Introduction
Sir, I was interested to read the letter from D. G. Hillam (Silent revolution, BDJ2008; 204:4–5) regarding the paper by Jones et al. (BDJ2007; 203: 524–525) which discussed the attitudes of dentists in Wales towards dually qualified dental hygienist-therapists. This work reiterated the findings of our earlier research gathered from a sample of dentists in South East Scotland.
It appears that much ignorance exists regarding the clinical remit of dually qualified dental hygienist-therapists and until this is addressed, suspicion arising from this lack of knowledge will undoubtedly persist. Firstly, we have to remind ourselves that the new generation of dental therapists also hold a qualification in dental hygiene, and are therefore dually qualified individuals. Their skills are extensive from a preventive, periodontal and restorative perspective. Furthermore, it is estimated that they can undertake 70% of routine dentistry amongst both the adult and child population.
A 'simple filling' as referred to by your correspondent can be defined as that which does not involve the adult pulp, or require the services of a dental laboratory. In addition to being able to treat advanced periodontal disease, dually qualified hygienist-therapists are trained to a very high standard to undertake many 'routine' restorative procedures. Indeed, it could be argued that significantly more time is spent by these individuals in doing more 'routine dentistry' than many an undergraduate in the UK because of the more limited nature of their clinical remit. This is certainly the case in the treatment of periodontal disease where even in an integrated hygiene-therapy programme, the practical experience gained is far greater.
D. G. Hillam states that some hygienist-therapists 'will push to the legal limits or even further, with or without the blessing of a dentist who may be unclear of the regulations'. This implies that these fully trained, qualified and statutorily registered dental professionals, who are only too aware of their clinical remit, may contemplate undertaking illegal practice. Law, ethics and professionalism are a significant component of the curriculum and indeed, the specific learning outcomes relating to this detailed in the curricula for both BDS undergraduates and DCPs are almost identical. There is no reason therefore to suggest that hygienist-therapists would have any less rigorous ethical standards than dentists, given they are subject to the same disciplinary procedures.
Your correspondent is inaccurate in observing that DCPs could 'undertake the business of dentistry sometime in the future'. This has been the case since July 2006 when they were also permitted to set up in practice, albeit operating via a referral system, or by employing a dentist who would see the patient for an initial examination. To suggest that 'quality, safe dentistry' may not be provided by hygienist-therapists is unreasonable. They are taught how to act in the best interest of the patient by making appropriate referrals should they find something which is beyond their clinical competence to treat, or where they recognise any abnormal lesions which give them cause for concern.
Mr Hillam goes on to state that 'therapist training has been at the expense of that for hygienists'. The curriculum for either a singly-qualified hygienist or a dually-qualified hygienist-therapist is identical and time spent developing hygienist and therapist skills are comparable with each other. It is also disappointing to note that Mr Hillam states that 'hygienists play a major role in assisting the dentist in the management of periodontal diseases'. This paints a rather subsidiary picture of the hygienist, instead of recognising their significant clinical expertise. Surely, given that the training a hygienist or hygienist-therapist receives in periodontal therapy is vastly greater than an undergraduate, they can do rather more than just 'assist' the dentist in this treatment?
Recent, but as yet unpublished, work we have undertaken in Scotland investigated final year dental undergraduates' course-based experience of teamworking, and their knowledge and attitudes towards the clinical remit of hygienists and hygienist-therapists. It became evident very quickly that many undergraduates knew little of the remit of other individuals and held them in low esteem, which was very disheartening, given they were coming to the end of their training. It is vital that each member of the dental team is aware of the clinical responsibility of each other as stated in the First five years and that professional knowledge and respect is encouraged at an early stage.
Dentistry has lagged behind medicine in terms of recognising the skills and abilities of all members of the team. In medicine, nurse practitioners, nurse consultants and nurse specialists exist and function effectively and efficiently alongside doctors in both the primary and secondary care setting. Those in dentistry should be encouraged to embrace change which has not evolved by chance, but by the realisation that it is time to move away from the hierarchical system which has reigned in our profession for too long. The oral health of the population is the concern of all dentists and dental care professionals, and by working in tandem we may make progress in addressing the unacceptable levels of disease which continue to exist in the UK.
