Ask Dental Protection

Patients are likely to be a lot more aware of infection control issues following the recent publicity surrounding a look back exercise involving 20,000 dental patients in the UK. If the cost of their dental care increases, patients are likely to be more critical in their choice of dental care provider. Choice and quality are two of the most important components of consumerism.

Patients who have come to appreciate the steps that are being taken by a practice to ensure their safety will be far less likely to move to another practice where it is not immediately obvious that the same standards of infection control apply.

Many of those patients who move from one practice to another never tell the original practice why they have left. They often have unspoken concerns and dissatisfaction and these can include doubts over infection control and the quality of care generally. A visible infection control policy and a willingness to explain to patients what is being done for their safety, and why, can address concerns and reinforce the patient’s decision to stay with the practice.

A deliberately high-profile and visible commitment to infection control can also help to justify a patient’s perception of value, especially if they have just agreed to pay privately for their dental care.

There are many different ways to get the point across – a poster in the waiting room or a page on your website can outline the basic principles. You can also reinforce the message every time you open bagged instruments from the steriliser or a new set of instruments by mentioning that they have just been sterilised. Disposable, single use items can also be pointed out to patients instead.

It is paradoxical that patients may be questioning standards of cross infection control in dentistry at a time when they are generally higher and safer than ever before.

Topics of inadequate infection control make good stories and help sell newspapers. Take the initiative and get your own story out there first.

Am I able to request assistance from Dental Protection in the event that a claim revolving around hypnosis is made against me?

Does the referring dentist need to understand hypnosis and should they include the request for hypnosis in the patient's treatment plan?

The practice of hypnosis for the provision of dental treatment attracts all the benefits of Dental Protection membership that would normally apply to your DCP membership category. Whilst hypnosis is not included in the current scope of practice for dental hygienists published by the General Dental Council (GDC), it is accepted that whilst hypnosis is not itself considered to be the practise of dentistry, it may be provided to facilitate other treatments that are recognised as the practise of dentistry.

With regard to including details of the referral in the treatment plan, Dental Protection would recommend that the referring dentist should specify in the treatment plan that they are prescribing the patient’s treatment to be provided under hypnosis. As with any other clinical situation, the prescribing dentist would be expected to have some knowledge of the procedure being prescribed, although they need not provide the service personally.

View the full benefits of membership for DCPs

Dental Protection takes the view that the provision of work experience opportunities is a recognised activity in many professional settings and no additional subscriptions are required by practice owners.  

We expect that those on work experience placement will not undertake any clinical work but instead observe and shadow your professional practice. Members are welcome to contact Dental Protection for advice about obtaining patient consent and confidentiality agreements as well as other aspects of induction for a practice visit.

You will be aware that dental graduates are obliged to undertake a year’s Foundation Training, following which they may apply to join the Performers’ List which enables them to provide NHS dental services. Many dental graduates feel that this 12-month period provides a welcome bridge between the relatively sheltered environment of dental school and the more challenging situations which they are likely to face as an independent practitioner.

When direct access was introduced, the GDC decided that DCPs would not be obliged to undertake an equivalent year of Foundation Training. There was no legal mechanism for the GDC to make such a change. However, there are some deaneries which do provide a Foundation Training scheme for dental therapists. The GDC’s view is that whilst there may not be a formal requirement to work to a dentist’s prescription, it strongly recommends that newly qualified dental hygienists and dental therapists should take the opportunity to practise in a sheltered environment, working on prescription in a supportive team. It has been suggested by the GDC and the British Society of Dental Hygiene and Therapy that this period could be 12 months. From a risk management perspective, Dental Protection would welcome a move to formalise this recommendation.

The GDC places the onus on the registrant to be capable of demonstrating that they have the necessary competencies to work under direct access, with an added requirement that these competencies can be evidenced on demand. This is particularly important for those DCPs who qualified prior to 2002 as they may not necessarily have had the chance to study for the extended duties which became part of the curriculum in 2002.

