New Frontiers for Biomedical Science in Oral Curricula: The Needs of Emerging Dental Professions Dr Louise Belfield Peninsula Dental School, UK.
Background: 2014 First cohort of Dental Therapy and Hygiene students Brand new curriculum (blank slate)
What are the emerging professions and what do they do? Drivers for change in the dental workforce Why does this matter to basic science teachers in dentistry? What are the challenges in design and delivery of biomedical science curricula? Final thoughts and future directions
Who are the Dental Care Professionals?
Who are the Dental Care Professionals? Dentist Dental assistant Dental Hygienist Dental Therapist Dental Technician
Who are the Dental Care Professionals (UK)? DN Dental Nurse DT Dental Technician CDT Clinical Dental Technician OT Orthodontic Therapist DH Dental Hygienist DHT Dental Hygienist / Therapist (dual qualification)
Scope of practice: DN Dental nurse: Chairside support Infection control procedures Record dental charting Prepare, mix and handle dental bio-materials Process dental radiographs Make appropriate referrals to other health professionals Extra skills training availble Dental nurses do not diagnose disease or treatment plan
Scope of practice: OT DT CDT Dental technician Make dental devices to a prescription from a dentist or clinical dental technician Repair dentures direct to members of the public. Clinical dental technician Provide complete dentures direct to edentulous patients and other dental devices on prescription from a dentist. Orthodontic therapist Carry out limited orthodontic techniques (mostly under prescription from a dentist). Orthodontic therapists and dental technicians do not diagnose disease or treatment plan
Scope of practice: DH Dental hygienist Examination Oral health advice Non surgical scaling Polishing Fissure sealants Referral Taking radiographs Hygienist Fillings which do not involve the pulp Extraction of deciduous teeth Pulpotomy Stainless steel crowns
Scope of practice: Dental therapist DH DT Examination Oral health advice Non surgical scaling Polishing Fissure sealants Referral Taking radiographs Hygienist Fillings which do not involve the pulp Extraction of deciduous teeth Pulpotomy Stainless steel crowns Therapist
Scope of practice: Dental hygienist / therapist DH DHT Examination Oral health advice Non surgical scaling Polishing Fissure sealants Referral Taking radiographs Hygienist Hygiene / therapist Fillings which do not involve the pulp Extraction of deciduous teeth Pulpotomy Stainless steel crowns Therapist
Scope of practice: DH DHT With extra training: Inhalation sedation Tooth whitening Removal of sutures after wound checked by dentist Hygienists dental therapy
Scope of practice: DH DHT Outside scope: Extractions of adult teeth Crown/bridge preparation Dentures Root fillings Orthodontics
DHT Focus on Dental Hygiene / Therapists Stakeholders believe that the skill mix in the multidisciplinary dental workforce is likely to change over the period this report covers, with DCPs taking on more of the activity currently undertaken by dentists. (CfWI Report, 2014)
UK dental workforce Demand for dental hygienists and therapists is expected to rise and exceed supply. If, by 2025, dental hygienists and therapists were to carry out 18 per cent of all direct patient care around 7,700 more full-time equivalent (FTE) dental hygienists and around 2,000 more FTE dental therapists would be needed (CfWI Report, 2014)
Dental Therapy and Hygiene an emerging profession? An extended scope of practice and role of the DHT (and other DCPs) within the dental team is emerging
A history of Dental Therapy and hygiene Dental therapists were originally employed to provide care for children and / or adults in areas where access to dental care was limited. (Nash et al, 2014) 1921: New Zealand 1947: Canada 1955: Tanzania 1971 : Australia 1949: Sri Lanka Timeline 1924: Norway 1948: Malaysia Japan 1950: Singapore 1959: United Kingdom >>> (Calache et al. 2012, Mathu-Muju et al. 2013)
54 countries now employ dental therapists as members of the dental workforce Mathu-Muju et al. 2013 Australia Australia New Zealand Fiji Papua New Guinea Samoa Africa Zimbabwe Botswana Seychelles South Africa Tanzania Europe United Kingdom Netherlands South America Trinidad & Tobago Guyana Suriname However, there is variation within the profession North America Canada United States Anguilla Bahamas Jamaica Asia Hong Kong Sri Lanka Singapore Malaysia Brunei Thailand
DHT nomenclature varies between countries (Wanyonyi et al, 2014) UK Brazil Oral health technicians Dental Hygiene-Therapists or Dental Therapists New Zealand USA Malaysia Holland Dental Therapists Oral health therapists
DHT training varies between countries 2 year, post-high school curriculum Vocational training 2-3 years norm 3 year undergraduate curriculum 4 year undergraduate curriculum Typical DHT curriculum: Early year(s): Basic biomedical sciences supporting dental practice and the acquisition of perceptual motor skills Later years: Intense clinical training
