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F. Nilchian, H. D. Rodd and P. G. Robinson British Dental Journal 2009; 207: E13

Editor's summary

The dental profession in the UK, and arguably around the world, has had a love-hate, on-off relationship with 'other dental professionals' for what seems like forever. Described under a variety of names from auxiliaries, ancillaries, hygienists, therapists, extended duties nurses and a plethora of other designations these non-dentist personnel have often been searching for a concerted and long-term identity.

In the UK it is the hygienists who have had the longest uninterrupted history of education and service, having been established after their introduction in the RAF during the Second World War. Therapists have had a much more chequered past. This pattern now seems set to continue with hygienist-therapists, as some schools are now switching back to hygienist only courses from exclusively running hygiene-therapy courses.

Such vacillation indicates a lack of objective thinking as to exactly why these groups of, now DCPs, are required. Is it to help dentists by being available to delegate to, is it to be 'mini-dentists' to become replacements and release dentists for other, more advanced treatment options, is it to fill a shortfall in the workforce, is it an economic contingency by a finance-wary administration? All of these or some of these depending on decade, disease levels and economic climate?

With this background it is not surprising to find in this paper an underlying sense of confusion, lack of clarity and personal preference in the referral of patients from dentists to dental hygienists and therapists rather than clear protocols that are easily followed and understood. To some extent this ambivalence was also reflected in the attitude of patients and parents, which might be expected in the absence of unambiguous clinical roles, duties and status.

What the paper demonstrates is a need for some overall direction in the utilisation of DCPs, their expectations, that of the dentist and of the way in which all members of the team are educated about the roles of their colleagues. We have a long way to go before clarity of purpose prevails and it may be that decades, disease levels and economics intervene once more before we get around to making up our minds.

The full paper can be accessed from the BDJ website ( http://www.bdj.co.uk ), under 'Research' in the table of contents for Volume 207 issue 7.

Stephen Hancocks, Editor-in-Chief

Comment

Given the emphasis on preventive dental care in the Steele review,1 consideration should be given to appropriate mechanisms for delivering it. What are the structures and processes that need to be in place in order to deliver effective preventive services? This paper explores one aspect of this problem, the extent to which dentists would, within the current funding system, refer children to dental care professionals (DCPs).

The authors have identified three sets of factors which influence the use of DCPs for the placement of fissure sealants, and in so doing provide possible guidance on their wider use in delivering preventive healthcare. First, the needs and demands for care should be appropriate to a system based on prevention – that is, the population that the healthcare serves should be relatively free from active disease but have a need for preventive care. By and large this would seem to be true in the United Kingdom, as argued in the Steele review.1 While there is an ongoing need for complex care for a sizeable group of individuals, low levels of caries suggest a shift to preventive care.

Second, and perhaps more controversially, the funding system needs to encourage the greater use of DCPs. This is the one of two fundamental problems with the use of DCPs currently. Unlike the situation in general medical practice, where incentives exist both to employ and refer to other healthcare professionals for screening, inoculation and other aspects of preventive care, currently (as suggested in the research here) there is a disincentive for general dental practitioners to refer any work to their DCPs. If greater use of prevention is to be possible, this barrier will need to be addressed. The second difficulty in greater use of DCPs is the size of the workforce – put simply, are there sufficient DCPs to go round?

Finally there are two other aspects which should be considered – would referral to a DCP be acceptable to patients (the present manuscript seems to suggest that they would), and would DCPs deliver the quality of care that would be expected? Again the research suggests that this is the case. The research described in this paper provides an invaluable commentary on the barriers facing the greater use of DCPs for prevention within the current United Kingdom NHS, particularly in general dental practice.

Author questions and answers

1. Why did you undertake this research?

We are keen to expand the role of skill mix in dentistry, but know little of how dental teams work together. Preventive treatment, including fissure sealants, is an important task delegated to DCPs and so formed a good case study of how delegation of care might take place.

In addition, we would like to compare the effectiveness of treatments (in this case fissure sealants) placed by DCPs and dentists but could not do that based on case-note review, without some understanding of the possible differences in the types of patients seen by both patient groups. A qualitative approach was adopted in order to uncover new areas or ideas that were not anticipated at the outset of the research.

2. What would you like to do next in this area to follow on from this work?

We should like to assess how common are the behaviours described in this research. It may be that education on teamwork needs to be enhanced both to qualified professionals and those in training. This work may not only involve listing the scope of practice of DCPs but also giving dental teams the attitudes and managerial expertise to employ skill mix effectively and efficiently.

We should like to compare the effectiveness of treatment provided by dentists and DCPs and will need to account for the factors raised in this research. For instance, if we find that DCPs are more successful when placing fissure sealants, we will need to rule out the possibility that they are referred only the most straightforward patients.