Click here to read our briefing document on Direct Access.

Yes. Direct access is now available as an option, but in no sense compulsory. The staff of each workplace are free to make up their own mind, whether to implement direct access and if so, how and to what extent. Some of them may not want to do so at all. Dental Protection’s experience of direct access in other countries is that most of the time, for most practices, very little changed. What it does do is make life easier for practices that use hygienists and therapists, and remove some of the obstacles to patient access to certain forms of dental care.

Whether or not the dentists you work with will want to continue examining patients for the sole purpose of referring them to you for specified treatment is a matter for mutual discussion and agreement. One of the major advantages for dentists is that they no longer need to do this, especially in circumstances where they could not receive any NHS remuneration for having done so.

Click here to read our briefing document on Direct Access.

You should always ensure that a valid consent has been obtained from the patient (and/or parent in the case of a minor), whether or not you are working to a prescription produced by a registered dentist. This is part of your duty of care to each and every patient you treat.

In this situation the responsibility to obtain a valid consent is wholly yours and you would be legally, ethically and professionally accountable if you treat a patient without obtaining it. Members are referred to our Advice Booklet on this subject (a different version exists for members practising in Scotland) which can be downloaded here.

Read our briefing document on Direct Access

The GDC has stated that the new arrangements have been made with patient safety as an up-most priority. Registrants treating patients directly must only do so if appropriately trained, competent and with adequate indemnity or insurance arrangements in place. They should also ensure that there are adequate onward referral arrangements in place and they must make clear to the patient the extent of their scope of practice and not work beyond it.

It should be remembered that to ensure patient safety:

• All registrants must be trained, competent and indemnified for any tasks they undertake
• All registrants must continue to work within their scope of practice regardless of these changes
• All registrants must continue to follow the GDC’s Standards for Dental Professionals
• Dental care professionals do not have to offer direct access and should not be made to offer it

Dental hygienists and dental therapists

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. They must be confident that they have the skills and competences required to treat patients directly before doing so. A period of practice working to a dentist’s prescription is a good way for registrants to assess this.

Registrants who qualified after 2002 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. Those who qualified before 2002, or who have not applied their skills recently, must review their training and experience to ensure they are competent to undertake all the duties within their scope of practice.

Dental nurses

Dental nurses can participate in preventive programmes without the patient having to see a dentist first.

Orthodontic therapists

Orthodontic therapists can continue to carry out the majority of their work under the prescription of a dentist and can carry out Index of Orthodontic Treatment Need (IOTN) screening without the patient having to see a dentist first.

Clinical dental technicians

Clinical dental technicians can continue to see patients directly for the provision and maintenance of full dentures only and should otherwise carry out their other work on the prescription of a dentist. However, the GDC stated that with the potential for further training for CDTs this decision could be reviewed.

Dental technicians

The work of a dental technician (other than repairs) should continue to be carried out on the prescription of a dentist. There has been no change to their Scope of Practice.

More detailed guidance on the implications for individual DCP registrant categories is provided on the GDC website (Guidance on Direct Access).

Click here to read our briefing document on Direct Access.

1. Does the new Direct Access Guidance affect whether an Orthodontic Therapist needs to work under the supervision of an orthodontist?

The GDC guidance on direct access relates to whether DCP’s can work without a patient initially being seen by a dentist and a prescription provided.  The guidance does not make any reference as to whether orthodontic therapists should be supervised when working and, as previously, orthodontic therapists are perfectly entitled to work without a dentist on the premises. The decision as to when an orthodontic therapist can work  without a dentist being present is, to a large extent, a matter of personal choice depending upon treatment being provided, competency and experience. 

2. By allowing direct access to orthodontic therapists does this mean that they can provide Index of Orthodontic Treatment Need (IOTN) screening in private dental practice or only as part a public health initiative?

