The Faculty of General Dental Practice (UK) and the Department of Health have been working together for the past three years to develop a series of competency frameworks for dentists with special interests (DwSIs). In this article, Sharon Drake outlines the recent developments to the DwSI programme, including two additional frameworks in prison dentistry and conscious sedation, as well as guidance for standards in leadership and management.

Over the past three years, the Faculty of General Dental Practice (UK) and the Department of Health (DH) have been working together to develop a series of competency frameworks for dentists with special interests (DwSIs). The frameworks are intended for use by dentists and primary care trusts (PCTs), and set out competencies for the scope of treatment that can be undertaken by dentists who have developed special interests in addition to their generalist role. Since April 2006, the Faculty has published frameworks in the areas of minor oral surgery, orthodontics, periodontics and endodontics, and at the end of 2007, two additional frameworks in prison dentistry and conscious sedation were made available. The FGDP(UK) has also set out guidance for standards in leadership and management.

Guidelines for DwSIs in conscious sedation

The Guidelines for the appointment of DwSIs in conscious sedation were developed by the FGDP(UK)/DH in conjunction with representatives from the Society for the Advancement of Anaesthesia in Dentistry and the Association of Dental Anaesthetists, among others. These guidelines are intended to provide PCTs with a competency framework to support the development of dental sedation services where there is a local need, and will also help interested dentists to identify their learning needs and undertake further training.

Conscious sedation is an integral element of the control of pain and anxiety in dentistry. The 'standard' conscious sedation techniques (intravenous midazolam for adults and nitrous oxide/oxygen for patients of all ages) are suitable for use by all appropriately trained and experienced primary care dentists. A DwSI in conscious sedation may, additionally, be able to:

  • Offer more advanced or 'alternative' conscious sedation techniques

  • Provide conscious sedation for patients with more complex medical histories and/or treatment needs

  • Provide conscious sedation for patients under 12 years of age using techniques other than inhaled nitrous oxide/oxygen

  • Accept referrals from other practices, clinics and hospitals.

Key publications in conscious sedation

The guidelines are intended to be read in conjunction with two key reports: Conscious sedation in the provision of dental care (Standing Dental Advisory Committee, 2003) and Standards for conscious sedation in dentistry: alternative techniques (Faculty of Dental Surgery of The Royal College of Surgeons of England and the Royal College of Anaesthetists, 2007). A DwSI should be able to demonstrate competence in some or all of the alternative methods of conscious sedation defined in the latter, namely:

  • Any form of conscious sedation for patients under the age of 12 years other than nitrous oxide/oxygen inhalation

  • A benzodiazepine plus any other intravenous agent (eg opioid, propofol, ketamine)

  • Propofol, either alone or with any other agent (eg benzodiazepine, opioid, ketamine)

  • Inhalational sedation using any agent other than nitrous oxide/oxygen alone

  • Combined routes, eg inhalational plus intravenous agents (except for the use of nitrous oxide/oxygen during cannulation).

Any of the above alternative treatments proposed by the DwSI need to be agreed by the PCT, in consultation with all relevant care agencies.

It is hoped that the publication of these guidelines will support dentists who wish to develop an interest in this important area of dental practice, and that this will benefit anxious patients faced with the prospect of an unpleasant and possibly distressing dental procedure.

National standards for prison dentistry

The dental health needs of prisoners differ from those of the general population. Prisoners generally have a poorer standard of oral health, with increased levels of emergency cases, higher rates of substance misuse and smoking, and underlying poor nutrition. The demand for dental care in prisons is also increasing as the prison population continues to grow.

Prison dentists, along with other healthcare workers in the prison setting, are in a unique position in that they are required to balance the need to provide the best possible care to their patients with the priorities and restrictions imposed by the environment in which they work. The FGDP(UK) has worked with the DH, the Oxford Deanery and the British Association for the Study of Community Dentistry to develop standards for prison dentists and those commissioning prison dental services.

The Guidelines for the appointment of dentists with special interests (DwSIs) in prison dentistry are intended to help prison managers and healthcare commissioners to define more closely the role and working arrangements for prison dentists. The competency frameworks set out in the document will also help prison dentists to identify their learning needs, and undertake further training so that they can improve standards of care.

