Proposals for a dental care professional qualification in special care dentistry: results of a UK survey

Transcription

1 Journal of Disability and Oral Health (2009) 10/ Proposals for a dental care professional qualification in special care dentistry: results of a UK survey Gillian Jones BDS, DDPHRCS (England), MCDH, FFPH 1, Janet Griffiths LDS (Bristol), BA (OU) 2, Neil McCusker BDS, MFDS 2, Colleen Rooney BDS, MFDS 3, Sue Hilton Dip Dent Hygiene, Dip Dental Therapy 4, Lindsay Hunter BDS, MScD, PhD, FDS(Paed)RCS (Edinburgh), FHEA 5 1 Peninsula Dental School, University of Plymouth, UK, 2 University Dental Hospital, Cardiff, UK, 3 Bristol Dental Hospital, Bristol, UK, 4 Community Dental Service, North Wales NHS Trust, 5 School of Dentistry, Cardiff University,UK. Abstract Aim and objectives: To investigate demographic details, scope of practice, mandatory training, opportunities for Continuing Professional Development (CPD) and interest in a post-qualification course in Special Care Dentistry (SCD) amongst dental hygienists and dental therapists working in the United Kingdom. Design: There were 5,224 dental hygienists and 461 dental therapists identified as registered with the General Dental Council (GDC) for 2006 and permitted to practise within the United Kingdom. A self-administered questionnaire was designed for data collection. A copy of the questionnaire was sent to all dental hygienists and dental therapists with registered addresses in Wales and one in ten of those with registered addresses in England, Scotland and Northern Ireland, giving a sample of 630. Results: A total of 262 completed questionnaires were returned after one mailing, a response rate of 41.6%. The results reveal some interesting trends that may be relevant to the development and implementation of a dental hygienist /therapist qualification in SCD. Conclusions: This study has shown that training courses in SCD for dental hygienists and dental therapists are likely to be highly valued and well-attended provided that funding issues are resolved. The authors suggest that such courses should, ideally, be overseen by one group and that closer links between dental hygiene/therapy and dental undergraduate training should be developed. Introduction The changing disease patterns of the last few decades, with a decline in caries experience, fewer dental extractions, and an increasingly elderly population who are maintaining a functional dentition for longer, has led to a need to redefine the role of each member of the dental workforce so that appropriate dental services can be provided for all the community (Baltutis and Morgan, 1998). These services, should, ideally, be widely accessible and affordable, offer choice to patients and provide high quality care with an emphasis on prevention of disease rather than only treating its effects. The Nuffield Foundation (1993) argued that one way to achieve such a service in the United Kingdom in particular was through a policy of wider skills mix in the dental team. In 2005, the General Dental Council (GDC) announced its support for a Specialty of Special Care Dentistry, (SCD) which is concerned with the improvement of the oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often,

2 116 Journal of Disability and Oral Health (2009) 10/3 a combination of a number of these factors (JACSCD, 2003). SCD largely falls within the definition of disability as defined by the Disability Discrimination Act ( 1995) a physical, sensory or mental impairment, that has an adverse effect on the individual s ability to carry out normal day-to-day activities, that the adverse effect is substantial and long-term, has lasted for 12 months or is likely to last for 12 months or a lifetime. Fiske et al. (2007) estimated that between 8.6 and 10.8 million people in the UK have a disability. Therefore the need for a wider skill mix within the dental team is especially true in SCD, where various factors are more likely to impact on both need and demand. These principally relate to the changes in the demography of the population, public values and expectations, reconfiguration of health service delivery and dental service developments (British Society for Disability and Oral Health, 2006). The legal requirements of the Disability Discrimination Act (1995) place an even greater responsibility on the dental team to be non-discriminatory in practice. The