Last year the General Dental Council introduced new standards guidance for the dental team. Section 7.1.1 of the guidance states: “you must find out about current evidence and best practice which affect your work, premises, equipment and business and follow them”.
The onus is now clearly on registrants to seek out and implement the best current evidence and
practice; overlooking a new directive or policy will no longer be acceptable. Associates, DCPs and nurses can no longer use the shield of their principals or practice managers and will be personally liable for updating themselves on current best
practice and evidence.
So where do we find out about current evidence and best practice from? Representative bodies, Indemnifiers, the Department of Health and Cochrane Reviews can all provide some useful help but there is another organisation that provides the gold standard for evidence based practice and unless you as registrant are conversant with its recommendations, then you are at risk if regulators decide to investigate your practice.
The National Institute for Health and Care Excellence (NICE) provides guidance that supports healthcare professionals and others to make sure that the care they provide is of the best possible quality. It provides independent, authoritative and evidence-based guidance on the most effective ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation. It does this in many ways, but primarily by the issuance of clinical guidelines, technology appraisals, guidance for public health, diagnostics, interventional procedures, medical technologies and cancer service. It
also issues Quality Standards that define what high quality care should look like for a specific disease,
condition or clinical area.
Over 40 clinical guidelines have been issued by NICE; technology appraisals, quality standards and interventional procedures guidance relevant to dentistry. You will no doubt be familiar with the guidelines on wisdom tooth removal, dental recall and infective endocarditis, but are you familiar with the published guidance on anaphylaxis, child maltreatment, head and neck cancer or smoking cessation?
In this series of articles we will examine the lesser known but equally important guidance documents and investigate the value of integrating this guidance into your clinical governance policies. We will examine the guidance under three specific areas - orally relevant, medically relevant and policies relevant to good clinical governance. The guidance on dental recall, wisdom tooth removal and infective endocarditis have been well publicised so won’t be reviewed in these articles.
Orally relevant snoring. The guidance on snoring relates to the use of soft palate implants to help control simple snoring (IPG240). These implants are suitable for simple snoring only and are not recommended for use in cases of sleep apnoea (IPG241). The implants are designed to stiffen the soft palate by fibrosis thereby reducing the soft tissue vibration associated with snoring.
No specific guidance has been published by NICE on the use of mandibular repositioning appliances and any dentists offering this form of treatment should make patients aware of other treatment options as part of a valid consent process. Non-surgical options include weight loss, smoking cessation, changes in sleeping position, avoidance of alcohol and sleeping tablets. Surgical options include injection snoreplasty, radiofrequency ablation of the soft palate (IPG124), laser-assisted uvulopalatoplasty, uvulopalatopharyngoplasty and cautery-assisted palatal stiffening.
Division of ankyloglossia (tonguetie for breastfeeding). Dentists, particularly those working in secondary care, may be asked for an opinion on the treatment of tongue-tie in young infants. Current evidence (IPG149) suggests that there are no major safety concerns about division of ankyloglossia and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support its use.
Tooth decay – HealOzone.
HealOzone is not recommended for the treatment of tooth decay (occlusal pit and fissure caries and root caries), except in well-designed randomised controlled trials (TA92).
Mini-implants for orthodontic anchorage. There is limited evidence that mini/micro screw implantation provides adequate orthodontic anchorage and there are no major safety concerns (IPG 238).
Customised titanium implants for orofacial reconstruction. Current evidence (IPG447) on the efficacy of inserting customised exposed titanium implants, without soft tissue cover, for complex orofacial reconstruction is limited. With regard to safety there is concern about the risk of recurrent infection and other complications resulting from long-term exposure of the implants. However the procedure is considered safe and effective if the implants are covered by soft tissue (IPG449).
Trigeminal neuralgia – Stereotactic radiosurgery using the gamma knife
Stereotactic radiosurgery with the gamma knife is used to treat trigeminal neuralgia. This is a condition characterised by sudden bursts (paroxysms) of facial pain. These bursts may be triggered by touch, talking, eating or brushing teeth. Trigeminal neuralgia is rare; the annual incidence is 4 per 100,000 of the population.
For most people, the paroxysmal bursts of severe pain continue indefinitely. The first-line treatment for trigeminal neuralgia is medication. Surgery is considered for people who experience severe pain despite medication, or who have adverse effects from medication. Current evidence on the safety and efficacy of stereotactic radiosurgery using the gamma knife appears
adequate to support the use of this procedure (IPG85).
Head and neck cancer
NICE has issued guidance on the organisation of healthcare for adults with head and neck cancers (CSGHN). The guidance recommends which healthcare professionals should be involved in treatment and care, and the types of hospital or cancer centre that are best suited to provide that healthcare.
The key recommendations are:
- Cancer networks should decide which hospitals will diagnose, treat and care for patients.
- Multidisciplinary teams should be responsible for every patient.
- Clear systems should be in place for patients to be seen quickly by specialists.
Dentists may be the first clinicians to suspect a head and neck cancer so should be familiar with local head and neck cancer pathways to ensure prompt specialist intervention.