non-verbal skills relate to the impression given to the patient and include: • A response matched to patient expectations • The physical proximity of the patient and Good communication is an essential part of you role. Dental Protection offers a few simple steps to help ensure good practice T practitioner • The practitioner’s physical appearance, manner and movement. For some patients, such issues as appearance, facial posture (smile), movement, general body posture, gestures and the physical distance between the two parties can influence their interpretation of the information supplied. Whilst good communication skills are required at all stages of treatment, there are three fundamental areas that demand special attention. 1. History taking The initial histories set the scene in which the patient will be investigated. They will also inform the subsequent treatment plan or plans presented to the patient. Similarly, at each stage of investigation or treatment an opportunity arises for the patient to give further input. Such input may be negative or positive but it can – and should – influence: • Further consideration of investigation • Diagnosis • Treatment plan • Treatment or follow up. 2. Consent Consent is based on the patient being able to absorb information, to consider the information and to make a reasoned decision. It is important not to lead a patient to a decision and it is equally important that every effort is made to help the patient understand issues in order to properly seek the preferred options. Communication in consent, as elsewhere, is dependent on a feedback mechanism. For example:
125 Indemnityand governance • Is the patient able (competent) to hear the discussion and make a meaningful decision? • If the answer is yes, can you pass on the information in a way in which the patient can understand? • Has the patient shown reasonable signs of understanding the issues? (This may require further questioning) • Has proper weight been attached to each issue to facilitate decision-making? • Have sequelae, cost and prognosis been explained? • Does the patient appear to understand? • Is the patient’s carer empowered to give authority on his or her behalf, for example in the case of a child? Only once all these considerations have been made can it be demonstrated that every effort has been made to communicate properly. Confidence can then be placed in the decision about treatment reached by the patient. 3. Record keeping Records should support the verbal and written interchange between patient and dental hygienist or therapist and, where necessary for the best interests of the patient, between colleagues. They need to be accurate, complete, contemporaneous and honest. Records need to be securely stored and kept for the right length of time. Visit www.dentalprotection.org for more details of appropriate storage times. Remember… When communication breaks down, it can often be the trigger for a patient complaint or claim. These dangers are magnified if both parties are speaking a different language. Even when speaking English, patients may have a different understanding of what a ‘familiar colloquial’ English phrase means. Remember, too, that front desk staff are often your ‘eyes and ears’ and it is important they understand their roles in feedback of information. That said, staff should consider that confidentiality in communication is a fundamental ethic and principle and nothing should be relayed to a third party (except in exceptional circumstances) without the patient’s permission. www.dentistry.co.uk Dental Protection offers communication education tools for its members across a multitude of platforms, including online, in publications, workshops, seminars and events. For more information please visit dentalprotection.org.
126 Indemnityand governance AbbreviationsUnless abbreviations are commonly recognised within the profession, it makes it difficult for other members of the team to understand a record card. If you intend using an abbreviation, it would be sensible to create a list of abbreviations, together with their meaning, that your dental team has agreed to use. This list can then be used by others who need to read the record card at a future date A ALARP: As low as is reasonably practicable ALS: advanced life support AMO: anterior maxillary osteotomy AP: adult prophylaxis AP: anterior-posterior APT: active periodontal treatment AR: amalgam restoration ARC: AIDS related complex B BA: broken appointment BBTD: baby bottle tooth decay BD: buccal distal BIS-GMA: bisphenol-a-glycidyl methacrylate BLS: basic life support BMS: burning mouth syndrome BOP: bleeding on probing BP: blood pressure BPE: basic periodontal examination BTI: bleeding time index BWX: bitewing X-ray C C&B: crown and bridge C/: complete upper denture /C: complete lower denture C/O: complaining of CAB: coronary artery bypass CAD: coronary artery disease CAD/CAM: computer-aided design/computer-aided manufacture CAL: clinical attachment level CBC: complete blood count CD: chemical dependency CE: cervical erosion CEJ: cementoenamel junction CFA: craniofacial analysis CHF: congestive heart failure CL: crown lengthening CL/CP: cleft lip, cleft palate CLD: complete lower denture CMB: chronic mouth breathing CP: child prophylaxis CPEC: comprehensive periodontal examination and charting CPD: Continuing Professional Development CPF: coronally positioned flap CPR: cardiopulmonary resuscitation CPT: caries prevention treatment CRO: centric relation occlusion CS: coronal scaling CS: conscious sedation CTS: cracked tooth syndrome CUD: complete upper denture D D: distal DB: distal buccal (distobuccal) DBA: dentine bonding agents DD: differential diagnosis DDR: direct digital radiography DEF: decayed, extracted, filled DFS: decayed filled surfaces DHS: dentine hypersensitivity DI: distal incisal DK: caries DL: distal lingual (distolingual) DM: diabetes mellitus DMF: decayed, missing, filled DNA: did not attend DO: distal occlusal DOB: distal occlusal buccal E E: extraction E&E: excavate and evaluate EAL: electronic apex locator EBD: evidence-based dentistry EDI: electronic data interchange EMO: edentulous mandibular overdenture EO: extra-oral EOP: early onset periodontal disease EPT: electric pulp test F F: facial F: failed appointment F/: maxillary full denture /F: mandibular full denture F/F: full maxillary denture over full mandibular denture F/L: full lower denture F/P: full maxillary denture over partial mandibular denture F/U: full upper denture FDI: World Dental Federation FDS: flap debridement surgery FGC: full gold crown FLD: full lower denture FPD fixed partial denture FU(D): full upper denture G GBI: gingival bleeding index GBS: gingival bleeding score GCF: gingival crevicular fluid GI: gingival Index GI: glass ionomer GIC: glass ionomer cement GIR: glass ionomer resin GTR: guided tissue regeneration
127 Indemnityand governance www.dentistry.co.uk H HAV: hepatitis A virus HBV: hepatitis B virus HNF: head-neck-face HP: handpiece I I: incisal IA: inferior alveolar IAL: incidental attachment loss IC: informed consent IDDM: insulin-dependent diabetes mellitus (Type 1) IFPD: implant fixed partial denture IPD: inflammatory periodontal disease IRMER: Ionising Radiation Medical Exposure Regulations L L: lingual LA: labial LA: local anaesthesia LCR: light cured resin LL: lower left LLQ: lower left quadrant LP: lichen planus LR: lower right LRQ: lower right quadrant M MB: mesial buccal MF: mesial facial MFL: mesial facial lingual MFP: myofascial pain MGJ: mucoginival junction MI: maximum intercuspation MI: mesial incisal MI: myocardial infarction MID: mesial incisal distal MID: minimal intervention (invasive) dentistry ML: mesial lingual MM: mucous membrane MO: mesial occlusal MOB: mesial occlusal buccal MOD: mesial occlusal distal MODB: mesial occlusal distal buccal MOL: mesial occlusal lingual N N/S: no show N/V: nausea and vomiting NaCl: sodium chloride NaF: sodium fluoride NAD: Nothing abnormal diagnosed NICE: National Institute for Clinical Excellence NSPT: non surgical periodontal therapy NUG: necrotising ulcerative gingivitis NVB: inferior alveolar neurovascular bundle O O: occlusal OTC: over the counter P P: palatal P&E: prophylaxis and exam P/: maxillary partial denture P/F: partial maxillary denture over full mandibular denture P/P: partial maxillary denture over partial mandibular denture PA: posterior-anterior PA: preparatory appointment PAL: probing attachment level PASS: plaque assessment scoring system PBI: papillary bleeding index PBI: periodontal pocket bleeding Index PBS: papillary bleeding score PC: periodontal chart PC: porcelain crown PC: poor contact PCO: periodontal chart only PCR: pseudo centric relation PCT: plaque control techniques PD: partial denture PDI: periodontal disease index PDP: Personal development plan PFG: porcelain fused to gold PFM: porcelain fused to metal PI: plaque index PL: partial lower denture PLD: partial lower denture PLP: palatal lift prosthesis PLV: porcelain laminate veneer PMC: porcelain to metal crown PPD: probing pocket depth PSR: periodontal screening and recording PST: post surgical treatment PUD: partial upper denture PVS: polyvinyl siloxane R R: recurrent decay RBFPD: resin-bonded fixed partial denture; maryland bridge RD: recession depth R-D: rubber dam ReDK: recurrent decay RME: rapid maxillary expansion RMGI: resin modified glass ionomer RMH: reviewed medical history ROHic: alcoholic RPD: removable partial denture RPE: rapid palatal expansion RPS: root planing and scaling RTC: return to clinic Rx: prescription S S&RP: scaling and root planing S&Sx: signs and symptoms S/D: systolic/diastolic blood pressure S/S: signs and symptoms SBE: subacute bacterial endocarditis SBI: sulcular bleeding index SC: subcutaneous SL: sublingual SM: submucosal SnF: stannous fluoride SPT: supportive periodontal treatment SRP: scaling and root planing STL: soft tissue lesion STM: soft tissue management SVOS: soft vinyl occlusal splint T TBA: tooth brush abrasion TMD: temporomandibular joint disorder TN: trigeminal neuralgia TP: treatment plan TP: therapeutic pulpotomy TPR: temperature, pulse, respiration TPT: thermal pulp test TTC: tetracycline U UL: upper left ULQ: upper left quadrant UR: upper right URQ: upper right quadrant

More Related Content

PDF
Implant maintenance: A clinical update
Minkle Gulati
 
PPTX
Implant Maintenance and Disease Prevention
Denise Hewitt
 
PPTX
Dental Implant Maintenance , Dental Implant Care
Dr. Rajat Sachdeva
 
PPTX
Maintenance of dental implants
Robert Cain
 
PDF
Adverse Effects of Orthodontic Treatment
Dr.Nasir Al-Hamlan
 
PPT
Mini Dental Implants
Ninian Peckitt
 
PPTX
Dental implants in a day
Dr. Rajat Sachdeva
 
PPT
Dental Implant Case Documentation
renewbiocare
 
Implant maintenance: A clinical update
Minkle Gulati
 
Implant Maintenance and Disease Prevention
Denise Hewitt
 
Dental Implant Maintenance , Dental Implant Care
Dr. Rajat Sachdeva
 
Maintenance of dental implants
Robert Cain
 
Adverse Effects of Orthodontic Treatment
Dr.Nasir Al-Hamlan
 
Mini Dental Implants
Ninian Peckitt
 
Dental implants in a day
Dr. Rajat Sachdeva
 
Dental Implant Case Documentation
renewbiocare
 

What's hot (20)

DOCX
Ld mini implants by dr vp abhishek open access
Dr VP Abhishek Sahu Orthodontist
 
PPTX
What to expect from an immediate dental implant surgery
Dr. Rajat Sachdeva
 
PPTX
Screw versus Cement for Implant Prosthesis Installation. Part 2: The Game Cha...
Emil Svoboda
 
PPTX
Complications failures and maintainence of dental implant
Rasleen87
 
PPT
Clinical procedures for the immediate reattachment jc / dental implant courses
Indian dental academy
 
PPTX
105 risks and complications associated with orthodontic treatment-mohamad abo...
Dr Mohamad ABOUALNASER -Orthodontist
 
PPTX
Attachments In Prosthodontics
Self employed
 
PPT
enamel demineralization in orthodontics
Maher Fouda
 
PDF
Dental implant maintenance_a_critical_factor_in_long_term_treatment_success
SSR Institute of International Journal of Life Sciences
 
PPTX
Preventing Peri-implantitis by Safer Prosthesis Installation
Emil Svoboda
 
PPT
Long term effects of orthodontic treatment /certified fixed orthodontic co...
Indian dental academy
 
PPT
Implants in oral and maxillo facial surgery /certified fixed orthodontic cou...
Indian dental academy
 
PPT
Immediate dentures/ lingual orthodontics courses
Indian dental academy
 
PPTX
Basal implants 3
Drvivekgaur Drvivekgaur
 
PPT
Post cementation/prosthodontic courses
Indian dental academy
 
PPTX
Re-Root Canal Therpy| Advanced Endodontic Courses in Delhi
Dr. Rajat Sachdeva
 
PDF
Immediate Anterior Dental Implant Placement:A Case Report
Abu-Hussein Muhamad
 
PPTX
Single visit endodontics
Rajana Raghunath
 
PPT
Failures of endosseous dental implants/ laser dentistry courses
Indian dental academy
 
DOCX
Crown and root fracture in primary teeth
Saya Aziz
 
Ld mini implants by dr vp abhishek open access
Dr VP Abhishek Sahu Orthodontist
 
What to expect from an immediate dental implant surgery
Dr. Rajat Sachdeva
 
Screw versus Cement for Implant Prosthesis Installation. Part 2: The Game Cha...
Emil Svoboda
 
Complications failures and maintainence of dental implant
Rasleen87
 
Clinical procedures for the immediate reattachment jc / dental implant courses
Indian dental academy
 
105 risks and complications associated with orthodontic treatment-mohamad abo...
Dr Mohamad ABOUALNASER -Orthodontist
 
Attachments In Prosthodontics
Self employed
 
enamel demineralization in orthodontics
Maher Fouda
 
Dental implant maintenance_a_critical_factor_in_long_term_treatment_success
SSR Institute of International Journal of Life Sciences
 
Preventing Peri-implantitis by Safer Prosthesis Installation
Emil Svoboda
 
Long term effects of orthodontic treatment /certified fixed orthodontic co...
Indian dental academy
 
Implants in oral and maxillo facial surgery /certified fixed orthodontic cou...
Indian dental academy
 
Immediate dentures/ lingual orthodontics courses
Indian dental academy
 
Basal implants 3
Drvivekgaur Drvivekgaur
 
Post cementation/prosthodontic courses
Indian dental academy
 
Re-Root Canal Therpy| Advanced Endodontic Courses in Delhi
Dr. Rajat Sachdeva
 
Immediate Anterior Dental Implant Placement:A Case Report
Abu-Hussein Muhamad
 
Single visit endodontics
Rajana Raghunath
 
Failures of endosseous dental implants/ laser dentistry courses
Indian dental academy
 
Crown and root fracture in primary teeth
Saya Aziz
 
Ad

Similar to DHT Handbook full (20)

PDF
The 5 Most Influential Leaders in Dentistry 2023V3 3.pdf
insightscare
 
PPTX
Preventive dental care new
Dr. Monika Agrawal
 
PPTX
The Basics of Dentistry
Nuface Multispeciality Dental Care
 
PDF
Celebrating Healthcare Sector’s Women Leaders.pdf
insightscare
 
PDF
Clinical Dentistry 3rd Edition Ivor G. Chestnutt
sutamahoumr
 
PDF
The Global Strategy and Teamwork for Periodontal Health and Overall Health - ...
fdiworlddental
 
PPTX
ORAL HYGIENE DAY (1).pptx
malti19
 
PDF
The Comprehensive Guide to a Modern Dental Hospital.pdf
chennaitop1to10
 
PPTX
ORAL HEALTH - RETURNING THE MOUTH TO THE BODY.pptx
drkrishnak79
 
PDF
Catalyst.jan .feb .2012.q1
Kola Wade
 
PDF
Clinical Dentistry 4th Edition Crispian Scully
lychezimany7
 
PDF
Clinical Dentistry 4th Edition Crispian Scully
lychezimany7
 
PDF
BDJ Team_Oct2015_pg_BADT
Julie Bissett
 
PDF
Pune's Most Recommended Dentists During Covid-19 October2020
insightscare
 
PPT
Dental decay and ways to prevent it
Smile Care
 
PDF
Simplyhealth's Annual Dental Survey 2011
SimplyhealthUK
 
PDF
Dental Update Volume 47 No 4 April 2020 1st edition ISSN 0305-5000 2515-589X
zbayelapfler
 
PPTX
Importance of dental care
Dentee Social
 
PDF
Dental Update Volume 48 No 1 February 2021 1st edition ISSN 0305-5000 2515-589X
roodekaoudyb
 
PPTX
Prevention of periodontal diseases
Dr. vasavi reddy
 
The 5 Most Influential Leaders in Dentistry 2023V3 3.pdf
insightscare
 
Preventive dental care new
Dr. Monika Agrawal
 
The Basics of Dentistry
Nuface Multispeciality Dental Care
 
Celebrating Healthcare Sector’s Women Leaders.pdf
insightscare
 
Clinical Dentistry 3rd Edition Ivor G. Chestnutt
sutamahoumr
 
The Global Strategy and Teamwork for Periodontal Health and Overall Health - ...
fdiworlddental
 
ORAL HYGIENE DAY (1).pptx
malti19
 
The Comprehensive Guide to a Modern Dental Hospital.pdf
chennaitop1to10
 
ORAL HEALTH - RETURNING THE MOUTH TO THE BODY.pptx
drkrishnak79
 
Catalyst.jan .feb .2012.q1
Kola Wade
 
Clinical Dentistry 4th Edition Crispian Scully
lychezimany7
 
Clinical Dentistry 4th Edition Crispian Scully
lychezimany7
 
BDJ Team_Oct2015_pg_BADT
Julie Bissett
 
Pune's Most Recommended Dentists During Covid-19 October2020
insightscare
 
Dental decay and ways to prevent it
Smile Care
 
Simplyhealth's Annual Dental Survey 2011
SimplyhealthUK
 
Dental Update Volume 47 No 4 April 2020 1st edition ISSN 0305-5000 2515-589X
zbayelapfler
 
Importance of dental care
Dentee Social
 
Dental Update Volume 48 No 1 February 2021 1st edition ISSN 0305-5000 2515-589X
roodekaoudyb
 
Prevention of periodontal diseases
Dr. vasavi reddy
 
Ad

More from Julie Bissett (8)