report of the Independent Inquiry into Inequalities in Health (Acheson, 1998) highlighted the need to reduce inequalities in the health of vulnerable groups. These inequalities are demonstrated in dentistry by studies that indicate that individuals with a learning disability or mental health problems have similar oral diseases but experience poorer oral health and less successful health outcomes from dental care than the general population (Fiske et al., 1999; British Society for Disability and Oral Health 2000; Royal College of Surgeons/ British Society for Disability and Oral Health, 2001; British Dental Association, 2003;). Inequalities are also shown in lower levels of oral health amongst people with a range of conditions such as cerebral palsy (Russell and Kinirons, 1992), epilepsy (Fiske and Boyle, 2002) and multiple sclerosis (Baird, 2003). Various studies have also demonstrated that treatments for people with a disability are more likely to involve extractions rather than fillings, crowns or bridges (Steele et al., 1998; Tiller et al., 2001; Lawton, 2002). Publication of the Nuffield Report in 1993 (which recommended a new type of auxiliary, the oral health therapist to replace existing dental hygienists and dental therapists) and the GDC Auxiliary Review Group of 1997 (DARG, 1998), which concluded, dental care in the next century will be provided by a multi-skilled team comprising members of the dental profession and professionals complementary, all led by a dentist, raised the profile of Dental Care Professionals (DCPs) and led to the emergence of combined dental hygiene and dental therapy training programmes. Equal working opportunities were recommended by the GDC in 1999 allowing dental therapists to work in all sectors of dentistry, including the general dental service. The range of duties for dental hygienists and dental therapists who had completed appropriate training was also extended, the introduction of these additional responsibilities reflecting the increasingly important role of these DCPs in the provision of dental care (Ward, 2006). In 1997/8, the British Society for Disability and Oral Health (BSDH) established the first course in SCD for dental nurses. After piloting in a number of centres, the course was adopted by the UK National Examining Board for Dental Nurses (UKNEBDN) in Those dental nurses who had successfully completed the pilot courses were retrospectively awarded the Certificate in Special Care Nursing by UKNEBDN. In 2005, BSDH set up a Working Group to review the development of a qualification in SCD for dental hygienists and dental therapists. This initiative was viewed as the first step towards giving formal recognition to dental hygienists and dental therapists working in the field, the definitive aim being the introduction of an accredited qualification analogous to that already available for dental nurses. BSDH recognised that a significant number of dental hygienists and dental therapists provided care for people requiring SCD. Furthermore, it was recognised that there was little information on the special care content in their training, and that their contribution to SCD was not being recognised. The Working Group s remit was: To review the existing courses and qualifications in SCD To determine the interest in participating in such a course To develop a syllabus based on the clinical needs of dental hygienists and dental therapists To identify entry criteria. Having reviewed the UKNEBDN Certificate in Special Care Dental Nursing (UKNEBDN SCDN) and the requirements for the Royal College of Surgeons of England s Diploma in Special Care Dentistry (JACSCD, 2003), the Working Group recommended that a revised syllabus based on UKNEBDN SCDN would be appropriate. A draft syllabus, reflecting a chronological approach to impairment and disability and the clinical responsibilities of dental hygienists and dental therapists was subsequently submitted to the BSDH committee. This was accompanied by a questionnaire designed to investigate the likely interest in such a course. During the course of the above discussions, the Department of Dental Postgraduate Education in Wales expressed interest in the proposal and the possibility of piloting a course in Wales for dental hygienists and dental therapists. The results of the preliminary questionnaire survey funded by the Department are presented in this paper.

