Summary Review/Effective Practice and Organisation of Care

Evidence-Based Dentistry (2013) 14, 36-37. doi:10.1038/sj.ebd.6400926

Evidence of improved access to dental care with direct access arrangements

Question: What is the evidence for the benefits and risks of introducing direct access to DCPs for patients, into dentistry in the United Kingdom?

Nicola P T Innes1 and Dafydd J P Evans1

1University of Dundee, Unit of Dental and Oral Health, Park Place, Dundee, Scotland, UK

Turner S, Tripathee S, MacGillvray S. Benefits and risks of direct access to treatment by dental care professionals: A rapid evidence review. Final Report to the General Dental Council. (available on-line version of literature review on direct access.pdf).

Address for correspondence Steven Turner, Dental Health Services Research Unit, University of Dundee. E mail:



Data sources


Medline, CINAHL, PsycINFO, SCI, SSCI, Cochrane Database of Systematic Reviews, Business Source Premier, Google scholar.

Study selection


Primary or secondary reports and studies, published in English, after 1993, likely to include data relevant to direct access, report on empirical data relating to the operation of that system.

Data extraction and synthesis


After initial screening, titles and abstracts were assessed by two reviewers, and disagreements resolved by the third. Full texts of these eligible ones were then assessed by the team until consensus reached. Data extraction by one reviewer was checked by a second and disagreements resolved by discussion with the third. Study quality was assessed through reference to CASP or SIGN checklists. Descriptive analyses and synthesis of findings were given.



From the 1,733 studies yielded from the search, over 100 research dental and other health-related papers were identified as relevant. Thirty-five studies were eligible for inclusion under dental health care direct access and 57 under non-dental health care direct access literature. The quality of the evidence was varied but on the whole assessed as moderately good quality.

There was no evidence of increased risk to patient safety in any of the included seven studies. Four studies on appropriateness of DCP referrals reported a high proportion of over-referral, one study found under-referral and one good agreement regarding referral decisions.

Six of the seven studies looking at DCPs' knowledge or support to patients for smoking cessation, diabetes, child abuse and domestic violence found deficiencies in DCPs' knowledge or support to patients, but these studies didn't have evidence to suggest how this compared to dentists.

Increasing access to dental therapists and hygienists (whether indirect, general or without supervision of a dentist) according to ten studies, resulted in greater access to and use of dental services by underserved populations. Three studies suggested variable and, at most, modest cost savings to patients and service providers. High levels of patient satisfaction were found in all eight studies reporting this, and DCP job satisfaction was reported to be higher with direct access.



Although over-referral of patients to dentists was suggested and a need for training on assessment and referral skills, there was no evidence of significant issues of patient safety from the clinical activities of DCPs. There was strong evidence of improved access to dental care with direct access arrangements, cost benefits to patients/service providers and high levels of patient satisfaction.