Much confusion still surrounds the role of dental therapist. Josephine Stockley sorts the facts from the fiction.
I have been working as a dental therapist on and off since 1979 in just about every setting possible, bar the armed forces. I have worked in community clinics in South and East London, Somerset, Bath and Bristol, in a major London teaching hospital treating medically compromised patients and those with compliance issues, in Western Australia, as well as busy PDS dental access centres in Bath and Bristol. In addition to this I currently work at Bristol Dental Hospital as a tutor dental therapist for two days a week; the other three days I spend as a clinician in dental access centres and community clinics.
Dental therapists (which will be referred to as DTs in this article) have been trained in the UK since the early 1960s. The first training school for DTs was situated in New Cross Hospital in South East London. Sixty students were trained each year until the school's closure in 1983.Footnote 1 A much smaller training establishment was then set up at the London Hospital in Whitechapel; eight students were trained there on a dual course for hygiene and therapy; since then many training courses for DTs have been established around the country.
Until 2002 DTs were limited as to where they could work, as unlike dental hygienists they were not allowed to work in general practice. When considering this one has to realise the reason for training DTs initially was to make up for a shortfall in dental practitioners in the then 'school dental service'. Following the war years and into the 1960s the caries rate was high and the school dental service at that time did 'check ups' on children in schools. These children were then invited to have their treatment done at the 'school dentist' so it was important that there were enough clinicians to carry out any necessary procedures.
To this effect DTs were only allowed to be employed in the 'salaried services', for example the school dental service, teaching and district hospitals or the armed forces. The school dental service eventually became incorporated into the community dental service which in turn employed the majority of the DTs working in the UK.
2002 saw a number of changes for UK DTs. Firstly, legislation changes made it possible for them to be employed in all sectors of dentistry. This was a very welcome move for DTs, as up until then they were the only members of the dental team who had restrictions imposed on them regarding where they could be employed.
Other important changes that were made in 2002 allowed expanded duties for both DTs and dental hygienists, thus widening the list of procedures they could carry out; this was of course subject to having attended verifiable training courses specific to the various procedures.
DTs and dental hygienists were then able to undertake the administration of inferior dental block local anaesthesia (previous to this they were only allowed to administer infiltration local anaesthesia). DTs could also carry out pulp therapy on primary teeth and prepare and fit pre-formed crowns to primary teeth, whilst both DTs and dental hygienists could re-cement crowns on adult teeth on a temporary basis and take impressions.
Recognition & duties
It would be fair to say that there are still many members of the dental profession who are unaware of what procedures DTs are able to undertake. This is, I believe, partly due to the fact that the concept of team training has not been widely adopted across all training establishments. This has now changed and DTs and dental hygienists are training alongside other dental care professionals. This ensures other clinicians are made aware of the duties the dental therapist can carry out and treatment plan accordingly.
“...there are still far too many health care professionals who have never heard of a dental therapist.”
DTs have always been able to treat adults as well as children but there is still the perception amongst some dentists that they only treat children; this may be due to the fact that they were previously employed mainly in the community setting, but DTs carry out exactly the same cavity preparation and restoration on the same teeth, on the same patients as a dentist. What they are not trained to do is root canal therapy on permanent teeth, extraction of permanent teeth, the fitting of crowns, bridges or dentures.
Since 2002 DTs have been employed in some practices to carry out the more routine restorative procedures. This allows the dentist to spend their time carrying out the more specialised and complicated work. This makes sound economic sense, as not only can DTs lessen the burden for dentists regarding restorative work, they can also give advice on oral health, instruction on tooth brushing techniques, diet advice etc plus take any radiographs which may be needed for the patient.
Dually qualified dental hygienist/therapists are able to give comprehensive holistic care to patients which covers extensive periodontal treatments as well as routine restorative work.