3 Jones et al.: Qualification in special care dentistry 117 Materials and methods A self administered questionnaire was designed for data collection. This comprised 18 closed questions including demographic details, scope of practice, mandatory training, access to and funding for Continuing Professional Development and a prediction of interest in a postqualification course in SCD, specifically one provided in Wales. A total of 5,224 dental hygienists and 461 dental therapists were identified as registered with the GDC for 2006 and permitted to practise within the United Kingdom. As the study was funded by the Department of Dental Postgraduate Education in Wales, and designed to establish interest in courses provided in Wales, a copy of the questionnaire was sent to all dental hygienists and dental therapists with registered addresses in the Principality. In addition, a copy of the questionnaire was sent to each tenth dental hygienist or dental therapist with a registered address in England, Scotland and Northern Ireland, giving 630 recipients in all. This single mailing included a covering letter and a postage-paid return envelope. Results Data are presented for the whole of the United Kingdom; results referring to the provision of a pilot course in Wales have been used to inform the decision of the Department of Dental Postgraduate Education in Wales as to the viability of the proposal to offer a course for DCPs in SCD. A total of 262 completed questionnaires were returned after one mailing, a response rate of 41.6%; in the response, dental hygienists and dental therapists in England and Wales were equally represented: 113 respondents (43.1%)), with 31 respondents (11.8%) from Scotland and 5 (1.9%) from Northern Ireland. One hundred and eighty questionnaires (68.7%) were returned by dental hygienists, 50 (19.1%) by dental therapists and 32 (12.2%) by dually qualified dental hygienist-therapists. The majority of respondents (185, 70.6%) qualified prior to 1990; 57 (21.8%) respondents qualified between 1991 and 2000, while 20 respondents (7.6%) were more recent entrants to the profession. Table 1 illustrates the settings in which respondents were employed. Expanding on their roles and responsibilities in these settings, 102 respondents (38.9%) stated that they worked with children and adolescents, while 129 (49.2%) stated that they worked mainly with adults and 125 (47.7%) with older people. These responses were not mutually exclusive. One hundred and three respondents (39.3%) indicated that they had experience of oral health promotion activities and 80 (30.5%) of providing domiciliary dental care. Table 2 illustrates the range of disabilities and conditions experienced by patients treated by respondents in their current practice. Table 3 illustrates the topics currently covered by mandatory training. Half the respondents, 131(50%), reported they had received training in Basic Life Support, and 117 (44.7%) respondents had received training in Health and Safety. Training in consent was reported by just over a third of respondents, 96 (36.6%) and approximately 1 in 5, 53 (20.2%), had received moving and handling training. Thirty-five (13.4%) respondents reported training in the principles of Physical Intervention. A minority of respondents (110, 42.3%) stated that they regularly received information on appropriate courses for professional development from their local dental postgraduate department. The majority of respondents (201, 76.7%) indicated that they had experienced no problems in obtaining study leave. One hundred and thirty five respondents provided information as to their source of funding for study leave. Table 4 illustrates these responses. Table 5 identifies the perceived barriers to accessing continuing education; it should be noted that responses were not mutually exclusive. One hundred and forty-one respondents provided information relating to their interest in completing a course in SCD. Of these, 81 (57.5%) indicated that they would currently be interested in pursuing this avenue; 16 (11.3%) thought that they might wish to complete extra skills training in the future, while 31 (22%) were currently undecided. A small percentage of respondents (9%) stated that, because of their existing job descriptions and roles within their current employment, they would not currently need to gain additional training in the care of individuals requiring SCD. Eighty-eight (33.6%) respondents provided information as to how they would like to see a course in SCD delivered, the majority of these (53.4%) indicating that 8-10 study days extending over a period of 8 months would be their preferred option. Discussion This study assessed the profiles, working patterns, training, opportunities for CPD and interest expressed in the need for a SCD qualification amongst dental hygienists and dental therapists working throughout the UK. The response rate was, unfortunately, low. While the results must therefore be interpreted with caution, some trends are apparent that may be relevant to the development and implementation of such a qualification; the results also demonstrate a lack of training in topics that are considered to be mandatory for all members of the dental team. The majority of respondents were dental hygienists and dental therapists who qualified before The report