PDF
YD March Rajveer PDF 2
Julie Bissett
 
PDF
IC#38 - Cycling
Julie Bissett
 
PDF
Standing Desks
Julie Bissett
 
PDF
011_pm_march15
Julie Bissett
 
DOCX
DP Dec stress2 article v10
Julie Bissett
 
PDF
005_pm_may15
Julie Bissett
 
PDF
Complex made Simple
Julie Bissett
 
PDF
Portuguese WDsi
Julie Bissett
 
YD March Rajveer PDF 2
Julie Bissett
 
IC#38 - Cycling
Julie Bissett
 
Standing Desks
Julie Bissett
 
011_pm_march15
Julie Bissett
 
DP Dec stress2 article v10
Julie Bissett
 
005_pm_may15
Julie Bissett
 
Complex made Simple
Julie Bissett
 
Portuguese WDsi
Julie Bissett
 

DHT Handbook full

  • 1. HandbookThe perfectly informed companion for dental hygenists and therapists 2015-2016 2015-2016Handbook
  • 2. 3 Introduction Foreword by BADT President Fiona Sandom Fiona Sandom says be inspired to raise your voice to the benefit of all I suspect the answer lies in a multitude of topics and new developments, not least of which is the drive by NHS England to harness a skill mix to deliver dentistry within an environment of preventive care. The NHS contract places pressure on all NHS practices to offer care within a primary dental fter being invited to write a foreword for this handbook generously sponsored by Dental Protection, I considered what were the key oral health developments in 2015 that will make this handbook current and an essential read for dental hygienists and therapists. A www.dentistry.co.uk Introduction
  • 3. 4 Introduction Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists. healthcare setting that is accessible to all – whilst maintaining financial viability. As we are all acutely aware, the business of dentistry is not immune to the current economic turmoil and it is, therefore, a tricky balance to strike. The debate that the skills of a dental therapist are, therefore, a cheaper route to care for many – and so more financially viable for government – is only part of the story. Improving the current dental health statistics Despite the naysayers, I truly believe that allowing dental therapists to use their whole scope of practice in general dental practice can empower dental phobics and other reluctant patients to engage actively in preventive oral healthcare, and this will ultimately lead to improving the current dental health statistics. As healthcare workers, surely we all need to be singing from the same song sheet if we are to raise public awareness of the importance of good habits, whether we are GPs, nurses or fellow members of the dental team. How care is delivered and who delivers it is inevitably a region-specific conundrum – with care in the valleys of Wales (my particular patient base) differing greatly from my London colleagues, for example. Access remains a challenge in places, and I do see a future that welcomes with open arms the skills of dental hygienists and therapists – especially in remote and rural areas of the UK. The media focus on the nation’s health, what they put in their mouths and how this affects their overall well being does not look set to disappear – and I feel it is here where we need to seize an opportunity caused by ‘hooking’ our home care hygiene instruction on the much-publicised demise of the western world’s health status. When I took over the presidency of the BADT last year, I vowed that my main aim was to raise the profile of dental therapy. It’s been a tough enough call amongst fellow dental professionals, but the rest of council and I have cast our net further afield – to the general public. A two-pronged attack My modus operandi is a two-pronged attack. I have reached out to other dental associations, secured two chief dental officers of England to speak at our annual conference last month (September) and am currently in ongoing conversations with the BDA about how best to get the UK dentally fit. I have also pledged to work towards changing the ‘unfair’ status quo on prescribing rights for dental therapists and hygienists. Alongside this, our council is heavily committed to media exposure – not the unpleasant experience that dentistry usually gets, but of a more informative variety. Via blogs on national health websites and in local newspapers and online forums, we are trying to raise the profile of dental therapy in the hope that patients will wake up to their own health risks as well an alternative route to care. As a dental therapist in North Wales Community Dental Services, I am acutely aware of what needs to be done and how it can best be achieved. As a postgraduate tutor at Cardiff University, I am equally passionate about how the next generation must help to raise the profile of this profession. I see education as a key to driving forward the role of hygienists and therapists – within dentistry, amongst newly qualifieds and, especially, with our patients. With change comes opportunity, and this DH&T Handbook offers perspectives and evidence on both. So, read on and be inspired to raise your voice to the
  • 4. 6 Introduction ContentsIntroduction 3 Foreword - Fiona Sandom 8 Acknowledgements 10 How this handbook works - Julian English New beginnings 14 Career checklist 16 First tasks 18 Registration and standards 19 Scope of practice 22 Reflective learning 24 CPD 26 Direct access 28 Foundation Traning Career options 32 CV and interview techniques 34 Extended duties 36 Career pathways 40 Salaried services 42 Remuneration and charging Organisations and associations 44 BSDHT update 46 BADT update 50 Key associations Clinical protocols 56 BPE scoring 58 Periodontal disease 61 Tooth notation 62 Periodontal disease and systemic health 64 Implant maintenance 66 Developing dentition 68 Xerostomia - Charlotte Wake 70 Xerostomia - Bal Chana 72 Tooth whitening 75 BADT minimally invasive dentistry 76 Treating endodontically-exposed implant threads 78 Minimally invasive dentistry 80 Dentine hypersensitivity
  • 5. 7 Introduction General practice 83 Referral letter template 84 Caries risk from sports drinks 86 Prescription-only medicines 87 Caring for the orthodontic patient 88 Avoiding needlestick injuries 90 Bruxism 91 Recall interval guidelines 92 Radiography and radiation protection 96 Medical emergencies: resuscitation 100 Oral cancer - early detection 102 Working with the elderly 104 Photography 106 Eating less sugar 108 Educating patients on sugar consumption 110 Increasing access 112 Social inequalities Indemnity and governance 116 Indemnity partnerships 118 Handling complaints 122 Social media usage 124 Good communication practices Glossary 126 Abbreviations www.dentistry.co.uk
  • 6. 6 Introduction Acknowledgements November 2015 FMC, Hertford House, Farm Close, Shenley, Hertfordshire WD7 9AB Tel: 01923 851777 Fax: 01923 851778 Website: www.dentistry.co.uk/oral-health-dental-hygiene-news/ Editorial: Julian English, julian.english@fmc.co.uk Editorial: Charlotte Lloyd, charlotte.lloyd@fmc.co.uk Editorial: Sophie Bracken, sophie.bracken@fmc.co.uk Designer: Brendan Morrell, brendan.morrell@fmc.co.uk Designer: Corin Skeggs, corin.skeggs@fmc.co.uk Head of production: Laurent Cabache, laurent.cabache@fmc.co.uk Production manager: K-Marcelyne McCalla, k-marcelyne.mccalla@fmc.co.uk Advertising manager: Tim Molony, tim.molony@fmc.co.uk Authors and advisers Scott Froum, New York dentist Graham Hart, radiography and IRMER regulations expert Debbie McGovern, chair of the BADT Baldeesh Chana, past president of BADT Heather Richardson, Browns Locumlink Pat Popat, dental hygienist and winner of DH&T’s Best Treatment of Nervous Patients 2014 Christina Chatfield, Brighton hygienist and owner of Dental Health Spa and winner of DH&T’s Dental Hygienist of the Year 2012 Charlotte Wake, dental hygienist and therapist Leon Bassi, dental hygienist at Bridge Dental, London Leanne Barwick, winner of DH&T’s Best Young Hygienist 2014 Julie Rosse, president of BSDHT Melanie Joyce, dental therapist Gareth Grimes, sales development manager, Astek Innovations Amanda Gallie, dental therapist, president-elect of the BADT Robiha Nazir, dental hygienist Damien Walmsley, specialist in prosthodontics Leigh Hunter, dental therapist and hygienist Fiona Sandom, dental therapist, president of the BADT Juliette Reeves, an expanded-duties hygienist and nutritionist Diane Rochford, dental hygienist and clinical coach for Jameson Management Mhari Coxon, registered dental hygienist and dental and senior professional marketing and relations manager for Philips Oral Healthcare, UK & Ireland Sheila Scott, consultant for dental business and dental practice management Henry Clover, former general dental practitioner and deputy chief dental officer for Denplan Kirstie Thwaites, dental hygienist and therapist Joe Ingham, Dental Protection Katrina Matthews, primary care dental therapist and manager
  • 7. 7 Introduction dentalhygienetherapy.co.uk Email subscriptions@fmc.co.uk to request a copy: £20 each. Printed by: Headley Bros, Kent ISSN: 2044-1436 The DH&T Handbook is an annual publication available to a controlled circulation of subscribers to Dental Hygiene & Therapy magazine. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form, including photocopies and information retrieval systems. The DH&T Handbook makes every effort to report clinical information and manufacturer’s product news accurately but cannot assume responsibility for the validity of product claims or for typographical errors. The publishers also do not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of the DH&T Handbook. Without the support of our sponsor, we could not have produced this publication. The DH&T Handbook would like to thank the team at Dental Protection and, in particular, communications manager David Croser, for an ongoing commitment to excellence in dental hygiene and therapy. We would also like to thank: Dental Hygiene & Therapy magazine British Society of Periodontology British Society for Dental Hygiene & Therapy British Association of Dental Therapy Ivoclar Vivadent Tepe Information contained in this handbook is believed to be correct at the time of going to press. The publishers also do not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of the DH&T Handbook or Dental Protection.
  • 8. 10 Introduction A guiding handJulian English welcomes you to the DH&T Handbook 2015 – an essential reference guide designed to help you with all aspects of dental therapy and dental hygiene reading, covering all aspects of dental hygiene and therapy. A quick scan of the handbook’s contents and sections should confirm its intentions. It is our aim and genuine belief that a dental therapist and hygienist can read this publication and find useful information within, and have genuine cause to retain it as an essential reference guide. The handbook contains the most up-to-date guidance, rules, regulations and best practice for dental therapists and dental hygienists. Enthusiasm, hard work and dedication have been poured into the production of the DH&T Handbook from the editorial team at FMC and all the contributors and sponsor Dental Protection. Nothing less than 100% dedication is required to produce a publication like this. I hope you enjoy it and find it of benefit and use. H&T magazine welcomes you to its guide to professional life. The intention of this guide is to produce a concise and entirely relevant handbook of practical information and advice to assist undergraduates, new graduates, and even the experienced dental therapist and dental hygienist practising in this professional landscape. This handbook has been compiled by the editorial team of DH&T magazine, with input from some of the opinion leaders in the profession. This includes the significant input from the dentolegal experts at Dental Protection, one of the leading UK defence organisations supporting therapists and hygienists throughout their career. There are more than 100 pages of essential D
  • 10. 14 Newbeginnings Set sailBal Chana’s top tips on cruising into the uncharted waters of dentistry ndergraduate training provides the basic skills required to gain qualification. Through experience and continuing professional development one develops and enhances one’s skills. Dentistry is a career that involves lifelong learning. The first stage of the journey is to identify needs, define goals and have a basic route towards a successful career in dentistry that will lead to great opportunities. U
  • 11. 15 Newbeginnings Career checklist 1 Work within a team environment and communicate. Look through your patient list and plan how you wish to work through the day. Do not struggle – ask for help if required. Have aide memoires (crib sheets) to help with treatment protocols, eg, history taking, treatment planning, etc. Use the skills of your dental nurse; an experienced dental nurse will literally hold your hand and guide you through the day. 2 Have a professional development plan (PDP). A PDP is defined as ‘a structured and supported process undertaken by an individual to reflect upon their own learning, performance and/or achievement and to plan for their personal, educational and career development’. • What would you like to achieve in the next five years, where do you see yourself in five years? A PDP will give you greater confidence in the skills, qualities and attributes that are required. 3 Work within your scope of practice and competency. If you feel treatment is beyond your competency, liaise with the prescribing dentist and either refer back, ideally if within your scope of practice, then get the dentist to guide you through the treatment. This will help you gain confidence and enhance your skills. 4 Join your professional associations. The benefits are: • An association supports members in all matters relative to their chosen profession, ranging from education, clinical techniques, employment and personal development • Members receive a professional journal and newsletters throughout the year • Reduced fees at national conferences and regional study days • Dedicated phone line and email address for advice and help from an experienced team • Forums for advice and discussion on the website • Networking opportunities with fellow professional • Tax relief on membership fees. 5 Continual professional development (CPD) – Patient safety is paramount. As a registrant of the GDC, one has to meet certain standards. The GDC expects professionals to: • Uphold and follow the required standards and any additional guidance (the standards guidance is a code of behaviour that registrants are required to abide by in order to safeguard the patient) • Maintain CPD – it is vital to keep your skills and knowledge up-to-date. 150 hours of CPD must be completed over a five-year cycle, with a minimum of 50 hours must be verifiable. You are also recommended to complete three core subjects which are: medical emergencies, infection control and decontamination and radiography and radiation protection • You are also expected to keep up to date in areas such as legal and ethical issues and handling complaints. Only CPD carried out within your cycle can be counted. www.dentistry.co.uk Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006.
  • 12. 16 Newbeginnings Plain sailing: first tasks You’re qualified and now raring to meet your first patients. There are some essential steps you need to take o, you’re now qualified and ready to jump headfirst into the exciting world of dentistry, but there are a few crucial steps you need to take first. They might seem like boring admin issues that you can push to one side, but it’s worth doing them straight away because, of course, it’s all just plain sailing after that… General Dental Council The General Dental Council (GDC) regulates dental professionals in the UK. By law, you must register with the council in order to legally practise in this country. The GDC protects patients and the profession S alike, dealing with standards of care, complaints, fitness to practise hearings and quality assurance through continuing professional development. Indemnity/defence organisations Dental Protection looks after the interests of dental hygienists and therapists in the UK. Its services You’re now qualified and ready to jump headfirst into the exciting world of dentistry...
  • 13. 17 Newbeginnings Essential steps 1 Register with the General Dental Council 2 Sickness insurance is optional, but recommended 3 Joining the BSDHT or the BADT is recommended 4 Joining the British Dental Health Foundation is recommended 5 Plan your career right now and take action. www.dentistry.co.uk include: • Access to defence and indemnity against claims for clinical negligence • Safeguarding professional reputation • Assisting in complaints and replying to them • Representing the clinician in court and at committees of investigation • Advising in matters affecting the DCP’s professional career • Representing the dental team’s interests in matters affecting the profession in general. Sickness insurance Sickness insurance providers to the UK’s dental profession include Dentists & General. Dentists & General is a friendly society and, as such, is a non-profit making organisation that enables a lump sum to be paid on retirement. The fund for this sum grows yearly by appointment of company profit and interest. The BSDHT The British Society of Dental Hygiene and Therapy welcomes members who are dental hygienists, dental hygienist-therapists and students. The BSDHT is a major organisation within dentistry that exists to represent your interests. The BADT The British Association of Dental Therapists promotes the advancement of dental therapy within the dental profession. Membership is available to all qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership). The BDHF The British Dental Health Foundation is a charity aimed at promoting oral health to the public. It provides a range of resources including leaflets, posters, stickers, books, DVDs and dental motivators to help educate and motivate patients.
  • 14. 18 Newbeginnings Registration and standardsJulian English presents the nine standards expected of a dental professional Registration with the GDC depends upon certain criteria – namely those with a recognised UK qualification. If you do not have a recognised UK qualification, please check the following points to see if you can have your qualification and/or experience assessed. If the assessment is successful, your name will be entered onto the DCP’s register. Assessment is available for those with a formal qualification from an EEA Member State or overseas. Those that are unsure should fill out the ‘route to registration’ questionnaire. You can find out if you are able to apply for registration, if your qualifications may need to be assessed, or if you need to pass the overseas registration exam before you can register. Standards The GDC, which holds the register of hygienists, also provides guidance to its registrants on a number of topics, including advertising, indemnity, prescribing medicines, using social media, child protection and GDC standards. The document sets out the standards of conduct, performance and ethics that govern you as a dental professional. It With more than 20 years’ experience at the helm of multi-award-winning Dentistry magazine and numerous other dental journals, editorial director of FMC, Julian, is a well-known face in the dental publishing industry. He is also a member of the editorial committee of the British Dental Industry Association. Julian attends many events at home and overseas throughout the year. specifies the principles, standards and guidance that apply to dental hygienists and therapists. There are nine standards, which set out what is expected and what patients expect. The principles must be kept at all times. They are: 1. Put patients’ interests first 2. Communicate effectively with patients 3. Obtain valid consent 4. Maintain and protect patients’ information 5. Have a clear and effective complaints procedure 6. Work with colleagues in a way that is in patients’ best interests 7. Maintain, develop and work within your professional knowledge and skills 8. Raise concerns if patients are at risk 9. Make sure your personal behaviour maintains patients’ confidence in you and the profession. You have an individual responsibility to behave professionally and follow these principles at all times. Reference www.gdc-uk.org/Dentalprofessionals/ Applyforregistration/Pages/default.aspx retrieved 13/10/15
  • 15. 19 Newbeginnings Scope of Practice he scope of your practice is a way of describing what you are trained and competent to do. It describes the areas in which you have the knowledge, skills and experience to practise safely and effectively in the best interests of patients. Orthodontic therapists Orthodontic therapists are registered dental professionals who carry out certain aspects of orthodontic treatment under prescription from a dentist. As an orthodontic therapist, you can undertake the following if you are trained, competent and indemnified: • Clean and prepare tooth surfaces ready for orthodontic treatment • Identify, select, use and maintain appropriate instruments • Insert passive removable orthodontic appliances • Insert removable appliances activated or adjusted by a dentist • Remove fixed appliances, orthodontic adhesives and cement • Identify, select, prepare and place auxiliaries • Take impressions • Pour, cast and trim study models • Make a patient’s orthodontic appliance safe in the www.dentistry.co.uk T absence of a dentist • Fit orthodontic headgear • Fit orthodontic facebows that have been adjusted by a dentist • Take occlusal records including orthognathic facebow readings • Take intraoral and extraoral photographs • Place brackets and bands • Prepare, insert, adjust and remove archwires previously prescribed or, where necessary, activated by a dentist • Give advice on appliance care and oral health instruction • Fit tooth separators and bonded retainers • Carry out Index of Orthodontic Treatment Need (IOTN) screening either under the direction of a dentist or direct to patients • Make appropriate referrals to other healthcare professionals • Keep full, accurate and contemporaneous patient records • Give appropriate patient advice. Additional skills that orthodontic therapists could develop include: With more than 20 years’ experience at the helm of multi-award-winning Dentistry magazine and numerous other dental journals, editorial director of FMC, Julian, is a well-known face in the dental publishing industry. He is also a member of the editorial committee of the British Dental Industry Association. Julian attends many events at home and overseas throughout the year. Julian English discusses the scope of practice for orthodontic therapists, dental hygienitsts and dental therapists
  • 16. 20 Newbeginnings • Applying fluoride varnish to the prescription of a dentist • Repairing the acrylic component part of orthodontic appliances • Measuring and recording plaque indices • Removing sutures after the wound has been checked by a dentist. Orthodontic therapists do not: • Modify prescribed archwires • Give local analgesia • Remove sub-gingival deposits • Re-cement crowns • Place temporary dressings • Diagnose disease • Treatment plan as these tasks are reserved to dental hygienists, dental therapists or dentists. Orthodontic therapists do not carry out lab work other than that listed above as that is reserved to dental technicians and clinical dental technicians. Dental hygienists Dental hygienists are registered dental professionals who help patients maintain their oral health by preventing and treating periodontal disease and promoting good oral health practices. They carry out treatment direct to patients (direct access) or under prescription from a dentist. As a hygienist, you can undertake the following if you are trained, competent and indemnified: • Provide dental hygiene care to a range of patients • Obtain a detailed dental history from patients and evaluate their medical history • Carry out a clinical examination within their competence • Complete periodontal examination and charting and use indices to screen and monitor periodontal disease • Diagnose and treatment plan within their competence • Prescribe radiographs • Take, process and interpret various film views used in general dental practice • Plan the delivery of care for patients • Give appropriate patient advice • Provide preventive oral care to patients and liaise with dentists over the treatment of caries, periodontal disease and tooth wear • Undertake supragingival and subgingival scaling and root surface debridement using manual and powered instruments • Use appropriate antimicrobial therapy to manage plaque-related diseases • Adjust restored surfaces in relation to periodontal treatment • Apply topical treatments and fissure sealants • Give patients advice on how to stop smoking • Take intraoral and extraoral photographs • Give infiltration and inferior dental block analgesia • Place temporary dressings and re-cement crowns with temporary cement • Place rubber dam and take impressions • Care of implants and treatment of peri-implant
  • 17. 21 Newbeginnings www.dentistry.co.uk tissues • Identify anatomical features, recognise abnormalities and interpret common pathology • Carry out oral cancer screening • If necessary, refer patients to other healthcare professionals • Keep full, accurate and contemporaneous patient records • If working on prescription, vary the detail but not the direction of the prescription according to patient needs. Additional skills that dental hygienists might develop include: • Tooth whitening to the prescription of a dentist • Administering inhalation sedation • Removing sutures after the wound has been checked by a dentist. Dental hygienists do not: • Restore or extract teeth • Carry out pulp treatments • Adjust unrestored surfaces. Other skills are reserved to orthodontic therapists, dental technicians, clinical dental technicians or dentists. Dental therapists Dental therapists are registered dental professionals who carry out certain items of dental treatment direct to patients or under prescription from a dentist. As a dental therapist, you can undertake the following if you are trained, competent and indemnified: • Obtain a detailed dental history from patients and evaluate their medical history • Carry out a clinical examination within their competence • Complete periodontal examination and charting and use indices to screen and monitor periodontal disease • Diagnose and treatment plan within their competence • Prescribe radiographs • Take, process and interpret various film views used in general denal practice • Plan the delivery of care for patients • Give appropriate patient advice • Provide preventive oral care to patients and liaise with dentists over the treatment of caries, periodontal disease and tooth wear • Undertake supragingival and subgingival scaling and root surface debridement using manual and powered instruments • Use appropriate antimicrobial therapy to manage plaque-related diseases • Adjust restored surfaces in relation to periodontal treatment • Apply topical treatments and fissure sealants • Give patients advice on how to stop smoking • Take intraoral and extraoral photographs • Give infiltration and inferior dental block analgesia • Place temporary dressings and re-cement crowns with temporary cement • Place rubber dam and take impressions • Care of implants and treatment of peri-implant tissues • Carry out direct restorations on primary and secondary teeth • Carry out pulpotomies on, and extract, primary teeth • Place pre-formed crowns on primary teeth • Identify anatomical features, recognise abnormalities and interpret common pathology • Carry out oral cancer screening • If necessary, refer patients to other healthcare professionals • Keep full, accurate and contemporaneous patient records • If working on prescription, vary the detail but not the direction of the prescription according to patient needs. Additional skills that dental therapists could develop include: • Carrying out tooth whitening to the prescription of a dentist • Administering inhalation sedation • Removing sutures after the wound has been checked by a dentist All other skills are reserved to orthodontic therapists, dental technicians, clinical dental technicians or dentists.
  • 18. 22 Newbeginnings Back to basicsThroughout your professional career, it is important to have a structured approach to your learning. Here, BADT president Fiona Sandom reflects on how best to shape your future safely and successfully uring your time as a student, your education is supported by lecturers within a carefully monitored environment. They provide feedback and guidance in order that you develop clinically. On qualification, there is then an expectation upon you to continue this process using different platforms, and a requirement to formulate and demonstrate by the GDC. Keeping abreast of new skills and knowledge is at the heart of dentistry and a commitment to the regulatory continuing professional development (CPD) is only a part of this. Keep a log A reflective log is a way of thinking in a critical D and analytical way about your work in progress. Self-evaluation is a key part of learning and keeping written reflective logs each time you take a new step is an essential part of your personal development activity. There is no standard format for a reflective log – but there are many templates available. Genuinely identifying areas for development means a clinician needs: • Focus – to pinpoint key areas for improvement • Courage – to recognise when something is wrong, however uncomfortable this may be • Honesty – to address the problem and, if needs be, share this with a mentor or trusted colleague and find a solution together. Reflective learning is an ongoing process, but
  • 19. 23 Newbeginnings www.dentistry.co.uk there are key moments when this may prove fruitful. • In times of innovation. Before offering new treatments, ask yourself why you should do so, what this will achieve for you and your patient and whether it is realistically achievable. So, if you are considering offering tooth whitening, for example, fully consider the skills you need to do so safely, which courses you will attend (and when and why) and how you will implement them in practice • When with colleagues. Making time to reflect with others on what you have learned, what you will do the same or differently as a result and whether your learning needs have changed, is essential. As well as developing your performance, it also fosters a confident, safe and competent dental team • When considering your next step. There is a propensity by many of us to learn what we already know and sit tight in our comfort zone. A reflective log is useful in identifying strengths and weaknesses and highlights the clinical skills with which we are less familiar or use less often. Seeking courses in these latent skills will only serve to develop you as a clinician • During research. The internet has opened up our access to knowledge – not always for the good. Auditing what you have read is an important part of the learning process and a reflective log aids in our assimilation of clinical information. Just like information accessed in books and journals, be sure to dispense with anything found online that does not have its roots in current scientific thinking as is therefore not evidence based. Increasingly, regulators are expecting the dental team to use a personal development plan (PDP). A PDP can identify goals for the forthcoming year and methods for achieving these goals and can work in tandem with a reflective log. Although not currently a requirement of the GDC (unless the registrant has had conditions placed upon them following a GDC inquiry), it is nevertheless a recommendation. The GDC maintains: ‘You are highly recommended to use a personal development plan (PDP), to help you make good CPD decisions, and review it regularly, ideally with an appropriate colleague. ‘Holding and maintaining a PDP will also enable you to identify your learning needs and consider them in a structured way.’ Confidence It’s the aim of the dental team to provide high quality oral healthcare to patients who are confident in their standards and are acting in their best interests at all times. A programme of CPD – together with comprehensive reflective practice and a well- considered (but flexible) PDP – supports this. Aims 1. To identify strengths and weaknesses 2. To improve and/or learn new skills 3. To consolidate these skills 4. To encourage a self-awareness 5. To improve performance and knowledge 6. To reflect on pathways 7. To offer respite from – and an outlet for – the stresses of a demanding workplace 8. To share with others in order to build a culture of openness and improvement. Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists.
  • 20. 24 Newbeginnings Love to learn As a registered dental care professional, you have a duty to keep your skills and knowledge up to date in order to give patients the best possible treatment and care. CPD is compulsory, but it should simply set out a formal framework for what you are already doing. What is CPD? CPD is an activity that contributes to your professional development. There are two kinds of CPD – general and verifiable. What is verifiable CPD? To count as verifiable CPD, an activity must have: • Concise educational aims and objectives • Clear anticipated outcomes • Quality controls • Documentary proof. A look at the many ways you can gain that all-essential CPD In other words, you should know what the activity is about and what you will learn, how it’s going to benefit your patients, whether you can provide feedback on the activity and that you will be given documentary proof (such as a certificate) that you carried out the activity. The certificate should come from the provider or organiser, and should show the number of hours you spent on the activity, your name and registration number, as well as the subject of the activity. How much CPD should I do? You must complete at least 150 hours of CPD over your five-year cycle. A minimum of 50 of these hours must be verifiable CPD. You must keep your CPD records for at least five years after the end of the cycle