Global scope of practice: Worldwide the scope of a dental therapist s practice generally includes: Examination Diagnosis and treatment planning Taking and interpreting radiographs Oral health education Preventive services such as prophylaxis, fluoride therapy, fissure sealants and dietary counselling Preparation of cavities in primary and permanent teeth and restoration with amalgam and composite Preformed stainless steel crowns Pulpotomies Extraction of primary teeth In some countries, they may also extract permanent teeth
Dental Hygiene / therapist workforce distribution Europe Canada, USA and Japan D D D D D D D Dentist Dental hygienist / therapist D D D D D D D D D D D D D D Dental hygienist / therapist 1:1 D D D D D D 18:1 11:1
UK dental workforce distribution https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/507376/cfwi_dental_care_professionals_stocktake.pdf
Dentists = 1/3 of the workforce Current care provision by UK dental workforce (2014)
Projected care provision by UK dental workforce (2025)
Drivers for change in the dental workforce Government Changing populations Access to oral healthcare Team work Share workload Concentrate on other aspects of dentistry The medical model Financial
The developing role of DHTs in the UK 1983 New Cross closed 2002 Requirement to work in community, armed forces, hospital only lifted 2013 Requirement to work under prescription of a dentist removed Direct access 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 dental auxiliary New Cross Hospital 1960
The developing role of DHTs in the UK 1983 New Cross closed 2002 Requirement to work in community, armed forces, hospital only lifted 2013 Requirement to work under prescription of a dentist removed Registrants qualified pre 2002 would need further training Registrants qualified post 2002 require no further training The dental auxiliary New Cross Hospital 1960
What does this mean for basic science teaching? The GDC preparing for practice document on underpinning science: The relevant sciences (biomedical, behavioural, engineering and materials) that underpin the clinical domain are fundamental to understanding oral conditions and how to treat them. Appropriate emphasis should be provided on the delivery and assessment of the sciences The sciences taught must be relevant to the practice of dentistry in order to understand patient conditions and behaviours and then apply to their assessment, diagnosis, treatment and care.
What does this mean for basic science teaching? The GDC preparing for practice document on underpinning science: The relevant sciences (biomedical, behavioural, engineering and materials) that underpin the clinical domain are fundamental to understanding oral conditions and how to treat them. Appropriate emphasis should be provided on the delivery and assessment of the sciences The sciences taught must be relevant to the practice of dentistry in order to understand patient conditions and behaviours and then apply to their assessment, diagnosis, treatment and care.
What does this mean for basic science teaching? The GDC preparing for practice document on underpinning science: The relevant sciences (biomedical, behavioural, engineering and materials) that underpin the clinical domain are fundamental to understanding oral conditions and how to treat them. Appropriate emphasis should be provided on the delivery and assessment of the sciences The sciences taught must be relevant to the practice of dentistry in order to understand patient conditions and behaviours and then apply to their assessment, diagnosis, treatment and care.
Some of the changes to preparing for practice learning outcomes means we have to rethink our science curricula Was: contribute to relevant special investigations and diagnostic procedures including radiography Now: undertake the relevant special investigations and diagnostic procedures including radiography
Some of the changes to preparing for practice learning outcomes means we have to rethink our science curricula Was: Carry out care as prescribed by the dentist in the most appropriate way for the patient Now: Plan the delivery of, and carry out, care in the best interests of the patient
What biomedical science teaching do we need to provide for DHTs? We need to prepare our DHT graduates to go out into independent practice and be safe, confident and competent clinicians Where there is overlap in clinical activity, understanding of basic sciences to underpin clinical practice should be the same for BDS and DHT. BDS DHT
Dental Hygiene / therapists thoughts on basic sciences for direct access
Practicing Dental Hygienist / Therapist and dental educator: you need to have a thorough understanding of the disease process that you are treating, like: Can you distinguish between different types of periodontal disease? Which bacteria are likely to be involved? Do we need to refer for antibiotics? Basically, do you understand what is happening in the tissues? Because that will inform your choice of treatment.