4 118 Journal of Disability and Oral Health (2009) 10/3 Table 1 Employment settings of responding DCPs Setting General Dental Practice only 182 (69.5%) Community Dental Service only 47 (17.9%) Hospital Dental Service only 7 (2.7%) GDP/CDS 12 (4.6%) GDP/HDS 11 (4,2%) CDS/HDS 3 (1.1%) Table 2 Conditions currently encountered by responding DCPs (responses not mutually exclusive) Condition Frail and dependent older people 133 (50.8%) Respiratory diseases eg asthma, respiratory 130 (49.6%) infections Diseases of liver, kidney & gastro-intestinal 128 (48.9%) disorders, diabetes Fear of, and anxiety about, dental treatment 127 (48.5%) Cardiovascular disease eg angina, coronary artery 125 (47.7%) thrombosis, heart valve disease, stroke Neurological disorders eg epilepsy, multiple sclerosis, 122 (46.6%) Alzheimer s disease Blood and bleeding disorders eg anaemia, haemophilia, 120 (45.8%) effects of anticoagulants Auto-immune diseases eg rheumatoid arthritis etc 120 (45.8%) Sight, hearing and speech impairments 119 (45.4%) Physical disabilities eg arthritis, Parkinson s disease, 114 (43.5%) trauma, spinal injuries Learning disabilities 110 (42.0%) Mental health problems 105 (40.1%) Congenital disabilities eg cerebral palsy, muscular 95 (36.3%) dystrophy, cleft lip / palate Infectious diseases eg tuberculosis, hepatitis B and 90 (34.4%) C, HIV and AIDS, MRSA Terminal illness eg malignant disease 88 (33.6%) Alcohol, drug and substance abuse 85 (32.4%) Autistic spectrum disorders (ASD) 75 (28.6%)

5 Jones et al.: Qualification in special care dentistry 119 Table 3 Topics currently covered by mandatory training (responses not mutually exclusive) Topic Moving and handling 53 (20.2%) Basic Life Support 131 (50.0%) Principles of Physical Intervention 35 (13.4%) Consent 96 (36.6%) Health and Safety 117 (44.7%) Other 20 (7.6%) Table 4 Source of funding for study leave Source of funding (n=135) Community Dental Service 21 (15.6%) General Dental Service 5 (3.7%) Hospital Dental Service 1 (0.7%) Self 88 (65.2%) Combination 20 (14.8%) Table 5 Barriers to access to continuing education (responses not mutually exclusive) Barrier Funding 89 (34.2%) Geographical location 62 (23.7%) Lack of opportunity 33 (12.6%) Travel 39 (14.9%) Lack of information 31 (11.8%) Family commitments 47 (17.9%) of the Dental Strategy Review Group (1981) recognised that dental hygienists had an important role to play in the provision of preventive care, especially for people with disabilities. In the intervening period, the role of DCPs has continued to evolve. This survey found that the majority of dental hygienists and dental therapists work in the GDS. Promoting Better Health, the government s white paper on primary health care (HMSO, 1987) emphasised the general dental practitioner s role in SCD. Gallagher and Fiske (2007) also state that, it is appropriate for most people with mild or moderate disability to receive care from a primary care practitioner. Hunter et al. (2004), however, found that most dentists working in the field of SCD are working in the salaried community dental service. Fiske et al. (2002) discovered, there may only be access to limited dental care with practitioners unwilling or unable to provide routine dental care because of the skills, experience, facilities or remuneration available to them. The current regulations state that dental hygienists and dental therapists can only carry out permitted dental work under the direction of a registered dentist, and after the dentist has examined the patient. Consequently, the barriers to care provision perceived by the dentist could limit the access by dental hygienists and dental therapists to patients requiring SCD. These results have also shown that dental hygienists and dental therapists encounter a wide range of impairments and disabilities in providing care for all age groups but with the majority treating frail and dependent older

