EXECUTIVE SUMMARY

  Following closure of three dental schools in the 1980s, there is now a shortage of dentists to manage the increasing demand and need from an aging population requiring complex dental treatments (restorative and periodontal). Good preventive care, such as can be provided by hygienists, could reduce the need for simple treatments. However, current trends are for the training of more dental therapists to perform these more simple treatments, at the expense of hygienist training. Furthermore, the duties of therapists are extending to permit much of the work of the general dentist and there are moves for them to work independently. Quality of care will ultimately suffer if therapists are allowed to work as independent "dentists" with only 102 weeks training. The numbers of hygienists should be increased, not reduced. At present one of their roles is advice on smoking cessation. This could be formally extended to include dietary and other advice on obesity and on alcohol intake.

  The submitter of this written evidence was a Consultant in Restorative Dentistry specialising in periodontology (diseases of the gums and supporting structures of the teeth) for 25 years, a post that was combined with Directorship of a training school for dental hygienists. He is also a former General Secretary and President of the European Federation of Periodontology and former President of the British Society of Periodontology. Other positions he has held include Clinical Manager of a Dental Hospital, chairmanship of the national Panel of Examiners for dental hygienists (GDC) and membership of numerous dental advisory and other committees at local and national level. He retired from active practice in 2001.

EVIDENCE

  1.  The parts of the committee's remit that I wish to comment on are:

(a)  The work of allied professions, (dental hygienists and therapists).

(b)  The extent to which dentists are encouraged to provide preventative care.

(c)  The quality of care provided to patients.

BACKGROUND

  2.  Up to the late 1950s, there were two training programmes for dentists, a four-year course leading to the LDS qualification in addition to 4.5-year and five-year programmes leading to the more academic BDS qualification. The LDS was phased out in favour of the, longer, more comprehensive courses.

  3.  Dental hygienists were introduced by the RAF during the war, followed by an experimental civilian scheme in the 1950s. This proved to be a success and national training programmes began throughout the UK in the 1960s and 1970s. Approximately 200 were trained each year. Their work includes the treatment of periodontal diseases (these rival tooth decay as a cause of tooth loss), the prevention of all oral diseases, taking radiographs, etc. Their course of training is currently two years long (minimum 90 weeks study[1]).

  4.  Also in the 1960s, when levels of decay in children were very high, therapists were introduced to do simple restorative and preventive treatments for children.

  5.  Towards the end of the 1960s, the introduction of fluoride toothpastes reduced levels of decay over the next decade and it was feared that there would be an over-supply of dentists. As a result, three UK dental schools closed in the 1980s despite some of us warning that the British public had become accustomed to restorative dentistry (as opposed to extractions and dentures) and the aging population will require more complex, difficult restorative work to maintain their heavily restored dentitions. This proved to be true, and at the present time there is a large need and demand for crowns, root canal treatments, bridges, implants, etc. Not only this, but with more teeth being preserved, more teeth are exposed to the risk of periodontal diseases leading to a greater demand for hygienists and dentists.

RECENT TRENDS IN THE DELIVERY OF DENTAL CARE

  6.  There has been an expansion of the role of therapists so that they are now permitted to undertake most of the more routine tasks of dentists after only 2.25 years training (minimum 102 weeks study1). Their work is no longer restricted to children and they are now permitted to work in all areas of dental practice.

  7.  There is a lack of clarity on what therapists are permitted to do, causing confusion to therapists and dentists alike. In addition to "simple" procedures, the GDC states that they must "Have a knowledge of advanced restorative techniques for both dentitions", ie children and adults. "Knowledge" is defined as "A sound theoretical knowledge of the subject but may only have limited clinical/practical experience"1. Furthermore, the same document states "there should be no barrier to prevent PCDs [including therapists] expanding their range of skills" and they are "Permitted to practise in respect of those responsibilities for which they have received education and training . . . and for which they have received authorisation from a registered dentist". It would appear from this that therapists may practise the whole range of dentistry, so long as they convince themselves and a dentist that they have received training and are competent.

  8. Moves are now afoot to allow diagnosis/prescription by hygienists and therapists and for them to be allowed to set up independent practice. Indeed, the regulations have already been changed that will ultimately enable them to set up their own businesses. As a result, I foresee the possibility of a grade of "dentist" appearing in the "High Street" with training of only 102 weeks. (Compare this with the phasing out of four-year trained dentists referred to in paragraph 2 above.)

  9.  The training of therapists is being progressively combined with that of hygienists. There are now very few places for the training of hygienists only.