  • 21. 25 Newbeginnings www.dentistry.co.uk in which they were completed. Which subjects should CPD cover? CPD is any activity that could reasonably be said to have benefitted you professionally, so you should use your own judgement when choosing subjects and activities. We recommend that you create a personal development plan, which will help you to meet your CPD requirement over your cycle. As well as your chosen areas there are three core subjects that we strongly recommend you complete as part of your verifiable CPD. The suggested minimum number of hours for dental care professionals in each subject are: • Medical emergencies - 10 hours per CPD cycle • Disinfection and decontamination - five hours per CPD cycle • Radiography and radiation protection - five hours per CPD cycle. We also recommend that you keep up to date by doing CPD in the following areas (verifiable or general, no suggested minimum number of hours): • Legal and ethical issues • Complaints handling • Oral cancer: improving early detection • Vulnerable children and adults. When do I start my CPD? Your CPD cycle is determined by your date of first registration. Your CPD cycle is always five years long, and this is the period in which you must complete your compulsory number of hours. You can break down your CPD each year in a way that works for you, but you should spread it out across your cycle as evenly as possible. Only CPD carried out within your cycle can be counted. Any activities you do before your cycle starts, or after it has ended, cannot be included. As a dental care professional, your first CPD cycle will start on 1 August after you register. Activities that count as CPD: • Courses and lectures • Distance learning • Private study • Journal reading • Multimedia learning • Training or study days • Educational elements of professional and specialist society meetings • Peer review and clinical audit • Background research. Information provided in this article comes directly from General Dental Council literature, by kind permission. If you have any questions about CPD, call 020 7167 6000, email information@gdc-uk.org or visit www.gdc-uk.org.
  • 22. 26 Newbeginnings Direct Access Charlotte Wake looks at the barriers and advantages of Direct Access ay 2013 saw a big shift to a new era in the world of dentistry with the introduction of Direct Access (DA). Direct Access is a term that reflects the exact meaning – it is the time when dental therapists and dental hygienists are able to work without a prescription and see a patient ‘directly’ without having seen the dentist first. As with any change there were, and are, people in agreement and disagreement. There were concerns about how patients would accept this and concern from within the profession about competency, workload and indeed whether this would be compulsory in daily work. The GDC provided some clarity with this statement: ‘Dental hygienists and dental therapists can carry out their full scope of practice without prescription and without the patient having to see a dentist first. The only exception to this is tooth whitening, which must still be carried out on prescription from a dentist. ‘Dental hygienists and dental therapists must be confident that they have the skills and competences to treat patients directly. A period of practice working to a dentist’s prescription is a good way to assess this. ‘Hygienists and therapists who qualified since 2002 should have covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything. However, many of these registrants will have addressed this via top-up training, CPD and experience. ‘Registrants who are unsure whether there are any gaps in their training should contact the dental school where they received their Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapists’ council, and is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice. M qualification, and check their indemnity arrangements before undertaking any new duties.’ It has been some time now since this new pathway was introduced and there are still some barriers in place that restrict the use of DA. More difficult to use in an NHS environment Currently it is only possible for a dentist who has a performer number to open and close a course of treatment. This means it is not possible for a dental hygienist or therapist to see a patient directly under the NHS. Prescription needed for local anaesthetic DA does not change the need to have a prescription to use local anaesthetic. This written prescription may come as a Patient Group Directive (PGD) or directly from the dentist. Tooth whitening and prescription only medication (POM) Again the introduction of DA does not change the need for a prescription if using any item labelled
  • 23. 27 Newbeginnings www.dentistry.co.uk as ‘POM’ or tooth whitening. This includes antibiotics, Duraphat toothpaste, topical fluoride and Ledermix. This prescription should be in writing. Advantages Direct Access would not have been introduced if it did not have advantages: Optional This is imperative. Use of Direct Access is optional. It is for each clinician to decide, if and when they will use DA. It is not compulsory. Promotes utilisation of skill mix DA allows you to undertake what is clinically necessary within your scope of practice. This encourages a therapist and hygienist to use all their skills. Increased access to dental care More patients are able to get appointments sooner as more clinical time is available. The importance of this must not be under emphasised. Able to see patient in an event of staff absence We have all been there when the dentist is not able to work, due to holiday or sickness and prior to DA if a new patient to the practice was booked then both those appointments would need to be re-scheduled. Now the patient is able to attend, for example, their hygiene treatment and return at a later date for their consultation with the dentist. Practice builder Offering DA can help build a practice and can become a unique selling point, certainly in situations where a hygiene appointment is requested prior to a major event such as a wedding. There are some key points that need to be acknowledged if you work with DA: • Make sure the patients know you are not a dentist and that there is a robust practice referral procedure in place should it be needed • Never work outside of your scope of practice or outside of your competency
  • 24. 28 Newbeginnings Dental foundation trainingA dental therapist foundation training programme provides a safe and secure transition from dental school to dental practice, highlights the BADT he purpose of dental foundation training for dentists is the first phase of continuing postgraduate education after graduation and is recognised as a part of career pathways in all sections of the dental profession. The purpose of dental therapist foundation training is similar and provides a structured introduction to working in dental general practice for dental therapists. There are two main strands of the programme, working in a protected environment within an approved practice that has been selected to provide training and mentoring. This is backed by a programme of study days, lectures and conferences organised by the Dental Postgraduate Education Department and tutorial/feedback sessions once a month with the practice trainer. The dental therapists who complete dental therapist foundation training are equipped with the necessary training and education required to continue to develop and expand the clinical and personal skills learnt as a student, and to gain the skills required to work successfully in a general dental practice environment. The positions in practice are usually part time and can be combined with split jobs in other practices or full time if the training practice T has the capacity. The BADT also support the development of a dental therapist foundation training programme, which provides a safe and secure transition from dental school to dental practice and the additional responsibilities that the NHS contract reform will give to dental therapists. Therapist Foundation Training Thames Valley and Wessex The Dental Therapist Foundation Training Scheme (TFT) is primarily aimed at newly qualified therapists to provide the initial stage of training and education required to practice in a general dental practice environment. Emphasis is placed on continuing professional development throughout the course. The therapist is encouraged to develop and expand the clinical and personal skills learned as a student. The scheme covers the Thames Valley and Wessex area (Berkshire, Buckinghamshire, Oxfordshire, Milton Keynes, Hampshire and the Isle of Wight). The programme, which will last for an academic year commences in September and is open to recently qualified therapists. Therapists will be employed within training practices, be allocated an approved trainer and attend the day-release
  • 25. 29 Newbeginnings www.dentistry.co.uk More information on the Dental Therapist Foundation Training Thames Valley and West Sussex scheme can be found at www.oxforddeanery.nhs.uk/dental_school/ therapist_foundation_training.aspx. For more information on the Welsh Dental Therapist Foundation Training Scheme, contact Kath Liddington at LiddingtonKE@cardiff.ac.uk, or telephone 02920 687 498. For further information regaring the West Midlands Foundation Training Scheme for Dental Therapists, contact Dr Steve Clements, programme director for Foundation Training Dental Therapy, HEWM Dental Team, St Chad’s Court, Hagley Road, Edgbaston, Birmingham, B16 9RG, or phone 0121 695 2587. For more general information contact Jane Ford, regional lifelong learning advisor. Contact via Judith Hunter at Judith.hunter@ne.hee.nhs.uk, or phone 0191 275 4714. educational programme organised by Oxford & Wessex Deaneries’ Dental School. Training Programme for Dental Therapists West Midlands Deanery The West Midlands Foundation Training Scheme for Dental Therapists was established in 2009 and is based on the Foundation Training Scheme for Dental Graduates. It is a structured introduction to NHS general dental practice for recently qualified dental therapists. The scheme is looking for suitable dentists and practices to provide a supportive environment for dental therapists. It is looking for recently qualified (or soon to be qualified) dental therapists who wish to pursue a career in NHS dentistry. Therapists will be based in practices around the West Midlands and attend monthly study days. Welsh Dental Therapist Foundation Training Scheme This programme provides a structured introduction to working in general practice for dental therapists. The two main strands of the programme are working in a protected environment within an approved practice that has been selected to provide training and mentoring. This is backed by a programme of study days, lectures and conferences organised by the department and tutorial/feedback sessions once a month with the practice trainer. The positions in practice are for two days a week so they can be combined with split jobs in other practices, or full time if the training practice has the capacity.
  • 27. 32 Careeroptions The job of dreams Need a fresh challenge? Heather Richardson of Browns Locumlink offers some key tips to those of you seeking pastures new f a new challenge is required then what should you be bearing in mind if you wish to get the job of your dreams? Let’s start at the beginning… Your CV This may seem an obvious thing to say but it needs to be said because so many professionals still get it wrong. Do your best to avoid any gaps in your employment history. If there are gaps, make sure you can adequately explain them. People often tell me that they have taken information out to shorten the CV to one page – this is not always best. It is important that we see all relevant experience and skills, even if this goes on for a couple of pages. You do not, however, need to add every single detail. How far will you travel? It is wise to be realistic. Enure you have researched a journey before applying for a position; there is nothing worse than pulling out at the point you are asked for an interview, or worse if the job is offered and you decide the journey is too far to travel on a regular basis. DBS checks and GDC credentials As you would expect, these all need to be in order and up to date. I
  • 28. 33 Careeroptions Browns Locumlink is one of the UK’s leading recruitment agencies specialising in finding locum and permanent work for dental, pharmacy and most recently GP professionals. With over 30 years of experience, the company has worked with thousands of professionals across the UK. For those looking for cover, Browns Locumlink has a database consisting of hundreds of registered dental professionals (both clinical and non-clinical) and pharmacists looking for work. This means that the team can find the most suitable candidate for the position. Whether it is short notice, a sick day for example, holiday cover, simply high demand, or something longer term such as maternity leave, or permanent such as unexpected staff shortage, the team will try their hardest to ensure you are covered. Contact the team today to put them to the test! Visit www.brownslocumlink.com for more information. www.dentistry.co.uk References Do you have good, solid references? A potential employer will quite frequently wish to see at least two clinical references before offering a position to you. Ensure you have more than two referees that are reliable and that will respond quickly to a request. Current referees are preferable and it would always be questionable if you cannot supply these. Flexibility What type of role is it that you are looking for? A degree flexibility is key – always attend an interview with an open mind. Many opportunities arise at this point – the more flexible that you can be, the more posts will be open and available to you. Remuneration Quite possibly number one on your list. It is of course a vital part of the process and one of the most important reasons for choosing or not choosing a role. Your expectations need to be realistic, however. It is tough out there and many dental professionals can have an overvalued opinion of what they are worth. Depending on the role, are you looking for a salaried position or a day/hourly rate? Have in your mind the minimum that you will consider and be open and honest about the numbers with any potential employer. There is no point in accepting an offer that you feel is too low; a frank dialogue is in everyone’s best interests. Discuss periodic pay reviews or bonus/ target incentives. Conditions and benefits These can be somewhat overlooked as many push for the salary above all else. Pension provision, holidays and flexible working hours can make a ‘maybe’ job become a ‘definitely’. Even if you are on a paid by day rate, take a step back and look around. Are the team happy and upbeat? Do the patients seem comfortable and relaxed? Does the role offer longevity? Above all, could you be happy here? Appropriate dress and appearance for interviews This may come as somewhat of a surprise in a recruitment article for dental professionals. In our experience though, it is not uncommon for candidates to get it spectacularly wrong when attending an interview. All we suggest is that you give this some consideration – no matter the role, who you are meeting or what level of seniority you are looking to hold, professional, clean and well presented applies to all. Register with agencies you can trust It generally doesn’t cost anything to join an agency but choose with care and ideally a name that has been associated specifically with the healthcare profession for some time. Ensure you find out how the agency takes their fee if you are looking to take up locum work; could they take a percentage of your invoice? Browns will not charge you to receive notifications of work or any fee to arrange this. It is entirely free to be registered and work through us, all we ask for in return is loyalty and some compliance documents.
  • 29. 34 Careeroptions The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership). • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. ental hygienists and therapists may develop additional skills in line with the GDC Scope of Practice guidance. These extended duties are: • Carrying out tooth whitening to the prescription of a dentist • Administering inhalation sedation • Removing sutures after the wound has been checked by a dentist. Additional training Dental hygienists and therapists that qualified before 2002 may also need to undertake additional training in the following areas: • Prescribing radiographs • Impression taking • Local anaesthetics. Dental therapists that qualified before 2002 may D
  • 30. 35 Careeroptions Another string to your bowFiona Sandom considers your potential extended duties Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists. For more about the BADT, visit badt.org.uk. www.dentistry.co.uk also need to undertake additional training in: • Prescribing radiographs • Impression taking • Administering inferior dental block anaesthetic • Pulpotomies in deciduous teeth • Stainless steel crowns for deciduous teeth. It is important to remember that a dental hygienist or dental therapist should only carry out a task or treatment about a patient’s care if they have the necessary skills.
  • 31. 36 Careeroptions Voyage of discoveryWhat routes to new horizons will you consider in the future? Kirstie Thwaites offers a road map to some key destinations patients and will raise our profile. Here are a few options you may wish to consider... Perfect therapy The pilots currently testing the NHS dental contract reforms are rooted in the principle that the skill mix of the whole team is the best way to e have an important role in promoting good oral health and, with our GDC Scope of Practice ever expanding and NHS dentistry looking towards a team approach to care, our options are increasing. We should all have a desire to develop our skill set; it prevents clinical complacency, offers more treatment options to W
  • 32. 37 Careeroptions www.dentistry.co.uk deliver dentistry – suiting clinical outcomes, the changing needs of a population and government purse strings. There have been claims that the increasing use of dental therapists in NHS general practice is simply a government ploy to deliver dentistry on a budget. But, many forward-thinking practices are realising that the more holistic approach we offer is better suited to a patient base that’s living longer and remaining dentate. Dental therapists can
  • 33. 38 Careeroptions treat these patients while dentists can focus on delivering the more complex (and more lucrative) treatments that are going to be in demand. There are a number of training options for hygienists wishing to extend their skill set to expand their scope of practice as a dental therapist. The University of Bristol, for example, offers a two- year part-time course and the University of Essex offers a one-year full-time course whilst remaining in practice. State of independence There have been many developments in dentistry over the years and being able to work without the dentist on the premises has been a massive change for the hygienist and therapist. To date, very few of us have monopolised on direct access in this way, coinciding as it did with a long period of global economic turmoil. For those of you who braved it and now practise independently, I salute you for it will be your blood, sweat and tears on which other hygiene practices will be built. The challenges are many – having the capital to invest, securing support from dental dealers and ensuring there is a solid referral arrangement in place are among the few obvious ones. But, the rewards are many and it offers patients a different path to care. Brace yourself For those wishing to extend their scope of practice in orthodontic care, the Royal College of Surgeons, among others, offers a diploma in orthodontic therapy. An orthodontic therapist can carry out a limited range of orthodontic procedures such as the placement of brackets and changing of orthodontic arch wires. The GDC requires all orthodontic students to train for a minimum of 45 weeks full time but training on a part-time basis is also available. Visit www.gdc-uk.org/dentalprofessionals/ education/pages/orthodontic-therapist- qualifications.aspx for a full list of course providers. Periodontally yours Do you have the enhanced skills in advanced care needed in the new dental contract? Dental practices that do are likely to be commissioned Kirstie Thwaites qualified in 2006 from the University of Leeds as a dental hygienist and dental therapist. Since qualifying she has completed a PG Certificate in Medical & Clinical Education at the University of Essex and a two year postgraduate programme in Enhanced Skills in Clinical Periodontology at King’s College Hospital. At the 2012 DH&T Awards Kirstie was the recipient of the Young Hygienist/Therapist award. 
She has previously worked in NHS practice and as a clinical educator teaching student dental hygienists from the University of Essex, she now divides her working week between private general & specialist practice and lecturing at the University of Essex. Kirstie is the Editorial Council member for BADT. to provide specialised services. Periodontology is just one of those specialised services you could be commissioned to do. The University of Essex offers a MSc advanced periodontal practice course that provides an educational route for you to acquire valuable skills and knowledge in periodontology. For more information, visit www.essex.ac.uk/coursefinder/course_details. aspx?course=MSC+A40136. Go public! Public health experts help shape decisions made by government policy makers and develop national public health programmes. An understanding of oral health strategy – based on evidence- based research – forms a key part of a clinician’s understanding and should be the foundation on which we all develop our clinical skills. Equally, a masters degree in dental public health may also set you on a more academic pathway. Research Branching out into the field of research is an exciting path to tread. Continuing your education long after qualification can spark renewed interest in – and give you a fresh pair of eyes on – the complexities of our chosen profession. We all know that preventing and controlling dental disease requires an evidence-based approach,
  • 34. 39 Careeroptions www.dentistry.co.uk but conducting research provides the scientific understanding of what we offer patients and why. You also learn new skills when coordinating or collaborating in clinical trials. Some faculties offer opportunities, as do dental companies that are keen to road test new dental products. University teaching Inspired by your course tutor? Enjoy the role of mentor? You may wish to consider academia. BADT president, Fiona Sandom, says of her role: ‘I have taught dental nurses in north Wales since 1994 and still do as part of my CDS role. I enjoy it a great deal. Once I qualified as a dental therapist from Liverpool, I was offered a tutor post. A few years later, in 2004, the Wales Deanery created the DCP postgraduate education department, which at the time was very forward thinking. I enjoy the variety and opportunities that my tutor’s role brings me and last year I gained my MSc in medical education from Cardiff University.’ Hungry for nutrition Increasingly, the evidence that links nutrition, dental health and overall wellbeing is taking dental hygienists and therapists into other areas of healthcare. Hygienists are now developing skills as nutritionists in order to understand and educate patients in the systemic links and treat them with a ‘whole body’ approach. Teaching patients proper nutrition and guiding them to an improved quality of life is a vital part of your role. Elderly care A population with a higher number of older people will require dental care to be provided in different settings – in their own home or in residential care homes, for example. We will be required to collaborate a lot more with other health and social care professionals. Challenges such as increased prevalence of dementia within society will also need to be considered. The ageing population is one that will need careful nurturing. Their mental health and dexterity may be compromised but they may remain dentally fit. Hygiene protocols will have to be adapted in order to meet their needs and capabilities and, only with the proper training, will successful outcomes be achieved.
  • 35. 40 Careeroptions Be dynamic Salaried services – have DH&Ts forgotten about this vital role? Dental therapist Leon Bassi reviews this all- encompassing role challenging and dynamic. It provides you the opportunity to use your full skill set. The team is led by a consultant paediatric dentist. The dental y dental therapy career started at Bart’s and the London School of Medicine and Dentistry. Most graduates are lured towards the sparkle of private practice but, just before I graduated, a post of staff therapist was advertised. The post would be working on the paediatric department at the London Dental Institute with Bart’s Health Trust. Working as a staff therapist, on a children’s department, is M Leon Bassi is a dental therapist whose dental therapy career started at Bart’s and the London school of medicine and dentistry.
  • 36. 41 Careeroptions Rewardingly different I would urge any new graduate to seriously consider a position within salaried services if there is an opportunity. The salaried service will always struggle to lure new graduates to the service due to restraints on pay scales, in particular compared to that of private hygiene or therapy services, but the rewards is being able to use our full scope of practice. Dental nurses and dentists both have postgraduate qualifications in special care; dentists have a clear pathway for postgraduate training within paediatric dentistry and dental therapists should work towards more specialised postgraduate training. www.dentistry.co.uk hospital provides you with the chance to work within a multi-disciplinary team. The patient base is far reaching and broad. Paint a picture To give you an idea of a typical child patient referred to a dental therapist, imagine a picture of early childhood rampant caries. Most of the children we see have high treatment needs with DMFTS 10 and above, will be from a large family with several siblings, and will speak English as an additional language. Communication between the patient, parent and the dental team can be problematic so we often use health advocates to interpret; learning a few words of several different languages is extremely helpful. Acclimatising children into the dental surgery setting can take time, especially as they have experienced episodes of pain relating to their teeth; we have toys and models to help with this and use a passport system to encourage progress. With such a high caries rate in young children, methods such as the Hall’s technique is very useful; we have found it a successful way of treating carious second primary molar teeth. Many of these patients require teeth to be extracted, and this can be done in a surgery setting using inhalation sedation, which helps make the experience easier. However, if the treatment is not suitable or too extensive, a referral is made for general anaesthetic. State of transition Salaried services are currently undergoing dynamic and far-reaching changes. The NHS is in a state of transition, which has impacted on community dental services. There has been a spilt between commissioners who are funding the services and Many patients have complex medical histories: • Bleeding disorders • Global developmental delay • Cleft lip and palate • Severe learning difficulties • Heart problems • Conditions only seen in very rare circumstances. providers who are supplying the service. This means that community dental services can be tendered for, and bid on, by interested parties. A contract is then agreed on. Hospital services are having to deliver services with tighter budgets as dental hospital services are in increasing demand. The way healthcare services are being delivered is changing; hopefully there will be a continued role for dental therapists working in salaried service settings, even if this not under the umbrella of the NHS. As clinicians, we represent good economic value for providing patient care. Because of the way NHS dentistry is funded, it is very hard to conduct cost-benefit analysis as all UDAs generated by dental therapists are submitted under a dentist’s performance number. Hospital services are paid differently to that of the CDS, but we still need recognition of the role the therapist plays in reducing waiting lists and having a positive affect on a child’s dental health. As salaried services are increasingly being target driven, I hope dental therapists continue to be used to provide care for patients and, as a group, we should push for greater recognition of our role among the commissioners who are funding the service and hospital boards.
  • 37. 42 Careeroptions Fee setting and pay scales Julian English presents a guide to the highs and lows in fees charging and remuneration there are four basic payment methods. A hygienist’s salary is paid as either: 1. A fixed annual salary 2. Straight commission 3. A combination of salary and commission 4. Daily/hourly rates. Each method has advantages and disadvantages. With a straight salary, paid vacations and sick leave usually are included. This can provide financial security. However, it may not be as rewarding. There may be less incentive to fill broken appointments and to maintain a good patient-return rate. Straight commission is usually paid at 30-40% of a hygienist’s daily production. Some dentists pay more. References Boyer EM (1990) Methods of charging and the fees charged for dental hygiene services in traditional and non-traditional settings. J Dent Hyg 64(3):144-9 www.payscale.com/research/uk/Job=Dental_ Hygienist/Hourly_Rate Retrieved 13/10/15 everal studies have been conducted regarding fee setting, such as that by Boyer (1990). This survey found that the methods of charging for services and the fees charged were similar. Although most hygienists provided many services, only one fee for those services was changed in most settings. The most recent data has been collected by publisher FMC, but not yet released at the time of going to press. However, the survey of dental fees suggests that the average hygienist’s hourly fee charged in the UK is £105, ranging from £70-£240 per hour for hygienist services. Salary setting Salary is one of the most important questions to think about. After all, would you work for free? Would you leave a job you love for more money? How much money would it take to get you to stay at a job you hate? Market demand ultimately determines the going hygienist pay rate. Cities have more dentists, which means that more hygienists will be needed, and, therefore, the dentists in big cities are going to pay far more to get the hygienists into the cities. To be compensated for your productivity, the dentist must see you as a great asset to the practice. And thinking is definitely changing, but even in countries like the US, still a whopping 40% of dentists do not employ a hygienist. There are two ways a dental hygienist can be classified: independent contractor or employee. And S Julian English is the editorial director at FMC.
  • 39. 44 Organisationsand associations Introducing the BSDHT British Society of Dental Hygiene and Therapy The main organisation for dental hygienists in a nutshell the interests of their profession. The mission of the BSDHT is to represent the interests of members and to provide a consultative body for public and private organisations on all matters relating to dental hygiene and therapy. It aims to work with other professional and regulatory groups to provide the highest level of information to its members as well as to the ith over 3,600 members, the British Society of Dental Hygiene and Therapy (BSDHT) is the primary UK organisation for hygienists and dental therapists. The BSDHT (formerly British Dental Hygienists’ Association, BDHA) was set up in 1949 by a group of 12 dental hygienists who felt the time was right to organise a professional association to represent W Incumbent president Michaela ONeill Ex-president Marina Harris
  • 40. 45 Organisationsand associations general public. The BSDHT directs the decision-making processes within the society and provides mechanisms to monitor progress and success. The plan is all-embracing and affects all aspects of the society’s business. The society seeks to increase the range of benefits offered to members by: • Representing members at national level, www.dentistry.co.uk particularly in the political arena • Providing services to members • Supporting members on issues that affect their working lives • Producing a publication that educates, updates and inspires • Providing CPD opportunities, both locally and nationally • Helping members to find employment and provide guidance on contractual matters, as well as salaries, and access to a 24/7 legal helpline • Listening to members and responding accordingly. All dental hygienists and therapists, and students thereof, should be members of the society. Ex-president Sally Simpson Ex-president Julie Rosse
  • 41. 46 Organisationsand associations The BADT – opening doors Katrina Matthews pays tribute to her ‘dental therapist family’ concept of dental therapy began to take seed. The early role of the dental auxiliary evolved into the dental therapist we know today, with a slow shift It was way back in 1950, when the state of children’s dental health was at a low and there was a shortage of dentists in the school services that the