6 120 Journal of Disability and Oral Health (2009) 10/3 people. Interestingly, Bickley (1990) reported that 73.5% of dental hygienists found their training to be inadequate in dealing with individuals with mental illness. The additional comments made by those qualified for some years confirms this view and indicates that the training in many UK Schools of Hygiene and Therapy may not adequately provide sufficient experience and levels of competence for the provision of SCD. Evaluation of dental undergraduate courses also reveals an ad-hoc approach to education in SCD (Erridge, 1986; Federation Dentaire Internationale 1989). This can lead to preconceived ideas and prejudices about people requiring SCD and a lack of confidence in providing necessary treatment (Bickley, 1990). Kiyak (1988) describes the influence of dentists attitudes on people s ability to access dental services as well as preventive and restorative dentistry. The study also highlighted the need for positive attitudes towards disability and calls for specialist training to improve access to care. The majority of dental hygienists and dental therapists (57.5%) stated that they would be interested in completing a course in SCD. This still, however, leaves 42.5% who are either not interested at all, not interested at the present time or undecided. This, in combination with the overall numbers working in the GDS and the funding issues, indicates a need to improve the undergraduate curriculum for dental hygiene and dental therapy training and arrange appropriate postgraduate courses for those wishing to further enhance their skills. This is recognised by the National Working Group for Older People (2005), which recommends that appropriate training pathways should be developed for dental hygienists and dental therapists who wish to develop their expertise in treating older people with complex needs, a growing population that meets the definition of special care. Most dental schools are now developing joint undergraduate training for dental hygienists, dental therapists and dental students. This will develop the skills for the dental team to help, recognise their duty of care in the attainment of achievable outcomes for patients either specific medical, physical or mental health problems and to know the appropriate pathways for referral of patients whom they are unable to treat or who require further assessment. (Thompson et al., 2001). Grace (1996) and Mason (1994) also suggested that dentists and DCPs should be trained together as often as possible to abandon the us and them approach that exists in some areas. The results of this study clearly indicate a need for suitable SCD training for qualified dental hygienists and dental therapists to enable them to provide the most effective and appropriate dental care for their patients. From the results of this survey in relation to the numbers of dental hygienists and dental therapists prepared to attend a SCD course (similar to that already offered to qualified and registered dental nurses), it would appear that there would be a need for at least two courses each year in different areas of the UK and that this provision would need to be sustainable for the next 10 years allowing for a maximum of ten individuals on each course. Another question to be answered regarding a dental hygiene/dental therapy qualification in SDC Dentistry is in relation to the provision of funding. Gallagher and Fiske (2007) reported that individuals who have undertaken training in special care dentistry have been responsible for their own training and argued, it should not be left to the individual to fund their training in special care dentistry. The suggestion is made that funding for this extra skills training is likely to fall firmly within the remit of the NHS. The study results have demonstrated that the majority of dental hygienists and dental therapists are responsible for funding their own study leave and that the main barrier to continuing education is funding. Almost 1 in 4 found geographical location to be a limiting factor. It is of particular concern that only half the respondents (50%) had received training in Basic Life Support, training which is mandatory for all members of the dental team, and in the context of the GDC s forthcoming requirements for CPD for all DCPs. Ross et al. (2005) also highlighted this problem when they discovered that access to continuing education was difficult and funding for continuing professional development absent for the majority of dental hygienists in Scotland. This is an issue that must be addressed prior to the implementation of any further extra skills courses. Conclusion The Commissioning Tool for Special Care Dentistry (BSDH, 2006) stated that, The NHS has a key role in commissioning dental services, to ensure that the oral health of vulnerable groups is improved and that expertise in special care dentistry is developed. All members of the dental team have a role to play. This study has shown that the introduction of training in SCD for dental hygienists and dental therapists will be highly valued and well-attended provided the funding issues are resolved. To avoid re-inventing and re-working programmes, it is essential that the specialist society for SCD, the British Society for Disability and Oral Health, takes responsibility for developing, implementing, guiding, directing and overseeing courses with an additional role of ensuring quality standards are achieved for the GDC. Further developments within the dental hygiene and dental therapy undergraduate curricula to establish closer links with dental undergraduate training should also be investigated. It is vital that the profession address this issue because health inequalities are stubborn, persistent and difficult to change and are, widening and will continue to do so unless we do things differently (Department of Health,