  10.  The recent scarcity of dentists has brought with it the need to import dentists from overseas, the training standards of whom are not monitored by the GDC in the same way as home-educated dentists. Many of the countries from which we import these dentists cannot afford the exodus of their personnel. I believe that we should be exporting our skills to less well-developed countries, not vice versa. Also, the GDC's Fitness to Practise hearings seem to be dominated by overseas trained dentists who have failed to match up to expected standards.

POSSIBLE CONSEQUENCES

  11.  I fear that the quality of care provided to patients is in jeopardy because of the short training of operating dental personnel (hygienist-therapists) and the need to import overseas dentists whose training has not been monitored by the GDC.

  12.  The risk is enhanced because of lack of clarity in the regulations. There is no longer a "red line" that must not be overstepped. I believe there will always be unscrupulous practitioners who will be tempted to work beyond their level of competency and the situation will be impossible to police.

  13.  There is taking place a serious reduction in the number of dental hygienists who play such a major role in the prevention of oral diseases. This is to be deplored.

MOTIVATION AND JOB SATISFACTION OF DENTISTS, HYGIENISTS AND THERAPISTS

  14.  I believe that the profession tends to attract two main personality types. They are, of course, not mutually exclusive but are a guide to those aspects of their occupations that provide greater job satisfaction:

Type 1.  Perhaps the more traditional type. They are motivated by an attraction to the practical aspects of dentistry; intricate fillings, crowns, bridges, implants, aesthetic improvements to the teeth. The "precision engineering" aspects.

Type 2.  These are motivated by a more "biological" approach; prevention, the treatment of gum diseases, care of the soft tissues of the mouth and the general health of the patient.

  15.  I believe that the current trend towards therapists is attractive to Type 1 individuals, perhaps those that cannot achieve the requirements to become dentists. This trend is at the expense of hygienists (Type 2), many of whom do not want to perform the extended duties of a therapist but who gain their job satisfaction by successfully treating periodontal diseases and motivating patients to prevention rather than by undertaking restorative treatments.

  16.  There is anecdotal evidence that some applicants for hygienist-therapist courses do not want to do therapy, but are forced into it because of the lack of places for hygienist training. Also, there is a high demand from preventively-minded dentists for the very limited supply of hygienists, not therapists. It could be argued that their preventive methods are so successful that they do not need therapists to undertake simple work.

WHAT IS NEEDED?

  17.  Diversion of resources to ensure that the UK has sufficient, well-trained, general dental practitioners to undertake most of the increasing amount of complex work needed for the aging population (restorative and periodontal), and also to encourage more preventive dentistry.

  18.  Improved referral services for cases of advanced periodontal diseases, by introducing consultant posts in periodontology, fully supported by hygienists. The present Consultant in Restorative Dentistry has to cover; restorations, root canal therapy, bridges, implants, dentures, etc. (Type 1), as well as the whole range of periodontal diseases (Type 2). It is just not possible to keep up with all the new knowledge and maintain expertise in all these areas of dentistry.

  19.  Expansion of the numbers of dental hygienists, sufficient to provide a comprehensive dental prevention service to the whole population as well as supporting the general and specialist dentist in the treatment of periodontal diseases. If preventive services improve sufficiently, there will be less need for therapists. In other words, there should be a reversal of the current trend to train therapists at the expense of hygienists.

  20.  Amongst other duties, the work of hygienists includes:

(a)  The removal of calcified bacterial deposits firmly attached to teeth within deep gum pockets where gums have detached from teeth following bone loss. This is technically a difficult, time consuming task and can only be done at its best by people whose skills are maintained by spending a high proportion of their time doing it.

(b)  The giving of preventive advice to patients on thorough tooth cleaning (especially important and difficult in patients with periodontal diseases).

(c)  The application of solutions to teeth to prevent decay and also to treat tooth sensitivity.

(d)  Giving advice on smoking cessation. (Smoking is linked to oral cancer.)

(e)  Giving dietary advice for the prevention of decay.

  21.  This could easily be extended to include:

(a)  Dietary and other advice on obesity.

(b)  Advice on alcohol intake.

  22.  The training of all groups (dentists, hygienists and therapists) must include experience in all environments where they may practise in future. At present, there is a trend for training to be predominantly (in some cases exclusively) in "outreach". In this environment, students are not exposed to difficult, referred cases and may be less able to recognise or cope with the treatment needs of this group of vulnerable patients, or to provide adequate support to consultants, without additional training.

D G Hillam BDS, MDS, FDSRCS

October 2007