The Direct Access Guidance introduces the option for orthodontic therapists to carry out IOTN screening, without a prescription from a dentist, subject to having completed appropriate training but it also refers to this being as part of a structured public health programme. 

The GDC has now clarified that orthodontic therapists can carry out IOTN screening direct to patients (should a practice chose to organise their service in such a way) or as part of a structured public health programme. The intention of the recommendation to Council was for the task itself – that orthodontic therapists can undertake IOTN screening without the patient having to see a dentist first. The GDC’s website has been altered to include this clarification.

3. Will my membership subscription increase if I expand my role to undertake IOTN screening?

Not if you continue to work the same hours and your position has not changed in terms of whether or not you own and operate a practice of your own, employ staff and/or contract with third parties for the commissioning of services to be provided by others.  Our dental subscription rates are reviewed annually, and members are notified of the new subscription at the time of their membership subscription renewal.  No additional subscription increases are being made as a result of direct access.

 4. What training do I need to undertake before I am able to undertake IOTN screening?

The GDC guidance stresses the need for orthodontic therapists to be trained and competent to undertake IOTN.  They have advised that training can either be undertaken through an accredited course, or can be carried out in-house.   When accredited external training is not undertaken, any in-house training taken should be carefully documented, noting the dates it was undertaken and what the training involved at each stage.  Additionally, irrespective of whether initial training is external or in-house, it would be appropriate to keep a log of a number of cases initially on which IOTN scoring was reviewed by another experienced colleague to demonstrate competency.

As IOTN scores may form the basis on which a patient may, or may not, be accepted for orthodontic care; where an IOTN score is borderline, it may be sensible to seek a second opinion, irrespective of the amount of training or experience of undertaking IOTN scoring.

Click here to read Our briefing document on Direct Access.

When new guidance is introduced this can produce a period of uncertainty for registrants, as they seek to understand how the changes may affect their practice.

Under direct access it is possible for dental hygienists and therapists to see a patient for treatment that would be within your normal scope of practice without first obtaining a prescription from a dentist. But, certain treatment, for example the use of local anaesthetic and tooth whitening, will still require a dentist’s prescription.

The procedures that you can provide under direct access have to be interpreted with reference to the existing guidance. GDC’s Guidance Scope of Practice is still current and this document specifies that hygienists / therapists cannot diagnose disease.  Therefore, it is not currently within your scope of practice to see patients on either an NHS or private basis to perform check-ups or examinations, regardless of the circumstances. It follows from this that at the moment you cannot provide check-ups for patients under your dentist’s performer number.

Click here to read our briefing document on Direct Access.

The GDC has also produced a statement in relation to direct access together with frequently asked questions and you may wish to review this information.

Dental hygienists and dental therapists offering treatment via direct access need to have clear arrangements in place to refer patients who need treatment which they cannot provide. In a multi-disciplinary practice where the dental team works together on one site, this should be straightforward. In a multi-site set-up where members of the dental team work in separate locations, there should be formal arrangements such as standard operating procedures in place for the transfer and updating of records, referrals and communication between the registrants.

Where hygienists and therapists choose to practice independently and there is no dentist present, they should have clear referral arrangements in place in the event that they need to refer a patient for further advice or treatment and those arrangements should be made clear in their practice literature.

If a patient requires a referral to a dentist with whom the hygienist or therapist does not have an arrangement, the DCP should set out for the patient, in writing, the treatment undertaken and the reasons why the patient should see their dentist.

In all cases, the need for referral should be explained to the patient and their consent obtained. The reason for the referral and the fact that the patient has consented to it should be recorded in the patient’s notes. Relevant clinical information, including copies of radiographs, should be provided with the referral.

If a patient refuses a referral to a dentist, the possible consequences of this should be explained to them and a note of the discussion made in the patient’s records. It may be helpful for members to contact Dental Protection for further advice.

Click here to read our briefing document on Direct Access.