Leadership and management standards

Over the past number of years, the dental care delivery system has been subject to many changes, such as the transfer of responsibilities for the commissioning of services to PCTs and increasing legislation affecting the provision of care, as well as higher patient expectations. This has led to a greater need for individuals who can demonstrate the necessary leadership and management competencies to ensure effective delivery of high quality dental care.

The FGDP(UK)'s Guidelines for standards in the development of leadership and management in the dental health sector build on the development of the DwSI guidelines. While they are aimed at those providing leadership and management in the delivery of dental care, many of the competencies are relevant to other healthcare disciplines, making the guidance of particular use to PCTs. Others who may benefit from the guidelines include employers, corporate organisations and dental practices, as well as dental professionals who wish to develop their leadership and management roles.

Future training models for DwSIs

The development of taught programmes to meet the requirements for future practitioners who wish to provide a special interest service has been an ambition of the FGDP(UK). The development of flexible, modular training programmes, aligned to the competencies as defined for the DwSI in each clinical area and leading to a recognised diploma, is one means of delivering such training.

The FGDP(UK) has developed a training programme for primary care dentists wishing to further their skills and/or develop a special interest in orthodontics. The programme, into its eighth month, takes place nationally over a three-year period, and combines academic teaching, workplace-based training and distance learning. During the programme, participants undertake approximately one session per week of clinical teaching and observation supported by a specialist trainer (a consultant or specialist practitioner). The training programme leading to a recognised diploma for primary care dentists, provides a quality standard to assist PCTs wishing to contract with dentists for special interest services.

In the same way, the FGDP(UK)'s Diploma in Restorative Dentistry, which includes modules in advanced periodontics and endodontics, enables practitioners to develop enhanced skills in a structured and progressive environment, which supports workplace-based training.

New certificate programmes in conscious sedation and minor oral surgery are planned for next year. The Certificate in Conscious Sedation will offer a learning and accreditation process for dentists already providing or planning to provide a service in sedation for dentistry, and will allow practitioners to develop the knowledge and skills necessary to use a range of conscious sedation techniques with confidence and safety.

The syllabus, curriculum and learning outcomes for DwSIs in minor oral surgery will inform the development of the Certificate in Minor Oral Surgery, and provide a training pathway for those practitioners wishing to gain accreditation as a DwSI in minor oral surgery with their local PCT. The Certificate will also, where necessary, provide practitioners with an opportunity to develop their surgical skills in preparation for other clinical diplomas with a surgical component.

Recognition of training towards specialisation

It would be a logical progression for DwSIs who wanted to go on to train to become specialists and/or NHS consultants to be able to have their accredited prior learning, training and experience recognised towards completion of full specialist training.

For example, the curriculum for the British Orthodontic Society/FGDP(UK) training programme leading to the Diploma in Primary Care Orthodontics will be mapped against the M(Orth), providing the potential for a general dental practitioner to progress beyond the diploma level towards specialisation in the future, taking into account training completed en route.

Local solutions: the future of DwSIs

Given that the appointment of a DwSI is a local decision, regional training programmes that take into account the health needs of the local population and strategic direction of the PCT are appropriate. Thus, local postgraduate dental deaneries will have a role in providing training for practitioners wishing to develop special interests.

To date, there has been local commissioning of DwSIs across England, but the overall provision is scant, albeit growing. The FGDP(UK) will continue to work with the DH and other relevant agencies such as Primary Care Contracting to disseminate information on local schemes with a view to sharing good practice and promoting the DwSI as a commissioning tool, where appropriate.

The FGDP(UK) also continues to promote the concept of the 'enhanced practitioner' in primary care, both as an alternative to a career in specialist dentistry and for the opportunity it affords generalists to develop their professional careers.

To find out more about DwSIs, or to view the guidance, visit http://www.fgdp.org.uk/dwsi/.

Sharon Drake is the Deputy Registrar at the Faculty of General Dental Practice (UK). Contact sdrake@rcseng.ac.uk.