  • 42. 47 Organisationsand associations www.dentistry.co.uk towards the doors opening for them to practise in a primary care environment. Along the way, there were expectations placed upon them that required patient management skills, an ability to educate patients in oral health care and above all, an affinity with patients and fellow dental professionals alike. Bridge the gap Slowly, the training developed into what we now know today – with much tenacious persuasion by those who cared passionately about the role. These ‘gentle persuaders’ blossomed along the way and, today, the British Association of Dental Therapists (BADT) still has that tenacity and staying power of their predecessors some six decades earlier. I qualified in 1974 and immediately joined the BADT and have been a member ever since. It was the only association for dental therapists until very recently, and I always felt it was my ‘dental therapist family’; so many people didn’t know (and perhaps are still learning!) about our profession. For many years, we were a very rare occupation. The support and friendship has been invaluable. The achievements of the BADT over the years has been amazing – working in practice and extended duties and raising our profile within the dental profession among them. We were always that person bridging the gap between dental nurse and dentist so we learnt excellent negotiating skills and quickly became a solid, valued member of the team. Our special clinician/patient dynamic and the long-standing and close association with the education, care and treatment of children’s teeth puts us at an advantage when it comes to a full understanding of the implications of poor oral hygiene, as well as the impact this has on their overall health and wellbeing. Once again, children’s dental health is in the spotlight and the lifted restrictions by the regulators, which allows us direct access, and underpins all that the BADT stands and fought for. Advise, support and protect Today, more than 500 members rely on us to advise, support and protect their interests. In this new dawn in dentistry, how you practise and what you can do may seem daunting and it is a role that requires careful navigation. For this reason, members are encouraged to look to us for assistance and we offer students and newly qualifieds reduced membership fees and access to some of the leading clinicians within dental therapy. This deep vault of knowledge held by experienced dental therapists – working in all areas of dentistry – is a hidden gem in the membership benefits. The council recently secured the help of patient membership scheme experts, Privilege Plan, to make it easier for its members to pay their fees by now accepting Direct Debit payments. Membership includes a quarterly peer-reviewed journal that includes two hours of non-verifiable CPD, accredited by Colgate. Online access is also available to previous issues of Dental Therapy Update. The journal aims to inform members of new clinical protocols and theory, keep them abreast of relevant news and views and highlight key courses and conferences, as well as offer insight into the working lives of therapist colleagues. Katrina Matthews works for Central London Community Health Care NHS Trust as manager for dental therapy and oral health promotion in the Specialist and Community Dental Services. Katrina qualified in 1974 and spent years as a tutor. She manages a team of dental therapists working across central and west London and a team of oral health promoters over four Trust areas. Katrina has spent the last 15 years working clinically in the specialist service, alongside a wide range of specialities and combine this with her interests in a range of dental public health programmes in the community, including fluoride varnish, adults with learning difficulty, early years settings, homeless and training of health, local authority and educational professionals.
  • 43. 48 Organisationsand associations The BADT has a vibrant social media presence, too, both on Twitter and Facebook and encourages members to share thoughts, comments and discuss common challenges in its own online forum at www.badt.org. There is a monthly e-newsletter to complement this, and to make it easy for our busy members to navigate their way directly to what they need to know. Heart So, although our association took root slowly, the heart of it remains the same. In her short time as president, Fiona Sandom has displayed the same passion as those who went before her, having For more information, visit www.badt.org. secured commitment from all four chief dental officers to understand and work towards solving issues affecting dental therapists. Some barriers to care remain within NHS regulations and prescribing rights and, although we aware that time frames to resolving these issues are lengthy, the BADT is in it for the long haul – much as it has ever been. Council is working towards understanding these barriers so we can use our full scope of practice directly with patients and therefore increasing their access to dental care.
  • 44. 50 Organisationsand associations Who’s whoA guide to the people and groups in the world of dentistry Month and Mouth Cancer Action Month. As a self- funded charity, the Foundation is very grateful to the support of its members, which enables it to provide such a wide range of important services. National Smile Month is the Foundation’s pro- active campaign designed to raise awareness of dental and oral health over one month. The campaign has now been running for 35 years and is one of the best established worldwide public awareness campaigns dedicated to the promotion of oral health. It encourages dentists, dental hygienists and therapists, and other dental professionals to get involved and spread good oral health messages to the public. Over the years, National Smile Month has been a great way for dental practices to organise themed events and publicise their business, as well as spreading a good oral health message to the public. It is also an excellent way for practices to encourage patients to maintain regular dental visits. A full range of patient awareness literature covering a wide range of dental topics is available as a resource to members and non-members of the British Dental Health Foundation to help educate and motivate patients. The range of resources includes leaflets, posters, stickers, books, DVDs and lots of fun dental motivators. The core of this material is the 50 titles in the ‘Tell me about…’ series, giving patients information on virtually every aspect of dental care. The BDHF also runs a dental advice line, the National Dental Helpline. For more, email sarah@dentalhealth.org. British Dental Industry Association Members of the British Dental Industry Association (BDIA) do more than just sell products and services to dentists and laboratories. Working with the profession, they help dentists deliver quality care to their patients. It is a partnership that can be rewarding to all concerned, including patients. Suppliers are constantly researching new products B is for. . . British Association of Dental Therapists The BADT promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome • Payment is available online, taken securely via Worldpay. For more, visit www.badt.o rg.uk. British Dental Health Foundation The British Dental Health Foundation is a national charity dedicated to promoting the benefits of oral healthcare to the public. It aims to serve the public interest by improving awareness of, and access to, the means of maintaining better oral health. As well as aiming to bring about improved standards of oral health care in the UK, the Foundation has a vastly growing overseas market, under the arm of the International Dental Health Foundation. The Foundation keeps in close communication with its members, who can benefit from direct involvement in its activities and campaigns, such as National Smile
  • 45. 51 Organisationsand associations www.dentistry.co.uk and services as well as developing established ones. Members of the dental team who work with BDIA members can be assured of a reliable service and continued support. They can be sure that the products and services they buy are of high quality and conform to all regulations and requirements of both UK and EU legislation, which is particularly important when investing in capital equipment. The BDIA also works in harmony with other dental associations to make sure that the products offered are what the dentist or dental care professional needs. The BDIA ensures the staff of its member companies are able to provide a good service to the dental team, who in turn can give the best to the patient. The BDIA runs courses every year to familiarise those new to dentistry with the basic knowledge they need. Most companies also offer training to dental teams to make the transition to a new product as smooth as possible. So, BDIA members are committed to providing the same high standards of quality as you are, giving you peace of mind when delivering dentistry to patients and clients. In summary, they: • Comply with a strict code of practice, meaning they are committed to providing the highest quality products and exceptional levels of customer service, minimising downtime and giving you the confidence to run a busy practice or laboratory • Research and develop new materials, equipment and technologies, providing you with more choice and the ability to work more efficiently and effectively • Provide courses and seminars to support you with the adoption of these innovations within the dental practice or laboratory • Are actively encouraged to train their staff, ensuring they have the relevant knowledge to understand the ever changing needs of the dental team. The BDIA is a primary source of information on dental suppliers and brands. When you are trying to source a particular product or replace a piece of equipment, rather than searching aimlessly through the internet, you may find it useful to search the online product and brand locators on the BDIA website, www.bdia.org.uk. British Society of Dental Hygiene & Therapy The BSDHT welcomes members who are dental hygienists, dental hygienist-therapists and students. The BSDHT is a major organisation within dentistry that exists to represent your interests. For example, representatives of the BSDHT maintain an ongoing dialogue with the General Dental Council (GDC), the Departments of Health and all the main groups representing dental care professionals. The BSDHT attends meetings of the dental All Party Parliamentary Group (APPG), bringing dental hygiene and therapy to the attention of government ministers and MPs. The BSDHT (formerly British Dental Hygienists’ Association, BDHA) was set up in 1949 by a group of 12 dental hygienists who felt the time was right to organise a professional association to represent the interests of their profession. Over 60 years later, the BSDHT is a nationally recognised body that represents around 3,600 members across the UK and beyond. There is 50% discount for newly qualified people for their first year of membership. The mission • Promote the study of oral health and to provide a consultative body to whom reference may be made by public or private bodies for guidance in connection with the dental hygienist/dental therapist profession • Maintain the honour and interests of the dental hygienist/dental therapist profession • Represent and safeguard the common interests of members • Provide opportunities for post qualification education. The aim • Represent members at national level, particularly in the political arena • Provide services to members • Support members on issues that affect their
  • 46. 52 Organisationsand associations working lives • Produce a publication that educates, updates and inspires • Provide CPD opportunities, both locally and nationally • Help members to find employment and provide guidance on contractual matters, as well as salaries, and access to a 24/7 legal helpline • Listen to members and respond accordingly. For more information, visit www.bsdht.org.uk. British Society of Periodontology The BSP exists to promote the art and science of periodontology. Membership includes specialist practitioners, periodontists, general dentists, consultants and trainees in restorative dentistry, clinical academics, DH&Ts, specialist trainees in periodontology and many others. For more information, visit www.bsperio.org.uk. C is for. . . Care Quality Commission CQC compliance inspectors started their visits to dental providers at the end of 2010. Wherever possible, inspectors give advance notice of an intended visit, as they do not want patient appointments to be disrupted or cancelled. So far, CQC visits have been planned reviews of compliance where, on the whole, there no concerns about the provider beforehand. However, the CQC may make an unannounced visit when a primary care trust, ‘whistleblower’, or another agency alerts of a possible major concern. Compliance inspectors come from a wide range of backgrounds. They are trained to ‘regulate whether providers are complying with the regulations’ and use a number of methods to review compliance. Having structures and processes in place are obviously necessary, but the CQC will look to make sure that all members of staff understand them when they check that a dental provider complies with these outcomes. Visits will last for about three hours and, in certain situations, a second visit may be necessary, with or without a dental specialist to check more details or actions required. Although CQC inspectors are not registered dentists, they can access these dental specialists who are spread throughout the country, and have vast experience in appraising, regulating and running both NHS and private dental practices. After leaving the practice, the inspector will compile a report, which will be sent, in draft, to the dental provider for any comments on factual accuracy, before it is finalised for publishing on the CQC website. D is for. . . Department of Health The Department of Health (DH) is responsible for numerous initiatives to improve oral health for the nation’s population. It manages the public dental workforce and reviews the capability and capacity of it. An increased focus on oral health improvement will reduce the need for treatment and improve the efficient use of financial resources. The chief dental officer (CDO) is the government’s most senior dental adviser for England and the professional head of dental staff in England. The holder of the role has close links with the profession and other staff across government, both to provide expert advice and to ensure a coherent input to policy across government. The CDO is the government’s senior adviser on all issues related to dental services and dental public health. The current CDO is Sara Hurley, she: • Provides professional leadership to the dental profession • Provides advice to ministers and other senior civil servants on improving oral health, reducing inequalities and developing high quality services for patients • Works closely with the professional regulatory body, the NHS and dental educators. For more information contact 0207 210 4850 or visit www.dh.gov.uk. Dental Protection Dental Protection Limited is a member of The Medical Protection Society Limited group of companies, the world’s leading defence organisation helping doctors, dentists and other healthcare
  • 47. 53 Organisationsand associations professionals to meet their professional obligation to make suitable indemnity arrangements. It offers members a first-class service combined with a wealth of educational information and risk management material. Key services • Protecting the professional integrity of its members • Advice and assistance, including legal advice and assistance in all matters that challenge a member’s professional registration • Indemnity against costs and damages in dental negligence claims. Neither Dental Protection or The Medical Protection Society are insurance companies; the benefits of membership are discretionary • More than 70 dento-legal advisers, who are all experienced dentists with legal expertise, provide expert guidance and support to members of the dental team in difficulty, including emergency advice available 24 hours a day, seven days a week. In addition, locally-based teams of dentists and lawyers with a specialised knowledge of dento- legal matters support the in-house advisers in all the nations where there are dental members • An independent and confidential counselling service specifically to assist members suffering from stress as a result of dento-legal issues. Educational services Dental Protection provides risk management publications, seminars and other educational resources, with the aim of preventing avoidable harm to patients and reducing risk to members. These are provided for members either free of charge on request, or at preferential rates. For more information, visit www.dentalprotection. org/uk. G is for. . . General Dental Council The GDC is the organisation that regulates dental professionals in the UK. By law, all dentists, dental nurses, dental technicians, clinical dental technicians, dental hygienists, dental therapists and orthodontic therapists must be registered with the GDC to work in the UK. The GDC’s purpose is to protect the public by regulating the dental team. It does that by: • Registering qualified professionals • Setting standards of dental practice and conduct • Assuring the quality of dental education • Ensuring professionals keep their skills up to date • Investigating allegations and complaints about dentists or dental care professionals and taking appropriate action • Working to strengthen patient protection. Registration The GDC has two registers; the Dentists Register and the Dental Care Professionals Register. These are updated daily and are publicly available on the GDC’s website, www.gdc-uk.org. The GDC can prosecute people who practise dentistry, but who aren’t registered. A list of dental specialists is also held. Any registered dentist can work in a particular branch of dentistry but only those on the 13 Specialist Lists can call themselves a specialist. Standards All dental patients are entitled to high standards of professional and personal behaviour from those providing their care. Every registrant is expected to meet the GDC’s Standards for the Dental Team, which sets out nine key principles of ethical practice. In addition, there are supplementary guidance sheets on topics such as advertising and prescribing medicines. Action can be taken against registrants who do not follow these principles. Education and quality assurance Currently, the aim of the GDC’s quality assurance process is to check whether courses for dentists and dental care professionals meet its training requirements, which are outlined in Preparing for practice – Dental team learning outcomes for registration. Dental professionals are required to keep their skills and knowledge up to date by carrying out continuing professional development (CPD). Complaints Most dental professionals are competent, www.dentistry.co.uk
  • 48. 54 Organisationsand associations conscientious people who patients can have complete confidence in. But there are times when the behaviour or health of a dental professional may cause concern. The GDC can act on complaints from patients or information received from other organisations (for example, the police or the NHS), which questions whether a registered dental professional should be practising. Action can be taken if a registrant’s fitness to practise may be impaired due to their health, conduct – including convictions and cautions – and performance. Fitness to practise hearings As part of its duty to protect the public, the GDC holds formal hearings into cases about dental professionals. The fitness to practise process begins when the complaint is assigned to a caseworker, who starts by comparing the complaint to the GDC Standards for the Dental Team to assess what should happen next. If a committee decides to erase or suspend a dental professional, they have 28 days to lodge an appeal with the High Court on the basis that the decision was too harsh. If the court agrees, it can substitute a different decision or send the case back to the Conduct Committee to dispose of the case according to the court’s directions. The Professional Standards Authority for Health and Social Care (PSA) has the power to appeal a Practice Committee decision if they consider that the outcome was unduly lenient. For more details on any of these issues, please log on to www.gdc-uk.org or call the customer advice and information team on 020 7167 6000. H is for. . . Hygienist Direct A website that allows registered dental hygienists and therapists to advertise their services to the public while complying with GDC guidance. Twenty-five per cent of funds raised from membership fees will go towards a new DH&T Benevolent Fund For more information, visit www.hygienistdirect. co.uk. I is for. . . International Federation of Dental Hygienists The IFDH was officially formed on June 28 1986 in Oslo, Norway. The forerunner was The International Liaison Committee on Dental Hygiene, established in 1973, by some European countries, the USA, Canada and Japan. The IFDH is an international, non-governmental, non-profit organisation. It unites dental hygiene associations from around the world in their common cause of promoting dental health. The stated purposes of the federation are to: • Safeguard and defend the interests of the profession of dental hygiene, represent and advance the profession of dental hygiene • Promote professional alliances with its association members as well as with other associations, federations and organisations whose objectives are similar • Promote and coordinate the exchange of knowledge and information about the profession, its education, and its practice • Promote access to quality preventive oral health services • Increase public awareness that oral disease can be prevented through proven regimens • Provide a forum for the understanding and discussion of issues pertaining to dental hygiene. T is for. . . Tooth Whitening Information Group TWIG was formed to unite people with a common purpose. Its mission statement is to work together to provide: • Clear guidance and supporting material for professionals on tooth whitening • Clear information for the public • Support to the official bodes who tackle illegal sales and illegal whitening.
  • 49. Keyclinical protocols 56 The proper way to scoreThe British Society of Periodontology’s guide to periodontal assessment thorough assessment and a consistent protocol from the practice team. But just why is it so important we involve our patients in determining the level of their periodontal health? 1. Because they have a right to know 2. It is our ethical duty to assess, diagnose and educate patients 3. Defence organisations have noted that their highest litigation costs are due to an increase in undiagnosed periodontal disease. Supervised neglect and failure to refer results in the ongoing existence of disease is a threat to systemic health and increased litigation within the profession atients’ understanding of periodontal disease is evolving, largely as a result of media coverage and also because of marketing by consumer healthcare companies (Balanoff and Duvall, 2010). However, despite the increasing emphasis on periodontal health and the oral systemic link, periodontal disease remains prevalent. As shown in the Adult Dental Health Survey, ‘83% of people show signs of gum disease’ (Office for National Statistics, 2009). Patient awareness and treatment acceptance, especially in the early stages of disease (when it is often asymptomatic) can be encouraged through P Code Definition Treatment required 0 No pockets >3.5mm, no calculus/ overhangs, no bleeding after probing (black band completely visible) No need for periodontal treatment 1 No pockets >3.5mm, no calculus/ overhangs, but bleeding after probing (black band completely visible) Oral hygiene instruction (OHI) 2 No pockets >3.5mm, but supra- or subgingival calculus/overhangs (black band completely visible) OHI, removal of plaque retentive factors, including all supra- and subgingival calculus 3 Probing depth 3.5-5.5mm (black band partially visible, indicating pocket of 4-5mm) OHI, root surface debridement (RSD) 4 Probing depth >5.5mm (black band entirely within the pocket, indicating pocket of 6mm or more) OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated * Furcation involvement OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.
  • 50. Keyclinical protocols 57 www.dentistry.co.uk (Mitchell, 2010) 4. It affords the opportunity for the practice to provide optimal patient care while enhancing practice-building opportunities. Many clinicians feel uncomfortable mentioning profit and ethics in the same sentence but, the fact is, dental practices are businesses that must generate revenue and profit while providing excellent care (Balanoff and Duvall, 2010) 5. It is important to assess the periodontal condition before commencing restorative treatment as there is evidence to suggest that, once the foundation of the periodontium is stable and a good level of plaque control is achieved, the restorative treatment will have better long-term prognosis (preshaw, 2008/9) 6. In line with Care Quality Commission regulations, all patients should have ‘a full examination of both the hard and soft tissues and supporting structures of the oral cavity using diagnostic aids such as radiographs as and when necessary’. This includes diagnostic and screening procedures for periodontal disease (Care Quality Commission, 2010). All new patients must be screened and evaluated for periodontal disease and it should be routine practice to probe every patient each time he or she is seen at recall. Periodontal protocol It is important to make a clear distinction between preventive care and periodontal therapy. The ‘routine scale and polish trap’ can induce a false sense of security in our patients for it communicates that all is well (Mitchell, 2010). In a well-defined periodontal protocol, patients are graded by their disease and risk level and the definition of disease is made clear. A good example of such a protocol is the Basic Periodontal Examination (BPE), which was developed by the British Society of Periodontology from the Community Periodontal Index of Treatment Needs (CPITN) (British Society of Periodontology, 2011). It is essentially a method of screening patients to estimate the level of disease present and the treatment required for each level. The BPE examination and scoring system divides the mouth into sextants. All the teeth in a sextant are examined and scored accordingly. The scores are detailed in the table on the opposite page. It is important to remember that in addition to BPE scores, a periodontal data chart is needed to determine the severity of disease, and provide a baseline for later comparison to assess the effects of the treatment (British Society of Periodontology, 2011). Communicating with patients Encourage patients to assume some responsibility for their role in controlling the disease. • When chatting to patients about their perio score it helps to have a typodont of the periodontium and a BPE probe to hand, as these can be used to illustrate various aspects of the disease • Technology can help patients ‘own’ their disease and diagnosis. Responsive software systems generate verbal feedback during probing and charting, which helps keep patients involved because they can hear the message generated by an ‘objective third party’ (the computer). You can provide the patient with a print-out of your findings • In the absence of technology, talk patients through examinations by using personal diagnosis. Disclose teeth and show them any areas of plaque accumulation. With a BPE probe point out any ‘hot spots’ (where there is bleeding on probing), demonstrate the depth of periodontal pockets and reinforce the message with radiographic evidence • Always back up any information you have given with educational literature. Younger patients In 2012, the British Society of Periodontology (BSP) and The British Society of Paediatric Dentistry collaborated to produce Guidelines for Periodontal Screening and Management of Children and Adolescents Under 18 Years of Age as it had been realised that there is a need to identify early signs of disease in younger patients. All clinicians should make themselves aware of this advice, which is available from the BSP website. For references, contact Julian@dentistry.co.uk.
  • 51. Keyclinical protocols 58 Periodontal disease and systemic health Charlotte Wake says that patients need to be educated about how their mouth can reflect on their overall health role as a profession to make sure we do all we can to get the message heard and understood. Risk factors Diabetes is an area well documented in its relationship with periodontitis. We have known atients are often aware that gum disease means that they can lose their teeth; in my experience they are less aware of the effect it can have on their overall health. In contrast they are not always educated on how systemic illness can affect their mouth, teeth and gums. It is our P
  • 52. Keyclinical protocols 59 for some time that diabetes is a risk factor in periodontal disease and the link is now considered two-way. If a patient is able to stabilise their diabetes this helps control their periodontitis; if their periodontal disease is controlled this can help stabilise their blood sugar level. With diabetes diagnosis on the rise I think this is going to become a bigger factor in our working life. An area that is slightly less understood is periodontal health and heart disease. The issue is a little bit like the chicken and egg. There are theories that relate to inflammation caused by periodontal disease increasing the buildup of fatty plaque, thus leading to swelling of the artery (www. perio.org, 2015). Another is that oral bacteria attach to the fatty plaques in the arteries, leading to clot formation and cardiovascular disease (www. perio.org, 2015). We know oral bacteria have been found in cardiovascular specimens and that smoking is a contributing factor to both diseases. Whether periodontal disease causes cardiovascular disease or indeed the other way around is still contested. Time may show they are not causative agents but risk factors to each other. We do however know that the two are linked, we know that they share risk factors and that ongoing research will help to shed light on the exact relationship between the two. The American Academy of Periodontology states on its website that as well as heart disease an additional study indicates a relationship between periodontal disease and strokes. It says that ‘people diagnosed with acute cerebrovascular ischemia [sic] were found more likely to have an oral infection when compared to those in the control group’. If this continues to prove to be the case then controlling periodontal disease can help to prevent our patients having a stroke. We understand that osteoporosis is a risk factor to periodontal disease. The bone density can be lost and this in turn can lead to premature tooth loss. Other areas of research have indicated a link of periodontal disease, pancreatic and kidney cancer. Pneumonia can be linked to periodontitis as the oral bacteria can be aspirated into the lungs. The possible illnesses continue as research is looking into a possible link between Porphyromonas gingivalis, periodontitis and rheumatoid arthritis. Research The risk of periodontitis to premature birth and low birth weight is well documented. We know that non-surgical periodontal therapy in mothers with periodontal disease can help reduce the risk of premature births (Tarannum and Faizuddin, 2007). Research in 2013 stated ‘a significant association between periodontitis (but not with gingivitis) and adverse pregnancy outcomes. Maternal periodontitis is associated with an increased risk of pre-eclampsia, intrauterine growth restriction, preterm delivery and low birth weight infants’ (Kumar et al, 2013). For men, their prostate health might be affected by periodontal health. The American Association of Periodontology explains: ‘Research has shown that men with indicators of periodontal disease such as red, swollen or tender gums as well as prostatitis (inflammation of the prostate) have higher levels of PSA [prostate-specific antigens] than men with only one of the conditions. This means that prostate health may be associated with periodontal health, and vice versa.’ Even in the last 10 years that I have been practising we have learnt so many more relationships; risk factors, be they solo or shared, and two-way links between not just periodontal disease and systemic health but for the oral cavity itself. It is important research continues and equally important the general public understands www.dentistry.co.uk Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapists’ council, and is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice.
  • 53. Keyclinical protocols 60 that looking after your teeth is not just about stopping tooth loss, decay and bad breath. They need to be educated about how their mouth can reflect on their overall health and well being. References Kumar A, Basra M, Begum N, Rani V, Prasad S, Lamba AK, Verma M, Agarwal S, Sharma S (2013). Association of maternal periodontal health with adverse pregnancy outcome. J Obstet Gynaecol Res 39(1): 40-5 Tarannum F Faizuddin M (2007). Effect of periodontal therapy on pregnancy outcome in women affected by periodontitis. J Periodontol 78(11): 2095-103 www.perio.org retrieved 29/9/15