7 Jones et al.: Qualification in special care dentistry ). Acknowledgments The authors would like to thank and acknowledge the support of Cardiff University Dental Postgraduate Department in carrying out this survey. References Acheson D. Inequalities in Health. Report of the Independent Inquiry into Inequalities in Health. Br Med J 1998; 317(7173):1659. Baird WO. Dental attendance pattern of people with multiple sclerosis. Master of Science in Health Services Research Dissertation; Leicester: University of Leicester, Baltutis L, Morgan M. The Changing Role of Dental Auxiliaries: A Literature Review. Aust Dent J 1998; 43: Bickley SR. Dental hygienists attitudes towards dental care for people with a mental handicap and their perceptions of the adequacy of their training Br Dent J 1990; 168: British Dental Association (2003) Oral Healthcare for Older People: 2020 Vision. London: British Dental Association. British Society for Disability and Oral Health. Oral health care for people with mental health problems: Guidelines and recommendations. Report of BSDH Working Group British Society for Disability and Oral Health. Commissioning Tool for Special Care Dentistry. Department of Health Dental Auxiliary Review Group. Report of the Dental Auxiliaries Review Group. London : BDA/JM Consultancy Ltd Dental Strategy Review Group. Towards Better Dental Health: guidelines for the future. London: DHSS, Department of Health. Tackling Health Inequalities: A Programme for Action; Department of Health Publications: London Disability Discrimination Act, Erridge PL. Dentistry for the handicapped: a survey of current teaching. Br Dent J. 1986; 161: Federation Dentaire Internationale. Commission on Research and Epidemiology. Report of Working Group 11 (Oral Health and the handicapped). Federation Dentaire Internationale. London Fiske J, Boyle C. Epilepsy and oral care. Dental Update 2002; 29: Fiske J, Dickinson C, Boyle C et al. Understanding special care dentistry. In Special Care Dentistry. pp1-8. London. Quintessence Publishing Fiske J, Griffiths J, Jamieson R et al. Guidelines for oral health care for long-stay patients and residents. Gerodontology 1999; 16: Fiske J, McGeoch, Savidge GF et al. The treatment needs of adults with bleeding disorders. J Disabil Oral Health 2002; 3: 59. Gallagher, JE, Fiske J. Special Care Dentistry: a professional challenge. Br Dent J 2007; 202: Grace M. Clinical dental auxiliary training. Editorial. Br Dent J 1996; 180: 81. Hunter ML, Hunter B, Thompson SA et al. Special Care Dentistry: attitudes of Specialists in Restorative Dentistry practising in the United Kingdom towards the creation of a new specialty. J Disabil Oral Health 2004; 6: Joint Advisory Committee for Special Care Dentistry, Royal College of Surgeons of England. Training in Special Care Dentistry Kiyak HA. Impact of patients and dentists attitudes on older persons use of dental services. Gerodontics 1988; 4: Lawton L. Providing dental care for special patients tips for the general dentists. J Am Dental Assoc 2002; 133: Mason D. The changing role of the dentist. Br Dent J 1994; 176: 5-9. National Working Group for Older People, Meeting the challenges of oral health for older people: a strategic review. Gerodontology 2005; 22 (Suppl 1): NEBN Certificate in Special Care Dental Nursing information pack. Nuffield Foundation. Education and Training of Personnel Auxiliary to Dentistry. London : Nuffield Foundation, Promoting Better Health: The Government s programme for improving primary health care. Cmnd249. London: HMSO, Ross M, Ibbetson RJ, Rennie JS. Educational needs and employments status of Scottish dental hygienists. Br Dent J 2005; 198: Royal College of Surgeons Faculty of Dental Surgery and British Society for Disability and Oral Health Clinical guidelines and integrated care pathways for the oral health care of people with learning difficulties. Russell GM, Kinirons MJ. A study of barriers to dental care in a sample of patients with cerebral palsy. Comm Dent Health; 10: Steele JG, Sheiham A, Marcenes W, Walls AWG. National Diet and Nutrition Survey; adults aged 65 and over. London: HMSO Thompson S, Griffiths J, Hunter ML et al. Development of an undergraduate curriculum in Special Care Dentistry. J Disabil Oral Health 2001; 1: Tiller S, Wilson KI, Gallagher JE. The dental health and dental service use of adults with learning disabilities. Comm Dent Health. 2001; 18: Ward P. The changing skill mix- experiences on the introduction of the dental therapist into general dental practice. Br Dent J 2006; 200: 193. Address of correspondence: Mrs GM Jones Senior Lecturer Peninsula Dental School John Bull Building Tamar Science Park Research Way Plymouth PL6 8BU gill.jones@pds.ac.uk