The DT's current list of permitted duties
Dentists considering employing a dental therapist within their practice should take into account the full range of duties they can carry out. These include:
Intra and extra oral assessment
Record indices and monitor disease
Scaling and polishing
Apply materials to teeth such as fluoride and fissure sealants
Take dental radiographs
Provide dental health education on a one to one basis or in a group situation
Routine restorations in both primary and permanent teeth, from Class 1-V cavity preparations
Can use all materials except pre cast or pinned placements
Treat all types of patient
Extract primary teeth under local analgesia.
From 1 July 2002 following legislative changes, DTs can, provided that they have completed appropriate training, perform these extended duties:
Pulp therapy treatment of primary teeth
Placement of pre formed crowns on primary teeth
Administration of inferior dental nerve block analgesia
Temporary replacement of crowns and fillings
Treat patients under conscious sedation provided the dentist remains in the surgery throughout the treatment.
As detailed above the list of procedures a DT may carry out is fairly extensive. DTs need a treatment plan written by a dentist prior to commencement of any procedures being undertaken on patients. Some dentists have raised concerns regarding how to employ and remunerate DTs. Some dental hygienists and DTs are self employed, and dentists employing DTs in this fashion should expect to pay at least the hourly rate they would expect to pay a dental hygienist and indeed may need to consider what they would be prepared to pay for restorative treatments which may involve irreversible procedures such as cavity preparation, extractions etc.
Some practice principals are now moving away from employing clinicians on a self employed basis. When looking to employ a dental therapist within the practice team a full time salary could be comparable to say an NHS band 6 agenda for change salary, which ranges from £24,831-£33,436, or for a more experienced clinician it may be fair to consider the equivalent of band 7 which ranges from £29,789-£39,273 (April 2009).
One needs to consider what one would pay if employing an associate dentist and work out the economic pros and cons. If a dental therapist is taken on as an employee it would be fair to expect them to engage in the mandatory CPD requirements and remuneration regarding this would need to be considered when looking at the contract of employment. Also, DTs must be registered with the GDC and need to have professional indemnity protection in place. Like dentists, DTs generally require a dental nurse, therefore this should also be taken into consideration from a cost point of view.
DTs generally have excellent patient management skills which can be particularly useful when very anxious patients present. Rather than taking up a dentist's valuable clinical time it may be pertinent to refer the patient on to a dental therapist for acclimatisation sessions. This use of a dental therapist can be a real practice builder. We are all too aware of the patients that present with the greeting 'I hate dentists'. Irksome though this is it is generally borne out of fear and it is useful to be able to say 'I could refer you on to our dental therapist who may be able to help you to overcome your fear by incorporating a step by step approach to your treatment'. Many patients can be won over if some time is devoted to them and procedures are thoroughly explained.
I spent 12 years out of dentistry because there were no dental therapist positions available. During this time I worked for the pharmaceutical industry where I acquired presentation skills, IT skills, teaching skills and management skills; these have all been useful since my return to dental therapy in 2000.
I, personally, have been very lucky to have worked with some amazing clinicians, nurses and support staff. While there are frustrations about job opportunities I have never regretted my career choice. I still gain as much satisfaction from restoring teeth today as I did when I first qualified. However, some clinicians are still reluctant to refer patients to DTs for restorative treatment. This may be due to the fact that they are unaware of the duties DTs can carry out which in turn goes back to the concept of team training. It may also be due to the fact that they are newly qualified themselves or are not overly confident about carrying out certain procedures so may be less likely to refer these on to a clinician who they perceive as 'less qualified than themselves'. Education for the dental team as a whole is the key factor here as there are still far too many health care professionals who have never heard of a dental therapist and when they do come across us assume we are not clinicians. It may be that in the future a name change such as 'oral health practitioner' may be the answer ... who knows?
For further advice about employing a dental therapist Josephine recommends contacting the British Association of Dental Therapists or the British Society of Dental Hygiene and Therapy.
*Also see: Lyall J. 'But for New Cross, dentistry would be the poorer.' Vital winter 2008; 14–15.