  • 55. Keyclinical protocols 61 Tooth notation differentiations A comprehensive guide to the different formats in tooth notation European, Scandinavian or Haderup system Permanent teeth 8+ 7+ 6+ 5+ 4+ 3+ 2+ 1+ +1 +2 +3 +4 +5 +6 +7 +8 R L 8- 7- 6- 5- 4- 3- 2- 1- -1 -2 -3 -4 -5 -6 -7 -8 Primary teeth 05+ 04+ 03+ 02+ 01+ +01 +02 +03 +04 +05 R L 05- 04- 03- 02- 01- -01 -02 -03 -04 -05 American system Permanent teeth 1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16 R L 32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17 Primary teeth A B C D E F G H I J R L T S R Q P O N M L K FDI two-digit system of tooth designation Permanent teeth upper right upper left 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 lower right lower left Primary teeth upper right upper left 55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75 lower right lower left Zsigmondy-Palmer, ‘Chevron’ or Set-Square system Permanent teeth 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 R L 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Primary teeth e d c b a a b c d e R L e d c b a a b c d e
  • 56. Keyclinical protocols 62 Periodontal disease and systemic health Oral-systemic connections are now widely accepted. Melonie Prebble looks at the evidence so far systemic link, it is more likely caused by diet. Acidic foods and drinks are well known sources of the problem; conditions such bulimia or anorexia nervosa can be, too. It’s our role to look for the signs and provide guidance and understanding of the effects on the oral cavity • Cancer - Researchers found that men with gum disease were 49% more likely to develop kidney cancer, 54% more likely to develop pancreatic cancer and 30% more likely to develop blood cancers. The most significant contributory factors to oral cancer are smoking and heavy drinking • Childbirth - Several studies have suggested that women with periodontal disease may be more likely to deliver babies prematurely or with low- birth weight than mothers with healthy gums. Additionally, babies with a birth weight of less than 5.5lbs may be at risk of long-term health problems such as delayed motor skills, Melonie is an experienced dental hygienist and therapist, having worked in the dental industry for over 20 years. She graduated from The London Hospital in 1995 and has been enhancing her skills and contributing to the industry ever since. Melonie currently offers her services at Abbey Road Dental, in north west London, and the clinic at The Luke Barnett Centre, Watford, Hertfordshire. ith more and more concrete evidence emerging, it is hoped that scientists will one day clarify the ‘whole body’ relationship. In the meantime, adding value to a patient’s visit continues to be an essential part of our everyday practice and this includes their overall health and well being. The GDC’s Standards for the Dental Team maintains that all aspects of patients’ health and well being should be considered and there is an expectation upon us all to inform and advise patients about any behavioural risks. At the frontline We are at the frontline of oral healthcare and regular dental examinations gives us the opportunity to detect early predictors of systemic and dental disease. In fact, we are perfectly placed to address the lifestyle choices patients make and if they are detrimental, to look after their mouths – and the rest of their bodies, too. An oral examination reveals a lot more than just the health of the oral cavity. Equally, recording a patient’s medical history can highlight these risks and we should review their habits jointly in order to address them. Lifestyle risks • Bulimia or anorexia nervosa - Although tooth surface loss through erosion may have a W
  • 57. Keyclinical protocols 63 The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. For more about the BADT, visit badt.org.uk. www.dentistry.co.uk social growth, or learning disabilities. Similar complications are true for babies born at least three weeks earlier than its due date • Diabetes and heart disease - It is important to help diabetic patients manage their diets, to control any negative impact it may have on their periodontal status. Public Health England’s Delivering Better Oral Health acknowledges that lowering the intake of sugars will have wider health benefits, by preventing weight gain, which in turn could reduce the risk of heart disease, type II diabetes and some cancers. Many cases of diabetes in the UK are undiagnosed and so have a useful role to identifying those who are, so far, unaware. Conversely, patients with diabetes also have a greater level of periodontitis and therefore, there are some important factors to consider in assessing the periodontal status of patients with diabetes, such as their degree of metabolic control, the presence of concurrent risk factors and their general level of well being (www. colgateprofessional.com, 2009) • Hypertension risk – Researchers recently found that oral hygiene may be considered an independent risk factor for hypertension and that maintaining good periodontal health habits may prevent and control the condition. The study, published in the July 2015 issue of the Journal of Periodontology, suggests periodontitis and hypertension may be linked by way of inflammation and blood pressure elevation • Osteoporosis - Researchers have suggested that a link between osteoporosis and bone loss in the jaw. Studies suggest that osteoporosis may lead to tooth loss because the density of the bone that supports the teeth may be decreased, which means the teeth no longer have a solid foundation • Respiratory disease - Research has found that bacteria that grow in the oral cavity can be aspirated into the lungs to cause respiratory diseases such as pneumonia, especially in people with periodontal disease. Treatment, therefore, should focus on the prevention of disease and oral inflammation, which is essential in controlling the oral complications associated with other diseases. Equally, control of periodontal infection and inflammation will improve the oral health of patients, decrease the systemic chronic inflammation burden caused by oral inflammation, improve general health, and may ultimately contribute to the reduction of disease elsewhere. References www.colgateprofessional.com/patient-education/ articles/periodontal-disease-and-diabetes www.colgateprofessional.com/Professional/v1/en/ us/locale-assets/docs/OSH-Cardiovascular Health-InflammationCardiovascularDisease.pdf Retrieved 13/10/15
  • 58. Keyclinical protocols 64 Peri-implantitis – the ‘time bomb’Peri-implantitis has been described as a ‘time bomb’ with many patients unaware of the consequences of poor care. Dental therapist Amanda Gallie offers some tips Amanda Gallie has 20 years’ experience as a hygienist and became a therapist in 2012 on a tutor conversion course at KCH. She is a BADT representaive and works in practice in Stamford. ental implants are an increasingly mainstream part of dental care – their popularity has grown rapidly in the UK in the last few years – and are now considered the treatment of choice for replacing missing D
  • 59. Keyclinical protocols 65 Diet and lifestyle To avoid the risk of peri-implantitis – and to help limit inflammation as a whole – advise patients to: • Drink lots of water • Eat plenty of green vegetables • Include olive oil and fish oil in their diet • Quit smoking • Keep to the recommended units of alcohol • Exercise regularly. The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. For more about the BADT, visit badt.org.uk. www.dentistry.co.uk teeth. According to the latest Adult Dental Health Survey, half a million adults have at least one dental implant. But, implants require long-term care and regular dental check ups as these are crucial in identifying disease. Like natural teeth, poor oral hygiene can cause plaque and bacteria accumulation but bone loss around implants tends to be far more rapid around an implants versus a natural tooth. Eventually, if left untreated, the implant may become loose and may have to be removed. Loss of an implant Studies have suggested that one third of implant patients may be affected by peri-implantitis. Amanda Gallie explains: ‘The scar tissue around the implant is less forgiving, more fragile and prone to breakdown in the presence of plaque. It can become inflamed and ulcerated – implant mucositis. The condition can progress to peri- implantitis and, if untreated, can lead to bone loss and eventual loss of the implant. ‘Symptoms may include soreness, redness, tender to touch, pus and bleeding, and there can be halitosis but, often, because bone loss is painless, many patients fail to realise they have the condition. So, good oral hygiene and regular hygiene appointments after an implant is fitted are essential.’ ‘We need to assess an implant – probing and palpate for signs of peri-implantitis, assess for calculus and visually assess soft tissue for mobility or pain. Home care is an essential part of prevention, as is biofilm disruption and recall appointment intervals should be set relevant to the patient. If inflammation is present, then biofilm disruption may be required more frequently.’ Supportive periodontal therapy Dental teams may also offer patients supportive periodontal therapy (SPT). Amanda explains: ‘This is usually a treatment phase to detoxify a patient’s gum and supporting tissues. Once this has been deemed successful, a patient goes into a maintenance phase of three-month appointments to keep the bacterial load at a minimum, so that the body can work in conjunction with good home care to keep the tissues healthy. The treatment is gentle and well tolerated but local anaesthetic can be used if needed or requested.’ And although peri-implantitis is not just an age-related disease – as Amanda explains, ‘it’s all about how your body reacts to the plaque bacteria’ – the maintenance of dental implants can prove a challenge in older, less dexterous patients. In these cases, Amanda advises using an electric toothbrush to remove the plaque efficiently. She says: ‘Hygienists and therapists can train family members and/or carers in how best to brush the teeth if that is agreed by the patient. More frequent professional cleaning may be advised, so every one to three months in some cases.’
  • 60. Keyclinical protocols 66 Developing dentitionFrom birth to permanent dentition, see below for a vital reference on all stages of tooth eruption 3-4 months Eruption begins. Parents will notice signs including irritation, redness, sleeplessness and teething. 6-12 months First tooth will erupt, usually an incisor. Usually in the mandible. The other incisors will follow close behind. Primary dentition Table 2: A = central or first incisor; B = lateral or second incisor; C = canine; D = first molar; E = second molar. Note: The lower incisors tent to erupt shortly before the upper incisors. Primary teeth Erupt Lost Central incisor 8-12 months 6-7 years Lateral incisor 9-13 months 7-8 years Canine 16-22 months 10-12 years First molar 13-19 months 9-11 years Second molar 25-33 months 10-12 years Tooth Commences to calcify (months before birth) Eruption (months) Crown calcification complete (months) Root calcification complete (months) Absorption commences (years) A 3-4 5-7 4 18-24 4 B 4-5 7-8 5 18-24 5 C 5 16-20 9 30-36 7 D 5 12-16 6 24-30 6 E 7-9 20-30 12 36 6
  • 61. Keyclinical protocols 67 www.dentistry.co.uk Table 3: 1 = central or first incisor; 2 = lateral or second incisor; 3 = canine; 4 = first premolar; 5 = second premolar; 6 = first molar; 7 = second molar; 8 = third molar or wisdom tooth. Note: The lower incisors and canine tend to erupt one year earlier than the upper incisors. They also complete their calcification one year earlier. Permanent dentition Tooth Commences to calcify Crown calcification eruption (years) Root calcification eruption (years) Complete (years) 1 3-4 months 6-7 4-5 10 2 10-12 months 7-8 4-5 11 3 4-5 months 10-12 6-7 12-13 4 1.5-2 years 9-11 5-6 12-13 5 2-2.5 years 10-11 6-7 12-14 6 Just before birth 5-7 3 10 7 3-4 years 12-13 8 15 8 8 years When sufficient. Usually 18-24 12-16 18-25 12-18 months The remainder of the incisors will erupt. The first molars often then come through before the canines, so that when you look into a baby’s mouth you might see four teeth anterior, then a space and then some more teeth in the posterior of the oral cavity. 12-24 months Canine and pre-molar primary teeth will erupt, as well as the molars all deciduous teeth have erupted by the end of this period. 3-5 years All primary teeth should have come in. Permanent teeth are preparing to erupt. 5+ years The child will lose primary teeth, and permanent teeth begin to come in, starting with molars.
  • 62. Keyclinical protocols 68 XerostomiaCharlotte Wake highlights the effects of xerostomia and discusses The Challacombe Scale of clinical oral dryness disrupted as there is already a reduction in natural saliva flow overnight. Taste may also be affected and some patients may not experience the usual increased flow when hungry or smelling food. Effects Patients suffering from xerostomia may complain of a sore throat or a burning sensation and an increase in oral candidiasis is more likely. Denture wearers might struggle with poor denture retention or present with more cheilitis. So as a condition oral dryness is clinically significant for us but it is often life changing for the patient. For some years there have been options for the management of xerostomia. These can be obtained on prescription and have primarily been salivary substitutes or stimulants. Substitutes are suited to patients who have impaired saliva flow due to the removal of a salivary gland for example. These efined as a dry mouth, xerostomia is a common condition and it is important we do not underestimate its discomfort for the patient. As clinicians we know saliva is an important aid for oral health – it has a great buffering capacity helping to maintain a neutral pH in the mouth. The enzyme ptyalin is present aiding digestion and saliva contains lysozyme that helps control bacterial growth. Our patients may be unaware of the clinical benefits but they know saliva helps them to speak, to eat and gives oral comfort, so when there is a reduction in the amount produced there will be both signs and symptoms present. Xerostomia leads to a rise in the risk of caries and periodontal disease and patients can produce a more rapid deposition of plaque. For the patient they may find mastication more difficult and oral clearance is likely to be impaired. Sleep may be D
  • 63. Keyclinical protocols 69 Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapist’s council, and is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice. www.dentistry.co.uk substitutes mimic natural saliva and are available in various forms such as sprays, tablets and liquids. The other option is a saliva stimulant – these are intended to help stimulate the salivary glands into increased production. Since 2011 we have had a tool to help us clinically identify and quantify whether our patient has a dry mouth. The Challacombe Scale of Clinical Oral Dryness was developed from research under the supervision of Professor Stephen Challacombe at King’s College London. The scale is free to download from the Challacombe Scale website (www.challacombescale.co.uk). There is also a patient review form for an individual patient that can be kept as a record in their notes. This scale allows us to monitor xerostomia and leads us to the appropriate advice for our patient. For patients presenting with oral dryness dentists may choose to include the use of fluoride in their treatment plans, more regular attendance to help monitor oral disease or may even refer for specialist intervention. With the help of this scale it is easier to monitor, it’s universal and is useful for future reference when continuing your patient’s dental care.
  • 64. Keyclinical protocols 70 XerostomiaBal Chana presents the causes and symptoms of xerostomia along with some effective management • Radiotherapy - The salivary glands can be damaged if they are exposed to radiation during cancer treatment • Chemotherapy - Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry. Approximately 500ml of saliva is secreted daily. However, the rate can vary amongst individuals. Salivary flow peaks in the afternoon and decreases at night when the major salivary glands are less active. Less than 2ml in 10 minutes unstimulated salivary flow is considered to indicate xerostomia. Salivary flow can be measured by asking the patient to tilt their head forward, allowing their saliva to flow into a container for 10 minutes. Symptoms of xerostomia Symptoms of xerostomia include the following: • Soreness or burning of the mouth, lips or tongue • Sleep disturbance due to thirst or oral discomfort • Difficulty chewing, speaking, swallowing and wearing dentures • Difficulty clearing oral debris • Complaint of dryness • Altered taste. Management strategies Advise the patient to: • Stay well hydrated • Suck ice chips • Sip liquids while eating • Rinse the oral cavity immediately after meals • Use a soft bristled toothbrush • Use interdental brushing aids such as Tepe’s • Use a fluoridated toothpaste and mouthwashes • Recommend saliva substitutes or atients presenting with xerostomia are frequently seen in the dental practice, especially the ageing population. Clinically, the mucosa will appear glazed and translucent. Plaque often is thicker and more tenacious and debris can be seen adhering to the tooth surface. The tongue is usually lobulated and fissured. On examination the mouth will feel dry and the mirror will adhere to the mucosa, making the examination very uncomfortable. There will be no saliva pooling in the floor of the mouth. The Challacombe Scale was developed by Professor Stephen Challacombe. It is a Clinical Oral Dryness Score and uses a simple numeric system that enables the clinician to quantify the severity of the xerostomia and to decide if the condition needs treatment or not. It lists 10 key features of dry mouth, accompanied by example images and allocates one point for each feature. The patient’s additive score indicates whether the dry mouth is mild (a score of 1-3), moderate (4-6) or severe (7-10). The patient score should be document in their clinical notes. A.S. Pharma has produced the scale in poster form, which is available for the dental team. Causes of xerostomia Xerostomia is caused by the salivary glands not functioning properly; this could be due to a number of reasons: • Side effects of medication - More than 500 medicines can cause the salivary glands to produce less saliva. For example, medicines for high blood pressure and depression often cause dry mouth • Disease - Some diseases affect the salivary glands such as, Sjögren’s syndrome P
  • 65. Keyclinical protocols 71 Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006. www.dentistry.co.uk saliva stimulants • Have regular dental examinations. Advise patients to avoid the use of: • Sugary, acidic, spicy and salty foods and drinks • Caffeine • Tobacco • Mouthwash with alcohol • Alcoholic drinks • Toothpastes containing sodium lauryl sulphate. Early recognition and management of xerostomia will prevent dental disease and will help improve the quality of life for these patients. Management of xerostomia should be a multidisciplinary approach due to the medical problems and pharmaceutical complications associated with this condition.
  • 66. Keyclinical protocols 72 White or wrong? Dental Protection puts hygienists and therapists in the picture on how best to approach tooth whitening he GDC states: ‘Dental hygienists and dental therapists can carry out tooth whitening on the prescription of a dentist, if they have the necessary additional skills. Taking impressions to a dentist’s prescription, and making bleaching trays to a dentist’s prescription, are within the scope of additional skills for dental nurses.’ Under the new law introduced by The Cosmetic Products (Safety) (Amendment) Regulations 2012 (The ‘regulations’), dental hygienists and therapists (DHTs) may provide tooth whitening using products containing or releasing up to 6% hydrogen peroxide under the direct supervision of a dentist, if an equivalent level of safety is ensured. This regulation is not altered by the announcement that direct access to DHTs was announced by the GDC with effect from May 2013. The tooth whitening treatment will still need to be provided under the direct supervision of a dentist. Dental Protection has sought legal advice on the meaning of direct supervision. The legal opinion advises that a dentist’s physical presence on the practice premises when the first use of the tooth-whitening product is provided to the patient is likely to be required. Therefore, Dental Protection advises members it is appropriate that the dentist is on the premises when the first use of the tooth whitening product is provided to the patient by a dental therapist or hygienist. An examination by the dentist prior to the cycle of tooth whitening is also required. The regulations prohibit the supply of the tooth whitening products containing or releasing up to 6% hydrogen peroxide to anyone other than a dentist. This means that a dental hygienist or therapist cannot legally purchase these tooth whitening products to use on patients. Cycle of use There is a risk that a patient who has not had appropriate instruction on loading a home tooth whitening tray with the tooth whitening product and who has not received instruction on fitting the tray in the mouth could be at risk of swallowing excess material. The requirement that the first use of each cycle is by a dental practitioner (or under their direct supervision) helps to allay these concerns as it allows the dental professional to demonstrate the amount of material to be used and how to load and seat the tray. Direct supervision Before undertaking any procedure, a registrant must ensure that they are trained and competent. The regulations do set out that the treatment is under the ‘direct supervision’ of the dentist but do not define ‘direct supervision’. In Maintaining Standards the GDC used the term ‘direct personal supervision’ to indicate when the dentist was to be on the premises. T
  • 67. Keyclinical protocols 73 Worth noting! • Tooth whitening is the practice of dentistry • GDC-registered dentists can carry out tooth whitening. GDC-registered DHTs can also carry out tooth whitening on the prescription of a dentist • To only be sold to dental practitioners • For each cycle of use, first use by a dental practitioner; or • Under their direct supervision, if an equivalent level of safety is ensured • Afterwards to be provided to the consumer to complete the cycle of use • Not to be used on a person under 18 years of age, but there are certain clinical situations where bleaching may be part of a comprehensive treatment plan for a child. Even though the GDC has indicated that is will not prosecute in cases where the consent is valid and such treatment would be in the best interest of the child, the law has not changed and it remains technically illegal to treat a person under the age of 18. www.dentistry.co.uk Afterwards After the first in-surgery application, the patient can be provided with the tooth whitening product for home use. The dentist’s duty extends to continuing to monitor the provision of top-up gels and ensuring that this is in accordance with his/her treatment plan. If the patient requires additional product for that course of treatment, assuming the patient had not been provided with the full amount of product required for the entire cycle of use from the outset, then it is the dentist’s duty to provide access to these. The dentist does not necessarily have to be physically present when the top-up gel is handed out, but the duty is to have a system that ensures what is handed out is in accordance with the specified treatment plan (ie, cycle of use). Under 18s The regulations and EU Directive specifically state the product should not be used on patients aged under 18. This means that it is only possible to use products containing or releasing up to 0.1% hydrogen peroxide on patients who are under 18. It has been suggested by some practitioners that tooth-whitening products could be classified as medical devices and as such The Cosmetic Products (Safety) (Amendment) Regulations 2012 do not apply. However, even where a product is marked with a CE mark the regulations do apply. A dental practitioner (or indeed anyone else acting in the course of their business) would be in breach of the regulations by using a tooth whitening product with a concentration higher than 0.1% on a patient under the age of 18, and so be potentially liable to prosecution and disciplinary action by the GDC. This may create a legal and ethical dilemma for members who consider, for example, that it would be in the best interests of a particular patient under 18 years of age, to provide tooth whitening to an isolated non-vital tooth. The member may consider that other treatments, for example crowns or veneers, would be unnecessarily destructive to the tooth/teeth. Dental Protection understands the ethical dilemma that the regulations may cause. Over 6% The use of products containing or releasing more than 6% hydrogen peroxide is a breach of the regulations. Dental Protection would expect members to comply with the law. If a member considers that it is in a patient’s best interests to use a product containing or releasing more than 6% hydrogen peroxide and a clinican chooses to use this product, they may be challenged on the use of the product by Trading Standards Officers or the GDC. Dental Protection appreciates that in a limited number of cases this may present an ethical dilemma. Dental Protection is a member of the Medical Protection Society. For more information or for dento-legal advice, visit www.dentalprotection.org/uk, or call 0800 561 1010.
  • 68. Keyclinical protocols 75 Keep it conservativeThe BADT presents fast facts on minimally invasive (MI) dentistry 5. Diagnosis and management of stained and sometimes early carious fissures can be difficult. MI dentistry aims to prevent the historical restorative cycle of traditional caries removal, and there are a wide range of diagnostic tools and interventions available. For more about the BADT, visit badt.org.uk. The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. istorically, dentistry has used a surgical approach to dealing with caries, with tooth removal once the only solution offered to patients. However, over time, the profession has found a more conservative approach to treatment in a bid to ensure the maximum preservation of healthy tooth structure. Fast facts 1. Thirty-one per cent of adults in the UK have tooth decay. Although levels of tooth decay have decreased over the last few decades, it is still one of the most widespread health problems in the country 2. Minimally invasive dental therapy has a simple goal – to preserve tissue 3. The concept of MI dentistry can embrace all aspects of the profession. Changes in how best to manage dental disease has developed rapidly in the last few decades – now is the time for these changes to be implemented in practice 4. Air abrasion is more conservative than a traditional drill, only removing desired material and suffering no chipping or stress fracturing. It greatly improves patient comfort and may not require anaesthesia. It resembles microscopic sandblasting and uses a stream of air combined with a super-fine abrasive powder www.dentistry.co.uk H
  • 69. Keyclinical protocols 76 Implants exposed Melanie Joyce explains how to treat exposed implant threads side motion, one thread at a time gently, like stairs (Wingrove, 2013). Chemical treatment Following mechanical debridement of the implant threads, an antimicrobial agent should be applied to the exposed threads to prevent recolonisation of the bacteria (Besimo et al, 1999). Many microorganisms such as S. aureus, are capable of overcoming the gap between the crown and implant and to proliferate in that area. The colonisation of an implant with S. aureus may result in peri-implantitis, which in turn may jeopardise the survival of the implant. Studies have shown that Cervitec Plus varnish is ‘capable of protecting implants from bacterial colonisation and reducing the risk of peri-implantitis’ (Besimo et al, 2000), therefore placing Cervitec Plus varnish on exposed implant threads following mechanical debridement could be an effective measure to help treat and prevent peri implant disease. Susan Wingrove (author of Peri implant therapy for the dental hygienist, 2013) recommends the patient continues to apply antimicrobial solutions to the exposed threads twice daily as part of their home oral health care. Ivoclar Vivadent produces two professional care products that meet this need in the form of Cervitec Liquid and Cervitec Gel, both of which contain chlorhexidine as their active ingredient. Conclusion Though implants are generally successful, failure can occur. Failure can be caused by peri- implant disease, which can lead to bone loss and subsequently exposure of the implant threads. Exposed implant threads can pose a significant dental implant is now commonly placed to restore spaces in the dentition. Titanium implants osseointegrate creating a bond between living bone tissue and the surface of the titanium implant. The typical basic implant structure we see placed today comprises of a screw-retained titanium implant that is implanted into the bone, then a transmucosal abutment is screwed into the implant providing an anchor for the coronal restoration. What causes an exposed implant thread? The literature varies but the success rate for implants is generally quite high, with over 90% success. One major reason for implant failure is peri-implant disease, which is caused by inflammation of the implant surrounding tissues due to bacterial colonisation. Peri-implant disease starts with peri-mucocitis and can progress to peri- implantitis, which – according to the PIMI scale – is characterised by bleeding on probing, generalised erythema around implant, presence of exudate, radiographic evidence of bone loss and the exposure of three or more threads (Wingrove, 2013). The screw threads of an implant becoming exposed can pose a significant issue when it comes to preventing bacterial colonisation and calculus build up. Mechanical treatment Exposed implant threads have a greater risk of bacterial colonisation and are prone to calculus build up. To remove the calculus and disrupt the biofilm it is recommended to scale using a shorter radius blade tip of an implant scaler, such as a Wingrove L5 mini to clean horizontally in a side to A
  • 70. Keyclinical protocols 77 Melanie Joyce started out as a dental nurse and in more recent years qualified with merit as a dental hygienist and therapist, she also holds qualifications in management and teaching in addition to her dental qualifications. She plays a role in the north east region for the BADT. She is currently working in a fully private and a mixed general practice as a dental therapist and is completing further advanced studies in her field. Her main interests lie in prevention and education particularly with regards to the periodontal-restorative interface and the maintenance of dental implants. dentalhygienetherapy.co.uk challenge when preventing bacterial colonisation and calculus build up. Mechanical debridement of the exposed threads is necessary to remove any calculus deposits and disrupt the biofilm. To prevent further colonisation, an antimicrobial varnish such as Cervitec Plus could be placed and a home care routine using Cervitec Liquid and Cervitec Gel advised. References Wingrove S (2013). Peri-Implant Therapy for the Dental Hygienist: Clinical Guide to Maintenance and Disease Complications. Ames:Wiley-Blackwell Besimo CE, Guindy JS, Lewetag D, Meyer J (1999). Prevention of bacterial leakage into and from prefabricated screw-retained crowns on implants in vitro. Int J Oral maxillofac Implants 14(5): 654-660 Besimo CHE, Guindy JS, Lewetag D, Besimo RH, Meyer J (2000). Marginale Passgenauigkeit und Bakteriendichtigkeit von verschraubten implantatgetragenen Suprastrukturen. Parodontologie 3: 217
  • 71. Keyclinical protocols 78 Minimum intervention – surely the only way is prevention Bal Chana believes an understanding of human behaviour is essential for successful preventive outcomes that is ultimately the patient’s own responsibility to control with the aid of the dental profession.’ The importance of oral health Oral health is important to general health and well being; poor oral health has a major impact on quality of life. Dental caries and periodontal disease are the most common dental problems in the UK. These preventable diseases can be painful, expensive to treat and can seriously damage health if left unchecked. Public Health England produced the 3rd edition of Delivering better oral health: An evidence-based toolkit for prevention, in June 2014. The document was developed by a number of well-known experts who have provided evidence-based oral health prevention and promotion guidelines. The entistry in the past has been treatment orientated, but we are now moving to a prevention-focused philosophy. It is far better to prevent the disease in the first place, than treat it once it has happened. The aim of preventive dentistry is to avoid disease altogether, in which the dental profession has a key role to play. Minimal intervention dentistry (MID) is a modern approach to the management of caries, which emphasises prevention and early interception of disease. Professor Avijit Banerjee from King’s College London states: ‘Changes in the outlook on management of oral health and dental disease have developed over decades. Minimum intervention is preventing disease rather than restoring teeth. We know dental caries is a lifestyle-related disease D
