Traditionally, since the Dentist's Act made a qualifying dental degree or diploma compulsory, the career path to become a dentist was unidirectional and not often deviated from. It is the same pathway that I myself followed; I left school after A-levels at 18 and went straight to dental school, gaining my degree and registration to practice dental surgery five years later. There is now the increasing trend, for people to train as one dental professional, to then return to education and re-train as another. This mobility within the profession can only be beneficial to patients as those wanting to re-train often show increased determination and ambition to provide a high standard of care, as well as having a broadened experience of the profession. The most common professionals to re-train are dental nurses and hygiene-therapists, often becoming dental surgeons. The cynic might say that the financial aspect to becoming a dentist was the main motivation to do this, but I feel that the ability to diagnose, the increased clinical responsibility and freedom are more likely to be the main motivation. Financial reward is important but if it is the sole reason to practise it does not lead to a happy and fulfilled career.
In my opinion any effort to increase clinical skills, whether by re-training or attending continuing professional development courses, is noble. A threat to this is direct access. Recently, partly due to pressure from the Office of Fair Trading (OFT), the General Dental Council (GDC) has been considering the removal of the conditions set out in 'Scope of Practice' to allow other professionals to see and assess patients themselves, without the prior prescription of dentists. The only current exception to this is clinical dental technicians who provide dentures directly to patients. On the face of it, direct access may sound like a good idea, but I have serious doubts as to whether such a move would be in the interest of patients, the public or the profession.
The assessment of a patient's needs in dental care is the most important aspect of treatment. The difference between a good practitioner and one who excels is the ability to formulate an effective treatment plan. Most failures in treatment are due to poor planning and anticipation of issues. As mentioned above, this planning is traditionally the realm of the dental surgeon and the difficulty of this task is reflected in the length of the undergraduate dental course. As well as this aspect, the depth and broad nature of the BDS gives its holders the ability to deal with complications and solve problems. I would be concerned by this task being given to professionals without the same breadth of training, due to the need to deal with unforeseen issues and plan treatment around these. Is it acceptable to place patients in a situation where they are having treatment given by professionals who do not have this breadth of knowledge that allows problems to be effectively managed? I am aware that it could be argued that dental surgeons routinely refer patients to more specialised colleagues, so why is it not acceptable to have the same situation for dental hygiene-therapists? The situations where a broad knowledge base would help a professional to provide treatment would require so many referrals, that a dentist would be inundated with referral requests for treatment from hygiene-therapists. This is less likely to occur if a patient has already been screened and deemed suitable to treatment by a hygiene-therapist by a dentist.
The dilution of professional duties is not a new concept. To draw a parallel between the medical and dental professions, medical nurses have been undertaking duties that traditionally have been part of the role of doctors for a long time. The difference between these two parallels is that doctors and nurses seldom practise in isolation. If direct access becomes a reality (and I firmly believe it will) then it will commonly create situations where dental hygienists and therapists practise completely independently from dental surgeons.
The conditions dentists diagnose most frequently are caries and periodontal disease. There is the belief that caries and periodontal disease require a five year dental degree to diagnose. I find this hard to agree with, but there is certainly a difference in diagnosing a condition and knowing the best way to treat it. Take a carious lesion for example, occlusal caries may not show on a radiograph as a true representation of its depth, the same might occur in a different lesion that appears at first to be shallow, but is in fact more extensive. In such a clinical instance, carious exposure may be a very real possibility. Conventionally, if a hygiene-therapist exposes a pulp, there should be a dentist there to advise on or even take over management. In a situation where a hygiene-therapist is practising in isolation, then how would this be managed as a hygiene-therapist is not able to offer root canal treatment, extractions or prescription of analgesics or antibiotics if complications arise? It worries me again that this isolated practise is not in the best interests of our patients.
The BDS delivers a level of medical training that allows dentists to assess whether patients with complex medical histories are suitable for routine dental treatment in general dental practice. The ability to recognise when a patient may need referral to another medical or dental professional is also important, for example in the case of oral cancer or other oral and mucosal conditions. Even dentists are not perfect at noticing these instances, so surely it must be best to give as much training as possible to all dental professionals in diagnosing these conditions. To place dental hygiene-therapists into a position where they can practise in isolation without giving more training really is not the best way of promoting better diagnosis of oral pathologies.
There is also the issue that the OFT seems to have forgotten, that the cost of dental treatment is high due to the high costs of operating a dental practice. This would not change just because the operators of the practice were hygienists and therapists, materials are not any cheaper and bills are no less. The argument that the charge for the clinician's time would be less is flawed, why should a hygiene-therapist be paid any less for work that is the same? Why would an exam, filling or any other treatment that took the same time, skill and use of materials cost differently? Is the idea of the OFT that a separate tier of service should be created to give patients more choice in treatment? If I were a hygiene-therapist, I would be insulted by their assumption that their work is any different in grade and quality to that of dentists.
I think the general use of hygiene-therapist's skills in clinical practice is often neglected and therefore the frustration of under-use is understandable. The opportunity of direct access is appealing as this underuse means the full advantage of the hygiene-therapist is not taken. Direct access would remove the need for a dentist's prescription and permission to treat. One cannot help but think that this would be unfortunate as all direct access will do is fragment and make impossible the teamworking that is fundamentally in both the interest of patients and the profession. It is impractical, unreasonable and unrealistic to expect patients to distinguish between a dentist and hygiene-therapist. I imagine most patients will not understand why they would be told to go and see a dentist after having seen a hygiene-therapist for treatment or for further investigation, especially if this treatment is within a different practice. It would also be unrealistic to expect a dentist to accept a referral from a dental care professional (DCP) and not carry out their own assessment and examination. This will potentially lead to wasting the patient's time, extra radiographs (if communication between DCP and dentist is not up to standard) and extra cost potentially to the patient. A recent survey by the GDC found that only a tiny percentage of the population surveyed was aware of the differentiation between hygiene-therapist and dentist and practically no one surveyed could accurately explain this difference if acknowledged. If direct access was brought in, I do have concerns how this perception could be changed, is it right to be confusing our patients?
In conclusion, direct access would create more isolation of different dental professionals; it would surely undermine the team focused approach that the GDC and the profession as a whole has been aiming for. I would welcome any change in the profession that was in the best interests of our patients. At this time, I feel that I cannot embrace direct access as I cannot see the benefits to those who we treat. The GDC is currently asking for ideas on direct access in the form of a questionnaire; I would urge anyone who feels strongly on this issue, whichever side of the argument their opinion falls upon, to take part. The questionnaire can be found at www.gdc-uk.org.