Practicing Dental Hygienist / Therapist and dental educator: Practicing Dental Hygienist / Therapist and dental educator: you need to have a thorough understanding of the disease process that you are treating, like: Can you distinguish between different types of periodontal disease? Which bacteria are likely to be involved? Do we need to refer for antibiotics? It wasn t apparent until I started practising that there were gaps in my knowledge... which couldn t be filled by clinical experience this was basic science knowledge. It quickly dawned on me that had I been provided with this foundation knowledge I would have been better prepared for the clinical challenges that come with caring for and treating patients Basically, do you understand what is happening in the tissues? Because that will inform your choice of treatment.
Practicing Dental Hygienist / Therapist and dental educator: Practicing Dental Hygienist / Therapist and dental educator: you need to have a thorough understanding of the disease process that you are treating, like: Can you distinguish between different types of periodontal disease? Which bacteria are likely to be involved? Do we need to refer for antibiotics? Basically, do you understand what is happening in the tissues? Because that will inform your choice of treatment. It wasn't apparent until I started practising that there were gaps in my knowledge... which couldn t be filled by clinical experience this was basic science knowledge. It quickly dawned on me that had I been provided with this foundation knowledge I would have been better prepared for the clinical challenges that come with caring for and treating patients Practicing Dental Hygienist / Therapist: [with regard to working under direct access] I don t think I would be happy to diagnose caries
Shared learning outcomes relevant to basic sciences 10 identical learning outcomes in the GDC Preparing for Practice document E.g. Explain the aetiology and pathogenesis of oral disease Describe relevant and appropriate physiology and explain its application to patient management Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management Undertake relevant special investigations and diagnostic procedures, including radiography Identify normal and abnormal facial growth, physical, mental and dental development and explain their significance
Inter-professional learning Evidence suggests best interests of patients Early integration encouraged (preparing for practice) We already have a wealth of expertise in our dental schools Shared learning means both programmes can utilise this expertise
Changing the workforce will not come easily Many questions and much reservation remain among the dental community and patients
Are DCPs safe to practice direct access? There have been many evaluations of the technical quality of care provided by dental therapists over the past 60 years. These studies have consistently found that the quality of technical care provided by dental therapists (within their scope of competency) was comparable to that of a dentist and in some studies was judged superior (Nash 2013)
But what about understanding when to refer for systemic health concerns? There was evidence of ongoing training needs to strengthen the assessment and referral skills of DCPs in respect to patients with other health problems or risk factors, but little evidence that dentists are any less in need of such training. (Turner et al, GDC, 2012)
Final message: Not a suggestion of what to teach, but what we (dental educators) should consider in our curriculum design: Change Pioneer Utilise expertise Shared learning Safe, independent clinicians Best patient care Prepare
Thank you!
References Mathu-Muju KR, Friedman JW, Nash DA. Oral health care for children in countries using dental therapists in public, school-based programs, contrasted with that of the United States, using dentists in a private practice model. Am J Public Health. 2013 Sep;103(9):e7-e13 Nash DA, Friedman JW, Mathu-Muju KR, Robinson PG, Satur J, Moffat S, Kardos R, Lo EC, Wong AH, Jaafar N, van den Heuvel J, Phantumvanit P, Chu EO, Naidu R, Naidoo L, McKenzie I, Fernando E. A review of the global literature on dental therapists. Community Dent Oral Epidemiol. 2014 Feb;42(1):1-10. Wanyonyi KL, Radford DR, Gallagher JE. Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England. Human Resources for Health. 2014;12:65. Hanny Calache and Matthew Hopcraft (2012). The Role of the Oral Health Therapist in the Provision of Oral Health Care to Patients Across All Ages, Oral Health Care - Prosthodontics, Periodontology, Biology, Research and Systemic Conditions, Prof. Mandeep Virdi (Ed.), InTech, DOI: 10.5772/33434. Centre for work intelligence: Dental care professionals stocktake. http://www.gov.uk Accessed: 05/016 Turner, Steve; Tripathee, Sheela; MacGillivray, Stephen. Benefits and risks of direct access to treatment by dental care professionals : a rapid evidence review. General Dental Council, 2012. 85 p.
Educator Clinician DTH Advocate Team player