  • 72. Keyclinical protocols 79 Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006. www.dentistry.co.uk document identifies key areas and comments on how the main problem areas can be addressed, by providing clear and simple messages to improve the oral health of individuals. As dental professionals we recognise the importance of oral health but do we really understand what it means and how to do it? More importantly, do our efforts result in patients improving their oral health? Improving patients’ oral health Effective plaque control is necessary to maintain oral health, as dental plaque is the main aetiological factors in both periodontal disease and dental caries. There are so many oral care products available on the market that it is easy for consumers to feel overwhelmed by the choice on offer and not select the most appropriate product for their own needs. It is important for dental professionals to consider manual dexterity, motivation and financial abilities of the individual, along with the available research supporting the product. A successful outcome Humans are complex individuals; an understanding of human behaviour is essential for a successful patient outcome. To help us achieve this we need to ask ourselves the following questions: • What are the key messages when managing our patients and how should they be addressed to make an impact? • What are the needs of the patient? • What are the patient’s expectations – are they the same as our expectations? • Have we been successful in meeting their needs and expectations? It is vital for dental professionals to communicate the key messages in a manner that patients can easily understand, remember and act upon. Communication takes place at two levels: 1. Cognitive (understanding) – getting the message across 2. Emotional (related to feelings) – how the message is conveyed. Effective communication makes it easier for patients to discuss problems and devise solutions. Treat people as you would like to be treated. Patients should have trust and confidence in you as a dental professional. The use of skill mix can assist a practice to become more prevention orientated. Teamwork is crucial in dentistry; it is vital for the dental team to work together. All members of the team contribute to the patient’s experience – key preventive messages can be delivered by all members of a dental team.
  • 73. Keyclinical protocols 80 A sensitive subject Leigh Hunter offers an insight into how you can help patients suffering from dentine hypersensitivity factors, particularly dietary and oral hygiene habits associated with erosion and abrasion. The relevant differential diagnosis should be considered to exclude all other dental conditions with similar pain symptoms, eg cracked tooth, pulpitis and so on. A wide variety of factors can contribute to gingival recession and subsequent dentine exposure, eg, poor oral hygiene techniques, periodontal therapy, labial frenum attachment, disease such as necrotizing ulcerative gingivitis (NUG), orthodontic therapy, restorative or surgical procedures, or metal jewellery used in oral piercing. Often, loss of tooth structure is multi-factorial with attrition and abrasion, in combination with erosive exposures, contributing to dentine exposure and resulting DHS. Education DHS management includes patient education alongside appropriate treatment interventions, which should be reviewed to evaluate effectiveness. The aim of treatment is to relieve pain and control or eliminate the contributing factors. Based on Brannstrom’s theory, desensitisation agents disrupt pain transmission by either preventing nerve polarisation or by preventing a stimulus moving tubule fluid by occluding the tubule orifice or reducing its diameter. Patient education may involve modifying behaviour such as dietary changes – not just what entine hypersensitivity (DHS) is one of the most painful and chronic dental conditions presented in practice, often difficult to diagnose and treat satisfactorily. Older people retaining teeth, parafunctional habits and lifestyle choices may result in an increased demand for effective solutions to DHS. Clinicians must screen for DHS and diagnose by exclusion, determine appropriate management, and provide treatment and preventive recommendations. While many theories exist to explain DHS, Brannstrom’s hydrodynamic theory is the most widely accepted. DHS was once described as an enigma frequently encountered yet poorly understood, but recently a more widely accepted definition is available in the literature. Patients complain of experiencing a short, sharp pain from exposed dentine often following some type of external stimuli that cannot be ascribed to any other form of dental pathology, defect or disease. Its definitive characteristic is that the pain is elicited by a stimulus and alleviated on its removal. Common causes Cold is the most common stimulus for DHS pain and is often related to cervical dentine exposure, but it may occur elsewhere. Correct diagnosis and recording of DHS includes the patient’s history and clinical examination, in combination with the identification of aetiologic and predisposing D
  • 74. Keyclinical protocols 81 TEETOC – an aid memoire • Thermal – from hot and cold food, drink or air • Evaporative – dehydration of oral fluids, eg, high speed suction or air drying from three-in-one syringe • Electrical – use of pulp tester • Tactile – from toothbrush or other oral hygiene aids, instruments, prosthetic clasps, etc • Osmotic – altering pressure in the dentinal tubules, eg, sugar or salt solutions, vital tooth bleaching materials • Chemical – eg, acids in foods and drinks, acidogenic bacteria and/or from gastric regurgitation, acid, etc. www.dentistry.co.uk is ingested but also how and when. Patterns such as brushing immediately after an acidic challenge can accelerate tooth structure loss (TSL). An alcohol-free, neutral pH mouthrinse or even water can help to neutralise an acid environment. Dental biofilm can increase the size of the tubule opening so effective control is a key factor in patient education – aim for gentle and effective. A soft toothbrush and/or the non-dominant hand can help to reduce the pressure on exposed dentine surfaces. Consider a power toothbrush, as these typically exert less pressure than a manual brush. Management Dental professionals must be knowledgeable about the wide range of desensitising agents available for home and surgery use. Home care products generally take two to four weeks to reduce DHS. These can be applied via toothbrushing, rinsing or burnishing directly onto affected surfaces. The most common agents include potassium salts, fluorides, oxalates, amorphous calcium phosphate (ACP), calcium sodium phosphosilicate (CSP – Novamin), casein phosphopeptide- amorphous calcium phosphate (Recaldent) and arginine and calcium carbonate. Professional measures include tray delivered fluoride agents, fluoride varnishes, oxalates, resins, hydroxyapatite agents, dentine bonding agents, bioglass particles, arginine and calcium carbonate paste, glass ionomers and soft tissue grafts. There are many causes and treatments for DHS. For every 20 patients, between two and seven will suffer from DHS. It is incumbent on dental professionals to investigate and offer effective and timely solutions for this ever-growing condition. Leigh H Hunter MSc, PGCFHE, Dip DT, Dip DH, Dip DHE (RSH), Cert HEd has more than 30 years’ experience in the UK and abroad, and has extensive experience in teaching hospital and community dentistry. She presently splits her time between general practice, education and training. Leigh lectures widely throughout the UK and Ireland to all dental team members. She is an active member of a number of professional organisations including the British Society of Periodontology and the British Society of Paediatric Dentistry.
  • 76. Keyclinical protocols 83 ReferralsDental Protection with the nuts and bolts of what to include in a referral letter form via their website. This can be completed by you and emailed back to the referral practice so that an appointment can be sent to your patient. Don’t forget to keep a note of the referral in the patient’s record. It is a good idea to follow up with the patient to see that they have attended the referral appointment. If they decline to attend, you should remind them of the outstanding treatment and warn them of the consequences. A note of the conversation should also be included in the patient’s record. Don’t forget to include: 1. The name, address and contact details of the patient, (phone, fax, email) 2. The correct date 3. The request for treatment, advice or information, including a working diagnosis if you have made one. 4. The background to the referral, including 5. The patient history, summarised from the records 6. The findings of your own examination 7. The summarised results of any tests (eg, periodontal charting or plaque scores) 8. Relevant medical history, including current medication and any known allergies 9. The level of urgency 10. The availability of the patient 11. Any relevant radiographs, in order to avoid taking duplicates 12. Proposal for future participation in the patient’s ongoing care. he referral letter to a colleague should be legible, on headed paper, with a clearly identified writer and contact details showing any non-working days in case the dentist being referred to needs to contact you. Some practices offer a downloadable referral www.dentistry.co.uk T
  • 77. 84 Generalpractice The caries risk of sport supplements The BADT says the dental team needs to identify those patients at an increased risk of developing dental caries and provide tailored advice on how to better manage the risk the numbers of people spending their hard-earned cash on related products such as gym wear and bodybuilding supplements that are increasingly becoming popular among gym goers. To get ‘ripped’ and build lean muscles, many body builders opt for supplements that can improve their physique and enhance their muscle growth. Not surprising then that, according to market analyst firm Euromonitor, the retail value of sales of sports nutrition products grew by 14% in 2010 to reach £200 million in the UK. Health food shops and pharmacies are the most popular sales outlets, but 6% of sales are now made via the internet. However, f obesity is now a national epidemic, with figures ballooning to the current figure of one in four UK adults being obese, then it is somewhat of an anomaly that, along that same timeline, we have become a nation of body image obsessives. The ‘fat shaming’ of celebrities, social media and the ubiquitous ’selfie’ all demonstrate a population fascinated by the ‘body beautiful’, and fuels the desire for the idealised perfect muscle-toned torso to which we are all we meant to strive. Bodybuilding For some, bodybuilding is a lifestyle trend, making a huge dent in their wallets as the industry spend has grown to match. Research conducted in the summer (on behalf of Alpha Man magazine) found that 82% of more than 1,200 men polled ‘feel more stressed about not having an impressive physique than they did five years ago’. Figures published by market researcher Mintel in September showed that the consumer spend on gyms had increased too, driven primarily by the trend for budget gyms that carry no contract fees. Additionally, with the growth of wearable tech, it suggested that almost four-fifths of UK adults now set themselves at least one health or fitness goal. This inevitably has a knock-on effect with The British Association of Dental Therapists (BADT) promotes the advancement of dental therapy within the dental profession. Membership is available to: • All qualified dental therapists (newly qualified therapists receive a 50% discount for their first year of membership) • Dental therapy students (student membership is free) • Associate membership for all members of the dental team • Overseas members welcome. Payment is available online, taken securely via Worldpay. I
  • 78. 85 Generalpractice www.dentistry.co.uk For more information about the BADT, visit badt.org.uk. what is now beginning to filter through is that these supplements often have a high sugar content and hygienists and therapists need to be aware – and make patients aware – of the drawbacks. Dental caries The dental team will need to identify those patients who are at an increased risk of developing dental caries and provide tailored advice on how to better manage the risk. In a study published online in July 2015 the BDJ entitled, Bodybuilding supplementation and tooth decay (www.nature.com, 2015), the authors suggested there is a very real need to raise awareness of the increasing consumption of bodybuilding supplements amongst fitness enthusiasts and amateur competitors. Acknowledging that supplementation is a ‘key component in bodybuilding and is increasingly being used by amateur weight lifters and enthusiasts to build their ideal bodies’, they said that ‘bodybuilding supplements are advertised to provide nutrients needed to help optimise muscle building but they can contain high amounts of sugar. Supplement users are consuming these products, while not being aware of their high sugar content, putting them at a higher risk of developing dental caries.’ The researchers based their comments on the discovery that 76% had gum disease while 55% had evidence of cavities, with 45% of the study participants having tooth erosion. Increased risk As frontline clinicians, it is important that hygienists and therapists recognise the increased risk for supplement users and raise awareness, providing appropriate preventative advice. The authors also suggest that dental professionals need to be knowledgeable of alternative products to help bodybuilders reach their goals, without increasing the risk of dental caries. Dental therapist and BADT chair, Debbie McGovern, says: ‘In all this, the patient’s history is a fundamental part of the investigative phase of dental care. The social history should include details of interests, hobbies, sports etc, as well as the other social and family-related information. By taking a detailed patient history – that includes pastimes and health habits – as dental therapists, we can tailor our advice and offer a more holistic approach to care.’ Tops tips for patients • Enlighten them. Evidence suggests that for most athletes and individuals engaged in physical activity, the use of sports drinks does not provide a benefit over water • Therefore, suggest water as a healthier drink to quench thirst • Tell them to avoid brushing immediately after drinking acidic drinks to avoid tooth erosion • Suggest they drink with a straw or in one sitting • Advise they chew sugar-free gum or rinse the mouth with water following consumption of sports drinks. Reference www.nature.com/bdj/journal/v219/n1/full/ sj.bdj.2015.521.html retrieved 13/10/15
  • 79. Keyclinical protocols 86 POMs – the right direction A look at the use of prescriptions by DHTs direction applies • The clinical conditions covered by the direction • A description of those patients excluded from treatment under the direction • A description of the circumstances under which further advice should be sought from a doctor (or dentist, as appropriate) and arrangements for referral made • Appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period over which the medicine should be administered • Relevant warnings and potential adverse reactions • Details of follow-up action and the circumstances • A statement of the records to be kept for audits. The Human Medicines Regulations 2012 allow independent hospitals, clinics and medical agencies to authorise their own PGDs. The regulations also allow dental practices and clinics registered with the CQC (or the HIW in Wales or the RQIA NI equivalent) for the treatment of disease, disorder or injury and/or diagnostic and screening procedures to authorise PGDs. This applies to both private and NHS treatments. Preparing a PGD Patient group directions are specific to individually named DHTs working in a particular practice. Consequently, it will be necessary to generate a new document every time a new DHT comes to work in that practice. This has implications for new staff members as well as locum and agency staff who will be providing treatment under an NHS contract. An injection of local anaesthetic or the provision of high-concentration fluoride products are procedures that are controlled by the Medicines Act 1968 (as amended by the Human Regulations 2012) because they involve the use of prescription-only medicines (POMs). This means they can only be prescribed by a qualified prescriber. The GDC has no influence over this legislation. Traditionally, this prescriber would be a doctor or a dentist. Legislation was introduced throughout the UK in 2000 that allows certain other healthcare professionals to administer POMs in specific circumstances. A POM may then be administered by dental hygeinist and therapists (DHTs) in one of two ways: 1. An approved prescriber may provide a documented, patient-specific direction that allows the healthcare professional to administer a POM to a specific patient 2. Patient Group Directions (PGD) This is a legal framework that allows a listed group of healthcare professionals to administer named medicines to a group of patients (that fulfils certain predefined criteria), without the need for a written patient-specific prescription or instruction from the approved prescriber. The guidance states that PGDs must legally include the following information: • The name of the body to which the direction applies • The date the direction comes into force and expires • A description of the medicine(s) to which the
  • 80. Keyclinical protocols 87 Hygiene for ortho patientsRobiha Nazir explains the importance of a strict oral health regime for orthodontic patients individuals • For Invisalign patients, the same regime as above is shown in detail with some being able to use floss and/or floss picks • Patients with an Incognito/lingual brace may find this appliance harder to keep clean. For those that have the P&G Oral-B electric toothbrush, the interspace brush head can be used for cleaning between and around brackets. Best results Patients enjoy the cleanliness of their mouth, from removal of plaque and calculus in hard to reach areas as well as the benefits of stain removal. The dentist and I work closely at these appointments to ensure that we get best access to teeth by removing the wires before a hygiene appointment. Every patient has different needs; motivating them to obtain the best oral health with a good oral health regime is a major part of my job satisfaction. rthodontic patients are usually the ones who will benefit from regular hygiene appointments the most. These patients have more accumulation of debris around brackets and are more prone to gingivitis, halitosis and tooth pathology. With orthodontic work it is in their best interest to see a hygienist every three months to help maintain optimal oral health. Patients who are embarking on any orthodontic treatment should have a hygiene session prior to an appliance being fitted. During this appointment the hygienist is able to go through an appropriate regime suited to the individual and advise the best interval period between future appointments. Regimental An oral health regime for a fitted orthodontic appliance is where my patients have shown great orthodontic care. The regime is to be carried out after meals and in the evenings. We go through the following implements to ensure optimal results: • The use of interdental aids for interdental cleaning, as well as cleaning between the wire and brackets before the use of a toothbrush • One can use an alcohol-free fluoride mouthwash alongside the use of an electric or manual toothbrush with care. Disclosing tablets can also use a helpful visual aid for younger O Your patients’ armamentarium: • Interdental brushes • Superfloss • Rubber stemmed brushes • An Airfloss or a Waterpik • Floss/floss picks for Invisalign patients • P&G Oral-B electric toothbrush for Incognito patients Robiha Nazir qualified from Newcastle University in 2004. She has a particular interest in dealing with nervous patients. www.dentistry.co.uk
  • 81. 88 Generalpractice How sharp are you?Dental Protection asks, are you up to date with the ‘safe sharps’ regulations? Dental Protection, the international leader in dental risk management, suggests all teams should frequently revisit regulations and check that their practice safety procedures are up to date, meet the necessary requirements and, just as importantly, are adhered to by the whole dental team. Following the introduction of The Health & Safety (Sharps Instruments in Healthcare) Regulations 2013, all healthcare facilities must ensure that they: • Implement safe procedures for using and disposing of sharp medical instruments and contaminated waste • Eliminate the unnecessary use of sharps by rimary dental care is – on the whole – delivered by relatively small teams, working closely together. It is this close involvement of practice principals in the day-to-day delivery of dental healthcare that often serves to ensure that employee safety, in matters of infection control and decontamination, is placed high on the agenda. However, with an increasing number of practices based across several sites, sometimes it can be difficult for employers and practice owners to ensure risks are being managed consistently. Equally, as a dental hygienist or therapist, you may work in several practices so it is important you are up to scratch on all practice policies. P
  • 82. 89 Generalpractice www.dentistry.co.uk implementing changes in practice and through providing medical devices incorporating safety- engineered protection mechanisms • Provide sharps disposal equipment as close as possible to the assessed areas where sharps are being used or found • Ban the practice of recapping • Use personal protective equipment • Train their practice staff on the correct use of sharps devices and the disposal of sharps waste • Familiarise themselves with the post-exposure protocols for each practice in which you work. Minimising the risk of accidental injury In terms of monitoring compliance and enforcing this legislation and others, such as the HTM 01-05 (infection control) guidelines from the Dental Protection offers risk management education tools for members across a multitude of platforms, including online, in publications, workshops and seminars and events. For more information, visit dentalprotection.org. Points to remember • Employers must be able to show they have taken steps to ensure all team members have been trained in the management of sharps. This involves the provision of information (especially when introducing new team members), training in safe practice when using sharps, the responsibility of employees to make employers aware when a sharps injury has occurred, and the procedures to be followed when an inoculation injury has occurred. Every such occurrence should be investigated proportionately to the severity of the incident and associated risk to the person concerned, and any relevant learning opportunities should be acted upon • Prevent the re-capping (re-sheathing) of needles. This involves the manual replacing of the protective sheath over the tip and shaft of a needle after use, and is a technique well known to have been associated with needlestick injuries in the past. It has particular relevance for dentistry, because of the level of exposure, ie, the number of occasions each day when hypodermic needles are used. Many systems are available whereby this risk can be reduced or eliminated, even when re-sheathing is considered necessary or desirable • Ensure the provision and prominent labelling of suitable secure containers in close proximity to the point of use. This is designed for the safe disposal and storage of sharps • Do not presume, or accept without question, the level of knowledge of a new team member • Ensure thorough induction training is carried out by an experienced and knowledgeable staff member, along with an assessment of the level of knowledge of the incoming person and also their practical ability to manage sharps safely and effectively • Keep a record of any training, and the subsequent appraisal of a new team member’s ability • Be aware of the risks when any third party is present in clinical/treatment area, such as parents and others accompanying patients • Assess the risks when using sharps away from the normal workplace for any reason eg, domiciliary visits. Department of Health, safe and effective sharps management remains an important feature of every dental practice inspection regime. The Regulations describe a ‘safer sharp’ as one that ‘is designed and constructed to incorporate a feature or mechanism which prevents or minimises the risk of accidental injury from cutting or pricking the skin’. This places an onus on employers – and those involved in the supplies procurement process – to demonstrate they have given thought to these options.
  • 83. Keyclinical protocols 90 The daily grind What to do if your patients show signs of bruxism any of the mouth guard systems on the market through your regular dental dealer to protect patients against night time teeth grinding by cushioning the patient’s teeth and keeping them apart, with the least material possible, in the most natural position. By preventing the upper and lower jaw from touching, a dental guard will help prevent damage to teeth, prevent noise associated with grinding, and associated symptoms like jaw pain, headaches and sleepless nights. eeth grinding affects more than 10% of the population, so it’s likely you will meet patients complaining of unexplained jaw pain and worn tooth enamel without most of them even realising that they are grinding their teeth. If the patient has any of the following symptoms: severe headaches, jaw pain, toothache, tooth wear (usually in the form of flattening and breakage and in some cases injury to the jaw), and indentations on their tongue, it is likely they have bruxism, putting their jaw under extreme pressure. Chill out One of the most common causes for teeth grinding is stress, so find out if the patient has undergone a particularly stressful event or is about to go through something they consider stressful, then you are more likely to get to the root of the problem. Even if a patient feels like they are getting a good handle on their stress, their subconscious may still incite their jaw to clench. Relaxing the jaw throughout the day and make facial relaxation a habit should be advised. Get the patient to set their watch or phone to beep every hour to check their facial tension and practice loosening the jaw. Nocturnal habit The onset of teeth grinding and clenching can happen at anytime but night time grinders have biting force six times greater than during the daytime, meaning that they can cause more damage throughout the night without being aware of it. Recommend a dental guard for night time. Try www.dentistry.co.uk T Symptoms: • Severe headaches • Toothache • Tooth wear • Indentations in the tongue
  • 84. 91 Generalpractice Recall intervals between routine dental examinations Recall guidelines that should be should be interpreted with individual patient needs For adults, the interval should be between three and 24 months. The guidelines also recommend • During a check up, the dental team should ensure that comprehensive histories are taken, examinations are conducted and preventive advice is given. This will allow the team and the patient to discuss, where appropriate: – The effects of oral hygiene, diet, fluoride use, tobacco and alcohol on oral health – The risk factors that may influence the patient’s oral health and their implications for deciding the appropriate recall interval – The outcome of previous care episodes and the suitability of previously recommended intervals – The patient’s ability or desire to visit the dentist at the recommended interval – The financial costs to the patient of having the check up and any subsequent treatments. • The interval before the next check up should be chosen, either at the end of a check up or on completion of specific treatment • The clincian should discuss the recommended recall interval with the patient and record this in the patient’s records, along withthe patient’s agreement or disagreement. uidelines that set out recommendations for dentists and the public on the recall interval between dental check ups* were published by the National Institute for Health and Care Excellence (NICE) and the National Collaborating Centre for Acute Care several years ago. They are still current. Tailored The guidelines state that the recommended interval between dental check ups should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease. The guideline recommends that for under-18s the interval between check-ups should be between three and 12 months. www.dentistry.co.uk *At the time of going to press, outcomes from the NHS contract pilot practices suggest a different approach to dental ‘check ups’ with different care pathways emerging as the best practice when meeting the different levels of oral health need of patients. G
  • 85. 92 Generalpractice The role of quality assurance in dental radiation protection Graham Hart provides a comprehensive guide to radiation protection quality assurance is carried out when the equipment is installed, but will need to be repeated in the event of any relocation of the equipment, or following a major maintenance procedure that might affect the performance of the X-ray set. The critical examination is designed to ensure that equipment is electrically, mechanically and radiologically safe to use on patients, and that the environment in which the equipment is going to be used will keep radiation doses to staff and visitors ‘ALARP’ (as low as reasonably practicable). The critical examination is aptly named, since its importance cannot be underestimated. The Othea database of radiation incidents notes two separate occasions where intraoral dental X-ray equipment was not subject to a thorough pre-use test and where faults in the equipment gave rise to unintended radiation exposure (www.othea.net, 2012; www.othea.net, undated). An incident in 2012 was caused by a dentist who removed a wall- mounted X-ray unit himself to allow the surgery to be re-decorated but trapped a wire when he re-attached the X-ray set, causing it to expose continuously as soon as mains power was supplied to the set. here are many facets to dental radiation protection, but quality assurance (QA) plays a key role in avoiding unnecessary patient and staff radiation exposure, the key element in complying with the Ionising Radiation (Medical Exposure) Regulations (IRMER) (UK Government, 2000) and IRR99 – the Ionising Radiations Regulations 1999 (UK Government, 1999). There are four parts to the overall QA process: • X-ray equipment • Image formation system • Clinical image quality • Procedural audit. X-ray equipment All dental X-ray equipment needs to be subject to two kinds of performance test – the so-called ‘critical examination’ and routine testing. Both are requirements of IRR99. The critical examination T
  • 86. 93 Generalpractice www.dentistry.co.uk Thankfully, this incident did not give rise to significant radiation doses to anyone. This was unfortunately not the case in the other incident, where a mis-wired and hence continuously- operating set gave the right shoulder of the dentist concerned an estimated dose of 20 Sv – more than enough to cause major tissue damage. The second type of test is the routine QA test, and the UK’s Dental Guidance Notes to IRR99 and IRMER (Department of Health, 2001) recommends that this be done at least every three years on intraoral and panoramic sets, and more frequently if image quality deteriorates. Guidance published by what is now Public Health England (PHE) for the use of cone beam computed tomography (CBCT) equipment recommends that CBCT equipment be subject to annual routine QA testing (Health Protection Agency, 2010). Both the critical examination and the routine tests should include as a minimum: • kV accuracy, which should be within 10% of the set values • Beam filtration. This should be a minimum of 1.5mmAl for sets operating up to 70kV, and greater than 2.5mmAl for sets operating above 70kV • Beam size. Intraoral sets using circular collimators should have a beam diameter at the patient of no greater than 60mm. Nevertheless, rectangular collimators have been strongly recommended for more than 15 years. This is simply because they will save more than 40% of patient (and hence staff) radiation dose on geometric grounds alone, since film or digital image receptors are rectangular in shape. OPTs should have a beam size less than 5mm x 150mm • Patient radiation dose. For intraoral sets, this is usually measured as the ‘patient entrance dose’. The national reference dose for mandibular molar exposures are currently set at 1.7mGy for adults and 0.7mGy for a child exposure. Practices should aim to be well within this value. As an example, a modern digital set operating at 70kV can produce acceptable image quality for an adult mandibular molar exposure at a third of the national reference dose. Patient exposures from panoramic equipment are usually measured as the ‘dose area product’, and the national reference doses for a ‘standard jaw’ are currently set at 93mGy.cm2 for an adult and 67mGy.cm2 for a child. Again, practices should aim to be well within these figures. For CBCT sets, tests of kV accuracy and beam filtration are the same. Although there is no national reference dose for CBCT as yet, current guidance recommends that patient radiation dose normalised to an imaged volume of 4cm x 4cm should be within the PHE’s ‘achievable dose’ of 250mGy.cm2 (Health Protection Agency, 2010). Other tests of image quality and consistency are needed but are beyond the scope of this article, and should be discussed with the practice’s medical physics expert. Image formation system The image formation system may either use film or a digital imaging system. If digital imaging is being used then the image system will either be a phosphor plate put into a reader or a sensor plate where the image is transferred directly to a PC or laptop, usually through a connecting wire. For practices still using film-based imaging systems, there are two different ways of testing the imaging system. One method tests the film processor by developing pre-exposed strips in the processor to see whether each of the individual
  • 87. 94 Generalpractice segments can clearly be delineated. The other way is to use a step wedge to expose the film on a standard setting and then develop the film, looking to see that all the steps are clearly visible. Step wedges have traditionally been made of aluminium, but a simple step wedge can be made by overlapping pieces of the lead foil found behind dental film to achieve a perfectly usable QA test object (Martin, 2007). For practices using digital imaging systems, there are two aspects to the QA procedure. The first is that the imaging system itself is behaving consistently, and this can be adequately tested using either of the same step wedge systems just described. The second aspect is the image display system. In order to maintain the quality of images displayed on monitors or screens used for interpreting and reviewing, weekly QA should be undertaken to ensure that the monitor can adequately resolve the image contrast. This can be achieved using a test pattern such that produced by American Association of Physicists in Medicine (AAPM) – the ‘TG-18C’ pattern, or the one produced by the Society of Motion Picture & Television Engineers (SMPTE) for medical image screens – the ‘SMPTE-RP133’ pattern. They both follow essentially the same concept and both can be downloaded from the internet. Clinical image quality The quality of the clinical image is not only the endpoint of the imaging process, but is often the first point where problems with other aspects of the imaging system come to light. Therefore, a regular audit programme of clinical image quality is vitally important to ensure ongoing high quality imaging. The Dental Guidance Notes to IRR99 and IRMER (Department of Health, 2001) recommend a simple three-point rating system, with intraoral and panoramic imaging having a target of not less than 70% of images having ‘excellent’ quality; not more than 20% being only ‘diagnostically acceptable’; and not more than 10% being ‘unacceptable’. The criteria are based on whether the image has no errors of patient preparation, exposure, positioning, processing or film handling; some errors but still allowing the image to be clinically usable; or sufficient errors to render the radiograph diagnostically unacceptable. The image quality rating system for dental CBCT imaging recommended in the Health Protection Agency/PHE guidance document (Health Protection Agency, 2010) is simpler still, with a target of not less than 95% of images being ‘diagnostically acceptable’; and less than 5% of images being ‘diagnostically unacceptable’. Here again the criteria relate to whether the image has no errors or minimal errors in patient preparation, exposure, positioning, or image reconstruction and is of sufficient image quality to answer the clinical question; or whether the image is diagnostically unacceptable. Whether for intraoral, panoramic or CBCT imaging, the audits of patient image quality can either be carried out prospectively or retrospectively. Regardless of the dental imaging modality, guidance documents recommend that these audits should be carried out at intervals of not greater than six months (Department of Health, 2001; Health Protection Agency, 2010). Prospective audits are usually simpler to arrange, rating the quality of the next 100 intraoral exposures, or perhaps the next 50 exposures for less frequent examinations such as panoramic or CBCT radiographs, to make the calculation of percentages easier. If an audit reveals a higher percentage of diagnostically unacceptable images than the guidance suggests, the reasons need to be investigated. The practice’s medical physics expert is likely to be able to provide useful advice at this point. Procedural audit IRMER also includes a requirement for the regular audit of the various policies, procedures and protocols that govern the way the practice makes X-ray exposures and which will reside in the practice’s radiation protection file. A review of these documents should be triggered whenever there are changes to staff, equipment, techniques or working practices, but a simple
  • 88. 95 Generalpractice documented review should occur at least on an annual basis to ensure that they remain relevant to the dental practice. One example of a procedure that is likely to need regular review is the one identifying the individuals entitled to act as referrer, IRMER practitioner and operator. The list of those individuals will clearly change as members of staff are employed, or cease employment, at the practice. One of the practice’s dental nurses may also achieve the Certificate in Dental Radiography and thus be allowed to take radiographic exposures unsupervised, and their status would also need to be updated accordingly. Other examples of procedures likely to need regular review are those surrounding the criteria for the selection and justification of patient for radiography. Although both UK and European guidance (Department of Health, 2001; European Commission, 2004) make it clear that only those radiographs that are strictly clinically necessary to change patient management should be made. Practices may experience pressure to X-ray all new patients and/or all patients at regular intervals, perhaps to avoid the threat of medico- legal issues arising from undiagnosed conditions. The procedures in the practice’s radiation protection file need to accurately reflect what happens in the practice, and not just be a form of standardised wording. Conclusion Following the above elements of QA will ensure that dental radiography will be ‘optimised’ – producing a diagnostically useful image at the lowest achievable radiation dose – and this is a cornerstone of IRMER. Of course, using the lowest dose necessary to produce quality clinical images will also help to keep staff radiation doses ‘ALARP’ – one of the cornerstones of IRR99. For references contact Julian@dentistry.co.uk. Graham Hart worked as a medical physicist within the NHS at Bradford Royal Infirmary for 30 years, initially in ultrasound and nuclear medicine and latterly in radiological physics and radiation, laser and non-ionising radiation protection. Over 10 years ago, Graham left to set up YourRPA, acting as an independent radiation and laser protection adviser in the dental, medical, veterinary and academic sectors, and where appropriate as a medical physics expert in diagnostic radiology. During his career, Graham has been (at various times) a member of the Council of the British Nuclear Medicine Society, Chair of the Institute of Physics & Engineering in Medicine’s Radiation Protection Special Interest Group, Chair of the Society for Radiological Protection’s Non-Ionising Radiation Topic Group and member of their Medical Sectorial Committee. Graham has written almost 50 published scientific papers and book chapters, and given over 40 oral presentations at scientific meetings. For more information, visit www. dentalrpa.co.uk or email Graham at yourrpa@yahoo.co.uk. www.dentistry.co.uk
  • 89. Keyclinical protocols 96 Resuscitation protocolsMedical emergencies are rare in a dental surgery, but you should still be familiar with the necessary procedures • There is a public expectation that dental practitioners and dental care professionals (DCPs) should be competent in managing common medical emergencies • All dental practices should have a process for medical risk assessment of their patients
  • 90. Keyclinical protocols 97 www.dentistry.co.uk • All dental practitioners and DCPs should adopt the ‘ABCDE’ approach to assessing the acutely sick patient • Specific emergency drugs and items of emergency medical equipment should be immediately available in all dental surgery premises. These should be standardised throughout the UK • All clinical areas should have immediate access to an automated external defibrillator (AED) • Dental practitioners and DCPs should all undergo training in cardiopulmonary resuscitation (CPR), basic airway management and the use of an AED • There should be regular practice- and scenario- based exercises using simulated emergencies • Dental practices should have a plan in place for summoning medical assistance in an emergency. For most practices this will mean calling 999 • Staff should be updated annually • Audit of all medical emergencies should take place. Emergency drugs in general dental practice Specific emergency drugs should be immediately available in all dental surgery premises. These should be standardised throughout the UK. 1. To manage the more common medical emergencies encountered in general dental practice the following drugs are recommended: • Glyceryl trinitrate (GTN) spray (400mcg/dose) • Salbutamol aerosol inhaler (100mcg/actuation) • Adrenaline injection (1:1000, 1mg/ml) • Aspirin dispersable (300mg) • Glucagon injection 1mg • Oral glucose solution/tablets/gel/powder • Midazolam 10mg/ml (buccal or intranasal) • Oxygen. 2. Where possible, drugs in solution should be in a prefilled syringe 3. The use of intravenous drugs for medical emergencies in general dental practice is to be discouraged. Intramuscular, inhalational, sublingual, buccal and intranasal routes are all much quicker to administer drugs in an emergency 4. All drugs should be stored together in a purposely-designed ‘emergency drug’ storage container 5. Oxygen cylinders should be of sufficient size to be easily portable but also allow for adequate flow rates – eg, 10-15 litres per minute – until the arrival of an ambulance or the patient fully recovers. A full D size cylinder contains 340 litres of oxygen and should allow a flow rate of 10-15 litres per minute for between 20 and 30 minutes. Two such cylinders may be necessary
  • 91. Keyclinical protocols 98 to ensure the supply of oxygen does not fail when it is used in a medical emergency. Medical emergency and resuscitation equipment The equipment used for any medical emergency or cardiopulmonary arrest should be standardised throughout general dental practices in the UK. All clinical areas should have immediate access to resuscitation drugs, equipment for airway management and an AED. Staff must be familiar with the location of all resuscitation equipment within their working area. The following is the minimum equipment recommended: • Portable oxygen cylinder (D size) with pressure reduction valve and flowmeter • Oxygen face mask with tubing • Basic set of oropharyngeal airways (sizes 1, 2, 3 and 4) • Pocket mask with oxygen port • Self-inflating bag and mask apparatus with oxygen reservoir and tubing • (1 litre size bag) where staff have been appropriately trained • Variety of well-fitting adult and child face masks for attaching to self-inflating bag • Portable suction with appropriate suction catheters and tubing eg, the Yankauer sucker • Single use sterile syringes and needles • ‘Spacer’ device for inhaled bronchodilators • Automated blood glucose measurement device • AED. The ‘ABCDE’ approach to the sick patient Dental practitioners, DCPs and their staff should be familiar with standard resuscitation procedures as recommended by the Resuscitation Council (UK). In all circumstances it is advisable to call for medical assistance as soon as possible by dialing 999. A systematic approach to recognising the acutely ill patient based on the ‘ABCDE’ principles is recommended. Accurate documentation of the patient’s medical history should further allow those ‘at risk’ of certain medical emergencies to be identified in advance Anaphylaxis treatment The UK incidence of anaphylactic reactions is increasing. Patients who have an anaphylactic reaction have life-threatening airway and/ or breathing and/or circulation problems usually associated with skin and mucosal changes. Patients having an anaphylactic reaction should be recognised and treated using the airway, breathing, circulation, disability, exposure (ABCDE) approach. of any proposed treatment. The elective nature of most dental practice allows time for discussion of medical problems with the patient’s general medical practitioner where necessary. In certain circumstances this may lead to a postponement of the treatment indicated or a recommendation that such treatment be undertaken in hospital. General principles 1. Follow the airway, breathing, circulation, disability, and exposure approach (ABCDE) to assess and treat the patient 2. Treat life-threatening problems as they are identified before moving to the next part of the assessment 3. Continually re-assess starting with airway if there is further deterioration 4. Assess the effects of any treatment given 5. Recognise when you need extra help and call for it early. This may mean dialling 999 for an ambulance 6. Use all members of your dental team. This will allow you to do several things at once, eg, collect emergency drugs and equipment, dial 999 7. Organise your team and communicate effectively 8. The aims of initial treatment are to keep the patient alive, achieve some clinical improvement and buy time for further treatment while waiting for help 9. Remember – it can take a few minutes for treatment to work 10. The ABCDE approach can be used
  • 92. Keyclinical protocols 99 www.dentistry.co.uk • Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines • The exact treatment will depend on the patient’s location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction • Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction • Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline • Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use • All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy • Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions. This guideline replaces the previous guideline from the Resuscitation Council (UK): The emergency medical treatment of anaphylactic reactions for first medical responders and for community nurses (originally published July 1999, revised January 2002, May 2005) • The recognition and treatment of an anaphylactic reaction has been simplified • The use of an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to recognise and treat an anaphylactic reaction has been introduced • The early use of intramuscular adrenaline by most rescuers to treat an anaphylactic reaction is emphasised • The use of intravenous adrenaline to treat an anaphylactic reaction is clarified. It must only be used by those skilled and experienced in its use in certain specialist settings • The age ranges and doses for adrenaline, hydrocortisone and chlorphenamine have been simplified. irrespective of your training and experience in clinical assessment or treatment. Individual experience and measures such as laying the patient down or giving oxygen are needed. First steps • In an emergency, stay calm. Ensure that you and your staff are safe • Look at the patient generally to see if they look unwell • In an awake patient ask, ‘How are you?’ If the patient is unresponsive, shake him and ask, ‘Are you all right?’ If they respond normally, they have a clear airway, are breathing and have brain perfusion. If they speak only in short sentences, they may have breathing problems. Failure of the patient to respond suggests that they are unwell. If they are not breathing and have no pulse or signs of life, start CPR according to current resuscitation guidelines. The latest guidance about required training for the dental team is available from www.gdc-uk.org. For information about courses and educational resources, visit www.resus.org.uk. Material by kind permission from the Resuscitation Council (UK) and correct at the time of writing.
  • 93. 100 Generalpractice One minute can save a lifeScott Froum discusses the importance of early detection of oral cancer deaths per year. Studies show that successful treatment of oral cancer is highly dependent upon diagnosing and treating this disease in its early stages. Although there have been advances quamos cell carcinoma (similar to skin cancer) of the oral cavity and throat accounts for around 45,000 cases each year in the United States, resulting in around 8,000 S
  • 94. 101 Generalpractice www.dentistry.co.uk Dr Scott H Froum is a board-certified periodontist who received his BA from Amherst College in Amherst, Massachussetts, with a major in biology. He received his DDS from the State University of New York Stony Brook School of Dental Medicine where he graduated with honours. He continued his dental training in the postgraduate periodontal department at the State University of New York Stony Brook School of Dental Medicine and received his periodontal certificate. He currently is a clinical associate professor at New York University in the Department of Periodontology and Implantology. He is also a clinical associate professor at the SUNY Stony Brook School of Dental Medicine in the Department of Periodontics. He is co-editor of the website The Surgical-Restorative Resource. He has lectured on national and international levels on implant therapy and complications. He has a private practice in New York City, NY. in surgical, chemotherapy and radiotherapy, treatment for oral cancer five-year survival rates of patients with this moderate to advanced disease are less than 60%. In addition, those patients that do survive typically have trouble chewing, speaking, eating and smiling after treatment. It is therefore tremendously important to diagnose oral cancer before it becomes advanced, since treatment for early cancer is not as severe. Statistics Of all head and neck cancers, 75% begin in the mouth. The most common regions of oral cancer involvement are the back of the throat, the sides of the tongue and underneath the tongue. Historically, smoking and alcohol use are highly related to the development of oral cancer and would affect people over the age of 50. Unfortunately because of the increase in the incidence of human papilloma virus (HPV 16-18), head and neck cancers have been increasing in men and women in their 20s and 30s. One very general trend is that tobacco/alcohol lesions tend to favour arising in the anterior tongue and mouth while HPV-positive lesions favour arising in the back of the mouth. Detection The best way to detect oral cancer early is to screen every patient at every dental visit. A clinical and mirror exam is usually all that is needed. Visual identification results can be enhanced by the use of lights. I use a non-invasive blue light fluorescence technology that is not painful and takes one minute perform the examination. The light picks up pre-cancerous, cancerous and HPV lesions that normally could go undetected. One minute can save a patient’s life.
  • 95. 102 Generalpractice Swinging into their 60sMhari Coxon considers whether the UK dental profession is prepared to meet the healthcare needs of our ageing population he population of the UK is ageing. Over the last 25 years, the percentage of the population aged 65 and over increased from 15% in 1983 to 16% in 2008, an increase of 1.5 million people in this age group. Over the same period, the percentage of the population aged 16 and under decreased from 21% to 19%. This trend is projected to continue. The mid-year population estimates from the Office for National Statistics, General Register Office for Scotland and the Northern Ireland Statistics and Research Agency show that by 2033, 23% of the population will be aged 65 and over compared to 18% aged 16 or younger. This ageing population is not exclusive to the UK and most developed countries are facing the same statistics. Living longer Being 60 now is completely different to when our grandparents or even our parents turned 60. We are staying healthier, keeping youthful and, most pertinent to us, keeping our teeth for longer too. Think of Helen Mirren in her bikini at 60 still turning heads. And Harrison Ford is still making women weak at the knees. Sixty is the new 40. And 40? Well, that’s still young. People could be living not only longer, but to a better quality, according to doctors writing in The Lancet medical journal, who say that most T evidence shows the under-85s are tending to remain more capable and mobile than before. They have more chronic illnesses, such as cancers and heart conditions, but people survive them because they are diagnosed earlier and get better treatment. Healthcare is being provided more and more in a non-hospital environment to ease the burden on our overstretched wards. What is healthy? Patients’ perceptions and expectations have changed a lot in attitude to their health, healthcare professionals and their thoughts on ageing. There was a time when it was expected and accepted that you would lose your teeth as you got older. Now that we have a large proportion of the elderly population that are dentate, we need to look at how we care for these patients and the work they have in their mouths. Problems that we see and deal with regularly in an ageing patient group are: • Xerostomia
  • 96. 103 Generalpractice www.dentistry.co.uk • Recession • Acid erosion • Periodontal disease • A rapid change in oral health due to systemic health changes. Mental health issues Alzheimer’s is on the increase and there are around 820,000 people living with dementia in the UK today, a number forecast to rise rapidly as the population ages. One in three over 65s will die with some form of dementia and this will completely change the type of treatment that is appropriate and the care plan in the oral healthcare. Early-onset memory problems can affect a patient’s oral health as they can forget to brush. More advanced problems can lead to longer lapses in personal care, in some instances filled by family members. Again, oral health can deteriorate. More advanced stages of this illness usually lead to institutionalised care with very little personal care given. Carers in these homes are limited in oral healthcare knowledge and sometimes unable to get compliance from patients. Can we meet demand? If we think of the average lifespan of a piece of work, even very good work, being around 20 years then we see that replacement work and maintenance work will reach a high level. This could see demand for dental work increasing dramatically over the next few years. Root canals will need to be redone, fillings replaced and upgraded to crowns, and more implants will be placed as people become less accepting of being edentulous. There is also the previous trend for heavy cosmetic restorations. Although this type of invasive treatment is thankfully almost completely a thing of the past, there are still patients who will need this work maintained and replaced up to three times in their lifetime. Figures based on population censuses show there were more than 11 million people of state pension age and over in the UK in 2005. That will be significantly higher now. Utopian future More people of pensionable age than working age will mean less taxable income for spending on health services and services generally. As we stand now there is no long-term plan in place to deal with the increase of dentate elderly and demand for treatment. The question these facts pose is this: are we looking at a future where it will be impossible to provide adequate service as we will become financially lacking as a nation? The most obvious solution to me is an increase in affordable oral health education and treatment for all. Long term, I believe we need to have more registered professionals delivering low-level preventive care in non-dental environments to cope with the pressure the profession will face and reduce the burden on the dental surgeon. In an ideal world, I would see each care home having a small team of oral health educators, training and mentoring the carers in looking after the mouth. It would become part of the wellness plan in general medical practices. The deterioration that is seen regularly in care homes in dentate patients can be horrific. In fact, oral health educators and hygienists would become attached to many places where there could be a rapid downhill in the dental health of someone, for example, stroke units and cancer units (I know this is already in place in many, but it should be all). In my utopian future, dentists would be supported by teams with the freedom to work in the best interests of the long-term care of their patients. And GP practices would all have an oral health advisor attached to them in the same way as a practice nurse. Mhari Coxon has over 20 years’ experience in dentistry. At present, she works as a senior professional marketing and relations manager for Philips Oral Healthcare UK and Ireland. She was awarded the Outstanding Contribution award in 2015 at the DH&T awards.
  • 97. 104 Generalpractice especially if they have completed a long course of treatment. These images prevent any doubts about improvements that have been achieved. Indemnity providers say that complaints they handle are often due to poor communication. Using photographs and words together for case presentations reduces misunderstandings. Images to take The American and British Academy of Cosmetic Dentistry (AACD and BACD) provide guidelines of images that are taken for accreditation. This is a good place to start when deciding which images are required to complete a comprehensive evaluation or provide effective patient education. • Portrait       • Smile • Right smile     • Left smile • Anterior retracted   • Right lateral retracted • Left lateral retracted  • Anterior close up • Right Anterior close up • Left Anteror close up • Upper occlusal    • Lower occlusal. Give it a go! As dental hygienists and therapists, we are responsible for our patients’ care, even more so for ith the increased availability of digital point-and-press cameras, digital single lens reflex cameras (DSLR) and intra- oral cameras, dental photography can be easily intergrated into patient visits. With good training, any member of the dental team should be able to attain good quality, reproducible images. Reasons for taking photographs Good quality intra and extraoral images complete a comprehensive evaluation. They create a visual baseline prior to treatment. Long, written notes describing the clinical situation of the patient are traditionally used, images can save time and provide a more accurate account of the situation. Presenting patients with photographs of their own mouths during case presentations increases treatment acceptance and is more time efficient as visual explanations have a greater impact than long, detailed verbal descriptions. ‘Before, during and after’ images are extremely useful for tooth whitening, other aesthetic dental procedures and orthodontics. Patients sometimes forget what the situation was at the beginning, W Need for good photographyWith studies showing that 80% of the population learn in a visual capacity, Diane Rochford discusses the need for good photography in practice
  • 98. 105 Generalpractice www.dentistry.co.uk those practising direct access. Implementing the use of photography enhances the level of treatment we provide and patients deserve. Using a new skill requires training, practice and patience, it can also be enjoyable, so why not give it a go! You will need… Camera Cameras are easily accessible, easy to use and affordable. The quality of the image produced can depend on the type of camera used. The table below highlights the differences between DSLR and point-and-press cameras. Single Lens Reflector (SLR) Compact Lenses can be changed Fixed lens Varied zoom capacity Limited zoom Wide angle Wide angle Macro lenses are more efficient for close-up work Image can distort on a ‘macro’ setting Ring flash is less harsh = no shadows Harsh flash = extreme shadows Ring flash provides even illumination of the mouth Inadequate illumination of the mouth Large sensor = high resolution Small sensor = poorer resolution Easily produced consistent results Unable to produce consistent results Retractors There are various types of retractors available. Separate retractors are held by the patient, and available in various sizes. With direction the patient can assist, allowing for a good view of both anterior and posterior teeth. Contrasters Black backgrounds show off teeth well, the patient bites gently on a black paddle, or piece of black paper. These images are effective before and after tooth whitening or other aesthetic procedures. Mirrors Mirrors are used for taking occlusal images, this type of photography requires practice and patience. Mirrors can easily mist during use, air from the 3-in-1 keeps a clear field of vision. Background A white, black, grey or blue background provides a less distracting photograph and better contrast when viewing portrait images. Diane Rochford qualified as a hygienist from Guy’s Hospital in 1996. She joined Dr Linda Greenwall’s team in September 1996 where she assists with teaching on bleaching courses. Diane is also a clinical coach for Jameson Management.
  • 99. 106 Generalpractice Eating less sugar Bal Chana addresses the issue of sugar consumption and provides tips on eating less sugar school children were admitted to hospital due to dental caries, costing the NHS £30 million. Not only does sugar affect oral health, it also has a detrimental effect on general health; in the UK 25% of adults are obese, and high consumption of amie Oliver states: ’Important changes need to be made to address the UK’s deteriorating dental health from sugar consumption’. Dental caries is the main reason young children are admitted to hospital; last year, 26,000 primary J
  • 100. 107 Generalpractice dentalhygienetherapy.co.uk Bal Chana is a DCP inspector with the General Dental Council. She is immediate past president of the BADT. Bal was recipient of The Dental Therapist of the Year award in 2006. sugar can also lead to type II diabetes. In the UK there are currently 3.3 million people living with diabetes; shockingly, 7,000 amputations are carried out a year due to diabetes. Experts are saying that we should have no more than 30g of sugar per day, which is approximately seven teaspoons a day. A can of fizzy drink contains 35g (nine teaspoons) of sugar. Sugar Manifesto Jamie Oliver has launched a new campaign and is lobbying the Government. He is calling for the introduction of a sugary drink duty. Jamie has set out a Sugar Manifesto, which will make a serious difference to the dental health of the nation. The manifesto suggests that a range of measures are needed to tackle the issue. The measures outlined in the Sugar Manifesto are: • A 20pence levy per litre on every soft drink containing added sugar. This would be 7pence per 330ml can • Legislate The Responsibility Deal: The Responsibility Deal exists to improve public health in England • Ban all junk food marketing on TV before 9pm and create more robust digital marketing regulations to protect children on the internet • Make the ‘traffic light’ labelling system mandatory on the front of all food and drink pack packaging • Show sugar content in teaspoons on the front of packaging for all sugary drinks. Tips on eating less sugar Jamie Oliver is not the only person campaigning. Action on Sugar is a group formed by specialists concerned with sugar and its effects on health. Action on Sugar’s nutritionist, Kawther Hashem, provides some tips on eating less sugar: • Remove sugar (white and brown), syrup, honey and molasses from the breakfast table — out of sight, out of mind • Cut back on the amount of sugar added to things you eat or drink regularly like cereal, pancakes, coffee or tea. Try cutting the usual amount of sugar you add by half and wean down from there • Instead of adding sugar to cereal or porridge, add fresh fruit • Instead of having sweetened yoghurt, have plain yoghurt and add fresh or dried fruit • When baking cookies, brownies or cakes, cut the sugar in your recipe by one-third to one-half • Instead of adding sugar in recipes, use extracts such as almond, vanilla, orange or lemon • Enhance foods with spices instead of sugar; try ginger, allspice, cinnamon or nutmeg • Buy sugar-free or low-calorie drinks • Use Foodswitch UK, a free smartphone app, to help you find food and drink products with less sugar. Let’s all join forces and work together to address this issue.
  • 101. 108 Generalpractice The sweetest taboo Melonie Prebble welcomes the global attack on sugar he year of the big sugar debate has undoubtedly been 2015. An ever-increasing number of evidence-based studies is drawing a wide range of scientific conclusions. But there’s little doubt that: • It’s addictive • It’s bad for our health • It’s contributing to both a childhood obesity crisis and a surge in cases of Type II diabetes • Much of the western population needs to curb its intake. Even if we didn’t know the scale of its impact on general health, as dental professionals we do understand what it is doing to our nation’s oral health. In July, the Scientific Advisory Committee on Nutrition advised the Government to halve the recommended intake of free sugars – the effectively nutrient-free refined sugar added to products such as sweetened drinks – to help T Melonie Prebble is an experienced dental hygienist and therapist, having worked in the dental industry for over 20 years. She graduated from The London Hospital in 1995 and has been enhancing her skills and contributing to the industry ever since. Melonie currently offers her services at Abbey Road Dental, in north west London, and the clinic at The Luke Barnett Centre, Watford, Hertfordshire.
  • 102. 109 Generalpractice www.dentistry.co.uk address the growing obesity and diabetes crises and to reduce the risk of tooth decay. In response to this, the British Dental Association called on Government to take heed of this latest expert advice and its petition at change.org (2015) has, so far, been signed by over 2,000 people. Additionally, the British Association of Dental Therapists (BADT) pledged its support for the pressure group, Action on Sugar, which is also working towards reversing the nation’s addiction to the ‘sweet stuff’. The group is made up of across- the-board health experts, united in their concern about sugar and its effects on health. It leads with an unprecedented call to tackle and reverse the obesity and diabetes epidemic. Joined-up approach But BADT president, Fiona Sandom, argues that what’s needed is a joined-up approach by health professionals to successfully tackle dental decay and related health issues caused by a high sugar diet. She says: ‘There is a real appetite for change over the unnecessary and unhealthy amount of sugar in our diets and it is up to all health professionals to ensure we educate our patients of the full health benefits of cutting sugar out of diets. ‘There has been overwhelming scientific evidence that sugary drinks are linked to poor health. More importantly, however, the evidence regarding sugary drinks and their link to tooth decay is universal and this in itself can be a precursor to other serious health issues – and there is much research that shows how periodontal disease and systemic health are closely linked. She believes that dental therapists and dental hygienists are well placed to offer guidance from an oral health perspective and, in doing so, can also help to reverse the alarming obesity and diabetes epidemic. But there appears to be little desire by the food industry to be ‘on side’. To date, out of all the major supermarket chains, only Tesco has committed to reducing sugar (by 5%) across its own-label soft drinks range, despite the fact that Public Health England said other drinks brands should now follow its lead. Sugar Swaps campaign However, despite the criticism of the Government’s lack of action, at the start of this year, its health campaign, Change4life, launched ‘Sugar Swaps’, offering tips to parents so they can substitute high sugar meals with low sugar options – swapping sugary cereal with plain cereal, ice cream with low-fat yoghurt and so on. It’s an excellent resource for the dental team and supports the BADT’s thinking that, only by collaboration with other health professionals, can the tide of sugar addiction be turned. This addiction to sugar is placing a huge burden on the NHS. By taking the time to communicate the health risks to our patients when they are in the dental chair not only demonstrates our responsibility to them, but shows our commitment to the future health of our nation – and the future of healthcare, too. For references contact Julian@dentistry.co.uk. Alarming facts to share with patients 1. Brits eat around 700gm of sugar a week: that’s an average of 140 teaspoons per person 2. Tooth decay is the number one cause of hospital admissions among children. A total of 46,500 young people under 19 were admitted to have teeth removed under general anaesthetic in a single year, with hospitals forced to run extra operations in the evenings and at weekends to deal with demand 3. Across the UK, three in 10 five-year olds have visible signs of decay and by the time they reach 15, this increases to nearly one in two 4. A high-sugar diet can lead to an impairment of early learning for both long- and short-term memory 5. Sugar-sweetened drinks may give rise to nearly two million diabetes cases over 10 years in the US and 80,000 in the UK.
  • 103. 110 Generalpractice Increasing access to dental careCharlotte Wake believes that accessing dental care is a serious issue appointment.’ This shows that accessing NHS dental care is possible but there are numerous reasons, not just access itself, that will stop people making the appointment or proceeding with necessary treatment. The report also tells us that 26% of people had chosen a type of treatment due to cost. 19% of people said they had delayed dental treatment, citing cost as the reason. very 10 years the Adult Dental Health Survey is taken. The first was in 1968 and the most recent was produced in 2009. This contains information about dentate adults, oral hygiene trends and attitudes to oral care. This latest report tells us that ‘58% of adults said that they had tried to make an NHS dental appointment in the previous three years. Of these adults, 92% successfully received and attended an E
  • 104. 111 Generalpractice www.dentistry.co.uk Charlotte Wake qualified as a dental therapist and dental hygienist in 2005 from St. Bart’s and the Royal London. Until recently Charlotte was on the British Association of Dental Therapist’s council, is a regular writer and a public speaker. Charlotte was winner of Dental Therapist of the Year 2011. Charlotte works four days a week in practice. Barriers We know that barriers include the cost of treatment, with another being dental anxiety. The survey explains that ‘12% of adults who had ever been to a dentist had a Modified Dental Anxiety Scale (MDAS) 2 score of 19 or more which suggests extreme dental anxiety.’ This anxiety was associated with the drill and with local anaesthetic injections. The number of adults that had a moderate level of dental anxiety was 36%. Regarding accessing care, the survey states that women are more likely to make the dental appointment and when patients had attended the feedback was generally positive, with 80% having no negative feedback at all about their dental visit. The general concerns when they were given, related to having time to discuss their oral health and worryingly not being involved as much as they would like in dental decisions and treatment. With this in mind, there are already procedures in place to help overcome some of these barriers to help improve access to care. The option of NHS treatment helps reduce costs and there are several types of dental plans available to help spread the cost of treatments within the private sector. The dental profession is aware of dental anxiety and we come into contact with this on a daily basis in varying degrees. Manufacturers make better dental materials than ever before and techniques continue to evolve to help provide a comfortable environment for treatment. Oral hygiene aids The introduction of fluoride toothpastes and the many oral hygiene aids available help people to care for their teeth at home better than ever before. Prevention is always better than cure and educating patients about their role in prevention with good lifestyle, diets and good oral hygiene regime helps prevent the need to have treatment and may indeed improve their systemic well being. The introduction of direct access in May 2013 has enabled more clinical time to be available. I acknowledge there are barriers to using direct access in an NHS environment without a performer number, but within the private sector patients no longer need to see a dentist prior to receiving treatment from a dental therapist or dental hygienist. Challenges the NHS faces In the summer of 2013, NHS England produced a document entitled: ‘Improving Dental Care and Oral Health – A Call to Action’. This, in part, sets out the challenges the NHS faces. It highlights the good progress made regarding accessing dental care in recent years. This says ‘1.4m more people having seen an NHS dentist in a 24-month period since 2010’. It claims the access can be improved and gives the example of extended hours to allow patients to attend after work or at weekends. It suggests that although care to those with special needs is often provided by community dental services, this could potentially change with dental practices seeing a wider range of patients. The report acknowledges routes to urgent care are too ‘variable and obscure’ to patients and advises this should be signposted. The fact that A&E departments continue to deal with dental pain that would be more appropriately treated by urgent dental services is also noted and further understanding of ‘eventual strategic framework’ is advised. Accessing dental care is a serious issue and although improvements have been made, we will see a bigger picture of its success or failure following the next adult dental health survey around 2019. Only then will we know what is left to be achieved.
  • 105. 112 Generalpractice Social and health inequalities BADT president Fiona Sandom considers the social gradient in healthcare decay, the inequality appears to be getting more profound and we won’t be able to treat away the difference’. Another frightening statement that he made was that: ‘Of the 15-year-olds that have caries, those that have free school meals are likely uge social and health inequalities in our society were highlighted by Professor Jimmy Steele in his BDJ/BDA anniversary lecture, who said that: ‘Although there has been a profound reduction in the prevalence of tooth H
  • 106. 113 Generalpractice www.dentistry.co.uk Fiona Sandom qualified as a dental hygienist from Manchester Dental Hospital in 1993 and as a dental therapist in 1999 from Liverpool University Dental Hospital and in 2013 gained her MSc in medical education from Cardiff University. She currently works three days clinically, one day teaching dental nurses for the North Wales Community Dental Service, and one day for Cardiff University as a postgraduate tutor for dental hygienists and dental therapists. She is also a quality assurance inspector for the GDC and an examiner for the RCS Edinburgh and president of the British Association of Dental Therapists. to have twice as much.’ Reducing health inequalities In November 2008, Professor Sir Michael Marmot was asked by the then Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010. Marmot reported that reducing health inequalities is a matter of fairness and social justice. In England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life. There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health. Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health. Actions must be universal Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. This is proportionate universalism. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs. That economic growth is not the most There is a social gradient in health – the lower a person’s social position, the worse his or her health important measure of our country’s success. The fair distribution of health, well being and sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together. Six policy objectives Sir Marmot concluded that reducing health inequalities will require action on six policy objectives: • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill-health prevention. Delivering these policy objectives will require action by central and local Government, the NHS, the public and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies. Effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities.
  • 108. 116 Indemnityand governance Protection through partnership he practice of dentistry is not without risk and there is an expectation upon you to have ‘appropriate arrangements in place for patients to seek compensation if they suffer harm’. The only types of cover recognised by the GDC are: • Dental defence organisation membership • Professional indemnity insurance held by you or your employer • NHS/Crown indemnity. As a dental defence organisation, Dental Protection offers professional protection, provided by world-class dentolegal experts, but this is only part of the story. In addition to defending members at the GDC, Dental Protection works tirelessly to help members create personal development plans and implement remediation where necessary. The team regularly offers the support of local dental advisers (who are also in practice like you) to reinforce the colleague-to- colleague support that members find so invaluable – there are even DCP-specific advisers who understand your role. Condition of registration The rules regarding indemnity have recently changed and dental professionals applying for registration or restoration, and those renewing There are changes afoot to your indemnity requirement and Dental Protection aims to help you with this – and more T their registration each year, will need to tell the GDC that they have access to indemnity – or will have by the time they start practising. So, when you renew your registration through EGDC, you must confirm you have access to indemnity. In order to renew your registration and make the declaration, you will need an EGDC account, so if you don’t already have one, now would be a good time to sign up. You can find instructions on how to do this at www.gdc-uk.org. As a result of changes in September 2015, anyone wishing to join the register for the first time, as well as restoring their name, now needs to declare that they have (or will have) access to indemnity in place during the application process. From the end of January 2016, those who are applying for restoration will be required to provide the GDC with evidence of their indemnity, or proposed indemnity, once they have restored to the register. If you are renewing your registration you should make this declaration during the annual retention fee collection period in summer
  • 109. 117 Indemnityand governance 2016. Dental care professionals will make their first indemnity declaration in July 2016 through the annual renewal process for the 12-month registration period that extends into 2017. Evidence that the GDC will accept include: • Copy of your Dental Protection membership certificate or the equivalent provided by any other arrangement • Copy of a cover letter addressed to you from a recognised dental defence organisation to confirm your application has been approved and you will have access to indemnity following registration with the GDC. Happily, Dental Protection’s promise of ‘more than just defence’ for its members will help meet these new requirements in a very simple and straightforward way in the form of a downloadable certificate of indemnity, which is available online via the member login area at www. dentalprotection.org. Genuine partner Like you, Dental Protection believes prevention is better than cure and is much more than a last line of defence, striving to be a ‘genuine partner’ throughout your career – to be by your side at every step, offering support, advice and world- class defence. As knowledge experts and international leaders in dentolegal advice, it understands the ever- changing world that today’s dental professionals work in. This means the team can adapt its service to your needs, actively protecting and helping you to develop, leaving you free to enjoy your career. www.dentistry.co.uk
  • 110. 118 Indemnityand governance Can you handle it? f a patient makes a complaint, it is usually around the following areas: • Their treatment – or lack of it, depending on the level of patient satisfaction • Adminastrative matters, ie, being kept waiting, treatment fee charges, staff behaviour • A clash of personalities or a breakdown in communication between the patient and dentist – this can sometimes involve the communication skills for tasks involving other member of the team. Whilst patients may not be able to judge ‘good dentistry’, they can certainly assess poor service or rude behaviour. So, here are some things to remember should you be faced with a complaint: It’s not personal There will always be patients who complain, no matter how professional you may be. The reaction to feel hurt and disappointment is inevitable when someone complains to – or about – you, especially early on in your career when it can also knock your confidence. Try to keep things in perspective – the real test of professionalism is how well you handle it. Invite feedback By having a proactive approach to feedback, you limit the potential damage wreaked by a broken relationship. By identifying disgruntled patients early on, you may reduce the risk of the matter developing into a formal complaint. Your interpersonal skills are important – and never more so when a patient rocks the boat with a complaint. Dental Protection offers some top tips I Quick steps to complaint handling Contact the complainant with an immediate acknowledgement, preferably in writing. Make sure it: • Offers an expression of sympathy or an apology • Gives clear explanations, avoids jargon and uses plain English • Suggests a way forward (if that is possible) • Informs the patient that you will provide an outline of option(s) after speaking to all the staff involved • Invites further comment. Provide a full written explanation of the treatment provided and instructions that were given, even if these had been delivered verbally. Good record keeping is always important. Further action could involve a conciliation meeting to which all parties should be invited to attend. Don’t do this over the telephone as the vital element of body language (non-verbal communication) is missing. Remember: • Don’t be afraid to say ‘I am sorry’ • Make eye contact • Don’t interrupt • Avoid statements or antagonistic questions • Ask open questions • Avoid leading questions • Avoid questions that give ‘yes’ ‘no’ answers – it closes things down.
  • 111. 119 Indemnityand governance Prevention is better than cure Prevention is better than cure. It’s well documented that a listening ear, a name remembered and a smile go a long way in retail – and this applies to dentistry, too. ‘Rapid response’ policy Adopt a ‘rapid response’ policy. By dealing with complaints swiftly, you should be able to prevent the complaint escalating from a local level to a higher authority or regulator. Be sure to speak to everyone involved in the matter before providing a definitive response to the patient. The root cause of the complaint What do they really want? It sounds simple enough, but getting to the root cause of the complaint is essential. To pursue a complaint takes both time and effort – but complainants can be surprisingly tenacious, so it is worth finding out what outcome they want. The internet is a ‘go-to’ source of information for many of us. We all go online to hunt for hotels, read reviews and look up facts and figures. As a nation, we are also becoming increasingly savvy about our rights as a consumer thanks to this plethora of information at our fingertips, which can make for an increase in the volume of challenges from patients. We can all learn from our mistakes. Taking time out for reflective learning is important as it offers a professional support mechanism that can develop a career safely and raise critical awareness. Sometimes your worst critic can become your biggest fan. If a complaint is efficiently handled – and amicably resolved – then the patient may well become a positive influence with friends and family. www.dentistry.co.uk Dental Protection offers a wealth of education tools and resources on the topic of complaints handling. Visit www.dentalprotection.org for more information.
  • 112. 122 Indemnityand governance Playing it safe with social media anning practice staff from using social media is not only impossible, but also undesirable. Indeed, the GDC acknowledges that social networking sites can be ‘an effective and entertaining way of communicating’. They can also be used exclusively for professional purposes by providing a platform for clinicians to share their thoughts on best practice, offering product tips and treatment successes. Additionally, patients and the NHS as a whole can benefit from more publicly accessible information and open discussion about public dental health and policy as well as when and how to access services. The dental profession also benefits from data and research shared across the globe. However, social media also brings with it many risks – and, these days, most workplaces will have a social media policy to which staff must adhere. If you practise across a number of workplaces, you need to be aware of the details within each policy. As well as adhering to any internet and social media policy set out by your employer, the main concerns regarding the use of social media by dental professionals are to: With Instagram, Twitter and Facebook an everyday part of life, dental professionals need to be mindful of their behaviour online, says Dental Protection B • Maintain and protect patients’ information by not publishing any information that could identify them on social media without their explicit consent • Maintain appropriate boundaries in the relationships you have with patients. Lost in translation Patient confidentiality will always be key, and you should ensure no patient details are unintentionally released to the public, via a professional or personal account. If this should happen, it will not only damage the reputation of the practice, it could unwittingly undermine your professional integrity, and even attract a complaint. Additionally, anything posted online that may be construed as bullying or harassment of colleagues should be avoided. The fact that you made a comment without malice is no defence – humour and sarcasm can get lost in translation within the virtual world of social media. You should also protect your personal information and it is wise to be well versed in the privacy settings of every social media site you use. However, do be mindful of the fact that this will not always guarantee complete protection
  • 113. 123 Indemnityand governance and it may be prudent to think along the lines of anything you put on the internet as potentially available for anyone to see – and that includes patients as well as employers! Those drunken ‘selfies’ taken in a bar in Spain in the summer may have seemed hilarious to post online at the time but, on reflection, they may be your downfall, perhaps putting paid to any new job opportunities you were hoping to secure. Self-censorship of uploads – whether images or opinions – is therefore essential and so too is the need to request friends to honour this. Remember, the GDC expects you to protect your professional name at all times and this includes online. As it states: ‘As a registrant, you have a responsibility to behave professionally and responsibly both online and offline. Your online image can impact on your professional life and you should not post any information, including photographs and videos, which could bring the profession into disrepute’. Maintaining the boundaries between personal and professional relationships is also important so be wary of accepting ‘friend’ or ‘follow’ requests from current or former patients – if in doubt, leave them out. www.dentistry.co.uk Dental Protection offers a wealth of education tools and resources on the topic of social media. Visit www.dentalprotection.org for more information.
  • 114. 124 Indemnityand governance More than just talking… he relationship with each patient is a very human and humane one that calls for understanding by both parties. At each stage of the professional relationship, the dental hygienist and dental therapist must ensure the patient understands the issues under discussion whether it is about: • Explaining histories • Agreeing treatment • Raising concerns over the outcome • The making of a complaint. Your skills must, therefore, include: • Maintaining control • Promoting the right body language • Listening • Clear articulation of information. Additional skills include: • Ability to generate a referral and to write to a patient • Accurate and complete record keeping. All have a role to play in communication and proper implementation should help control the situation for the benefit of the patient. Non-verbal skills Non-verbal skills relate to the impression given to the patient and include: • A response matched to patient expectations • The physical proximity of the patient and Good communication is an essential part of you role. Dental Protection offers a few simple steps to help ensure good practice T practitioner • The practitioner’s physical appearance, manner and movement. For some patients, such issues as appearance, facial posture (smile), movement, general body posture, gestures and the physical distance between the two parties can influence their interpretation of the information supplied. Whilst good communication skills are required at all stages of treatment, there are three fundamental areas that demand special attention. 1. History taking The initial histories set the scene in which the patient will be investigated. They will also inform the subsequent treatment plan or plans presented to the patient. Similarly, at each stage of investigation or treatment an opportunity arises for the patient to give further input. Such input may be negative or positive but it can – and should – influence: • Further consideration of investigation • Diagnosis • Treatment plan • Treatment or follow up. 2. Consent Consent is based on the patient being able to absorb information, to consider the information and to make a reasoned decision. It is important not to lead a patient to a decision and it is equally important that every effort is made to help the patient understand issues in order to properly seek the preferred options. Communication in consent, as elsewhere, is dependent on a feedback mechanism. For example:
  • 115. 125 Indemnityand governance • Is the patient able (competent) to hear the discussion and make a meaningful decision? • If the answer is yes, can you pass on the information in a way in which the patient can understand? • Has the patient shown reasonable signs of understanding the issues? (This may require further questioning) • Has proper weight been attached to each issue to facilitate decision-making? • Have sequelae, cost and prognosis been explained? • Does the patient appear to understand? • Is the patient’s carer empowered to give authority on his or her behalf, for example in the case of a child? Only once all these considerations have been made can it be demonstrated that every effort has been made to communicate properly. Confidence can then be placed in the decision about treatment reached by the patient. 3. Record keeping Records should support the verbal and written interchange between patient and dental hygienist or therapist and, where necessary for the best interests of the patient, between colleagues. They need to be accurate, complete, contemporaneous and honest. Records need to be securely stored and kept for the right length of time. Visit www.dentalprotection.org for more details of appropriate storage times. Remember… When communication breaks down, it can often be the trigger for a patient complaint or claim. These dangers are magnified if both parties are speaking a different language. Even when speaking English, patients may have a different understanding of what a ‘familiar colloquial’ English phrase means. Remember, too, that front desk staff are often your ‘eyes and ears’ and it is important they understand their roles in feedback of information. That said, staff should consider that confidentiality in communication is a fundamental ethic and principle and nothing should be relayed to a third party (except in exceptional circumstances) without the patient’s permission. www.dentistry.co.uk Dental Protection offers communication education tools for its members across a multitude of platforms, including online, in publications, workshops, seminars and events. For more information please visit dentalprotection.org.
  • 116. 126 Indemnityand governance AbbreviationsUnless abbreviations are commonly recognised within the profession, it makes it difficult for other members of the team to understand a record card. If you intend using an abbreviation, it would be sensible to create a list of abbreviations, together with their meaning, that your dental team has agreed to use. This list can then be used by others who need to read the record card at a future date A ALARP: As low as is reasonably practicable ALS: advanced life support AMO: anterior maxillary osteotomy AP: adult prophylaxis AP: anterior-posterior APT: active periodontal treatment AR: amalgam restoration ARC: AIDS related complex B BA: broken appointment BBTD: baby bottle tooth decay BD: buccal distal BIS-GMA: bisphenol-a-glycidyl methacrylate BLS: basic life support BMS: burning mouth syndrome BOP: bleeding on probing BP: blood pressure BPE: basic periodontal examination BTI: bleeding time index BWX: bitewing X-ray C C&B: crown and bridge C/: complete upper denture /C: complete lower denture C/O: complaining of CAB: coronary artery bypass CAD: coronary artery disease CAD/CAM: computer-aided design/computer-aided manufacture CAL: clinical attachment level CBC: complete blood count CD: chemical dependency CE: cervical erosion CEJ: cementoenamel junction CFA: craniofacial analysis CHF: congestive heart failure CL: crown lengthening CL/CP: cleft lip, cleft palate CLD: complete lower denture CMB: chronic mouth breathing CP: child prophylaxis CPEC: comprehensive periodontal examination and charting CPD: Continuing Professional Development CPF: coronally positioned flap CPR: cardiopulmonary resuscitation CPT: caries prevention treatment CRO: centric relation occlusion CS: coronal scaling CS: conscious sedation CTS: cracked tooth syndrome CUD: complete upper denture D D: distal DB: distal buccal (distobuccal) DBA: dentine bonding agents DD: differential diagnosis DDR: direct digital radiography DEF: decayed, extracted, filled DFS: decayed filled surfaces DHS: dentine hypersensitivity DI: distal incisal DK: caries DL: distal lingual (distolingual) DM: diabetes mellitus DMF: decayed, missing, filled DNA: did not attend DO: distal occlusal DOB: distal occlusal buccal E E: extraction E&E: excavate and evaluate EAL: electronic apex locator EBD: evidence-based dentistry EDI: electronic data interchange EMO: edentulous mandibular overdenture EO: extra-oral EOP: early onset periodontal disease EPT: electric pulp test F F: facial F: failed appointment F/: maxillary full denture /F: mandibular full denture F/F: full maxillary denture over full mandibular denture F/L: full lower denture F/P: full maxillary denture over partial mandibular denture F/U: full upper denture FDI: World Dental Federation FDS: flap debridement surgery FGC: full gold crown FLD: full lower denture FPD fixed partial denture FU(D): full upper denture G GBI: gingival bleeding index GBS: gingival bleeding score GCF: gingival crevicular fluid GI: gingival Index GI: glass ionomer GIC: glass ionomer cement GIR: glass ionomer resin GTR: guided tissue regeneration
  • 117. 127 Indemnityand governance www.dentistry.co.uk H HAV: hepatitis A virus HBV: hepatitis B virus HNF: head-neck-face HP: handpiece I I: incisal IA: inferior alveolar IAL: incidental attachment loss IC: informed consent IDDM: insulin-dependent diabetes mellitus (Type 1) IFPD: implant fixed partial denture IPD: inflammatory periodontal disease IRMER: Ionising Radiation Medical Exposure Regulations L L: lingual LA: labial LA: local anaesthesia LCR: light cured resin LL: lower left LLQ: lower left quadrant LP: lichen planus LR: lower right LRQ: lower right quadrant M MB: mesial buccal MF: mesial facial MFL: mesial facial lingual MFP: myofascial pain MGJ: mucoginival junction MI: maximum intercuspation MI: mesial incisal MI: myocardial infarction MID: mesial incisal distal MID: minimal intervention (invasive) dentistry ML: mesial lingual MM: mucous membrane MO: mesial occlusal MOB: mesial occlusal buccal MOD: mesial occlusal distal MODB: mesial occlusal distal buccal MOL: mesial occlusal lingual N N/S: no show N/V: nausea and vomiting NaCl: sodium chloride NaF: sodium fluoride NAD: Nothing abnormal diagnosed NICE: National Institute for Clinical Excellence NSPT: non surgical periodontal therapy NUG: necrotising ulcerative gingivitis NVB: inferior alveolar neurovascular bundle O O: occlusal OTC: over the counter P P: palatal P&E: prophylaxis and exam P/: maxillary partial denture P/F: partial maxillary denture over full mandibular denture P/P: partial maxillary denture over partial mandibular denture PA: posterior-anterior PA: preparatory appointment PAL: probing attachment level PASS: plaque assessment scoring system PBI: papillary bleeding index PBI: periodontal pocket bleeding Index PBS: papillary bleeding score PC: periodontal chart PC: porcelain crown PC: poor contact PCO: periodontal chart only PCR: pseudo centric relation PCT: plaque control techniques PD: partial denture PDI: periodontal disease index PDP: Personal development plan PFG: porcelain fused to gold PFM: porcelain fused to metal PI: plaque index PL: partial lower denture PLD: partial lower denture PLP: palatal lift prosthesis PLV: porcelain laminate veneer PMC: porcelain to metal crown PPD: probing pocket depth PSR: periodontal screening and recording PST: post surgical treatment PUD: partial upper denture PVS: polyvinyl siloxane R R: recurrent decay RBFPD: resin-bonded fixed partial denture; maryland bridge RD: recession depth R-D: rubber dam ReDK: recurrent decay RME: rapid maxillary expansion RMGI: resin modified glass ionomer RMH: reviewed medical history ROHic: alcoholic RPD: removable partial denture RPE: rapid palatal expansion RPS: root planing and scaling RTC: return to clinic Rx: prescription S S&RP: scaling and root planing S&Sx: signs and symptoms S/D: systolic/diastolic blood pressure S/S: signs and symptoms SBE: subacute bacterial endocarditis SBI: sulcular bleeding index SC: subcutaneous SL: sublingual SM: submucosal SnF: stannous fluoride SPT: supportive periodontal treatment SRP: scaling and root planing STL: soft tissue lesion STM: soft tissue management SVOS: soft vinyl occlusal splint T TBA: tooth brush abrasion TMD: temporomandibular joint disorder TN: trigeminal neuralgia TP: treatment plan TP: therapeutic pulpotomy TPR: temperature, pulse, respiration TPT: thermal pulp test TTC: tetracycline U UL: upper left ULQ: upper left quadrant UR: upper right URQ: upper right quadrant