Andrew Barrs urges caution over the proposal to expand the scope of practice of clinical dental technicians.
This article is in response to the proposal made by the CDTA UK to expand the scope of practice (SOP) of clinical dental technicians (CDTs).
It could be argued that the CDT SOP is an area that the GDC needs to look at, especially with regard to care home dentistry. But many of the points made in the proposal are, in my opinion, very combative.
Let me first introduce myself. My name is Andrew Barrs.
I qualified as a denturist in 2000 through the George Brown College, Toronto, and then as a CDT through the Royal College of Surgeons in 2007. In addition, I am a former president of the British Association of Clinical Dental Technology (BACDT) and have attended many meetings and social occasions with other dental groups at the General Dental Council and other venues, so I know first-hand how CDTs are viewed within the wider dental profession.
I currently work as a full time CDT and run my own denture clinic. I have a wide range of dentists who I can refer patients to, for anything from a simple referral to more complex treatments including implants. In addition, I receive many referrals directly from dentists, who either do not enjoy making dentures, have not got a capable prosthetic technician or who feel I am better qualified at making a successful denture than they can. This then frees up their diaries to do more profitable work.
I also work part time, when needed, as a clinical advisor and expert witness for the GDC with regards to complaints and fitness to practise cases. Part of my job with the GDC is to read the information and evidence provided to me and then use my knowledge and expertise to write a report for them.
Proposal response
In this article, and in response to CDTA UK proposals, I will be questioning some of the points they have raised and will show an alternative point of view. I will also explain why I feel that CDTs are a very important, valued part of the dental team.
I feel, in most cases, we are well respected, and by working with good dentists who understand the benefits of working with a CDT, our current SOP enables us to provide an outstanding denture service with our USP. Although it is not perfect, I feel that our current SOP works very well while also doing a good job of protecting patients.
Remember, the GDC’s primary purpose is to protect patient safety and maintain public confidence in the dental professions.
There are nine principles that make up the GDC standards for the dental team. These are, I feel, the most relevant ones in this situation:
- 1.7.1 – You must always put the patient’s interests before any financial, personal or other gain
- 6.3.3 – You should refer patients on if the treatment required is outside your scope of practice or competence. You should be clear about the procedure for doing this
- 7.2.1 – You must only carry out a task or a type of treatment if you are appropriately trained, competent, confident and indemnified. Training can take many different forms. You must be sure that you have undertaken training which is appropriate for you and equips you with the appropriate knowledge and skills to perform a task safely.
I will now focus on the different sections of the CDTA UKs proposals…
Restrictive practice
Regarding the reference to access barriers and six million patients waiting for appointments, I am guessing that these figures are based on NHS statistics.
I would argue that NHS access statistics are not a fair reference point, because CDTs are unable to provide patients directly with NHS dentures as no CDT is allowed to hold an NHS contract. The only way a CDT can provide NHS dentures is if they work within a dental practice and, therefore, the work is under the auspices of the dentist.
All of the work provided by CDTs practising in their own clinics is on a purely private basis. Why then are the figures presented not based on private referrals where there are no patients waiting for appointments?
In my experience, my patients are able to be seen very quickly, and in some cases even on the same day for emergencies.
Best interests
The proposal says that CDTs often have to choose between the patients interests or complying with a restrictive SOP. Our SOP states: ‘Patients with natural teeth or implants must see a dentist before a CDT can begin treatment’.
I am not sure where the dilemma comes in. It is quite straightforward really – patients who have some remaining teeth need to be referred, and if you have a referral pathway in place, there are no issues.
I wonder what CDTA UK mean by best interest – is it in the patient’s best interest not to see a dentist? Or is it in the CDT’s best interest because they don’t have the effort, hassle, slight delay or the risk of losing a patient and they can start denture treatment straight away?
Oral health survey
The proposal also references findings from the ‘Oral health survey of adults attending dental practices 2018’ that an extra 211,640 extra dental appointments could be generated if CDTs did not have to refer patients for prescriptions.
The survey also says, which CDTA UK failed to mention, that:
- More than a quarter (27%) had tooth decay having an average of 2.1 decayed teeth and more than half (53%) had gingival (gum) bleeding
- Some 18% currently reported being in pain and the same number had experienced one or more impacts of poor oral health ‘fairly’ or ‘very often’ in the previous year
- Around two thirds of participants aged 85 and over did not have a functional dentition
- One in three had untreated tooth decay.
This information indicates to me that many partially dentate patients that present themselves to the CDT clinic are going to need treatment by a dentist. If this is the case, then wouldn’t it be far easier for the CDT to refer them for both the treatment and the prescription?
Is it not far better to delay treatment until the patient is dentally fit? Surely being dentally fit is in the patient’s best interest.
Research
I carried out some research of my own a few years ago at my clinic to see if there was a case for CDTs to increase their SOP. This was not something I was looking to do, but as president of the BACDT I felt it was important the association look at this matter. I was interested to see if CDTs could present a strong case based on my survey.
I kept a log of 100 patients and these are some of the points I looked at:
- Were they new or existing patients?
- Did the patient come directly to me or via a referral from a dentist?
- Was the patient partially dentate?
- Was the patient edentulous?
- Those who were partially dentate – how many needed no treatment at all?
My findings were (shortened with reference to this article):
- 63 had some teeth. Of the 63, 18 were referred by a dentist
- 23 were new cases coming directly to my clinic
- 22 were existing patients.
So, out of the 45 patients who came directly to my clinic, only four needed absolutely no treatment at all.
That meant that less than 10% of patients coming to my CDT clinic would need no treatment at all. Extrapolated, this means that 90% of the patients who came to see a CDT directly for dentures would need some form of treatment by a dentist before a CDT could begin denture treatment.
Exaggerated figures?
In my experience, most new patients already have their own dentist, but some patients will decide that they want to be treated by a CDT. If they have been to see their dentist in the last few weeks, a CDT can give that patient a prescription form so the dentist can sign the form, confirming the dentist is happy for the CDT to carry out denture treatment – no further appointments would be needed with the dentist.
Also I would like to add that many CDTs work within a dental practice, working either full or part time, therefore reducing the number of appointments needed with a dentist (based on CDTA UK’s figure of 10 patients per week).
Looking at the figure of 10 referrals per week, in my opinion this is extremely high amount of patients. I , personally, do not see that amount of new patients every week. That said, if the authors do have 10 partial denture patients to refer each week, how about employing a dentist to come in once a week to see 10 patients and give you 10 referrals?
My conclusion, therefore, is the reference to 211,640 appointments is vastly exaggerated. This figure is based on six million people needing treatment which works out at 3.53%. This means, even based on their exaggerated figures, that a tiny amount of extra appointments will become available.
Difficulty obtaining a prescription
I am not sure why any CDT would refer a patient back to an already overstretched NHS dental practice when the patient is already paying privately for their denture treatment. By referring to a private dental practice, the patient will usually be seen more quickly and delay in treatment is significantly reduced.
In many cases, a lot of patients have had their dentures for many years – a short delay for an appointment to see the dentist is usually going to be fine. I have found that most patients, including those with dental phobias, are happy to see the dentist if you take the time to explain that we as CDTs need them to see a dentist before we can make the denture, and how important it is for their dental health.
My feeling is that any lack of awareness of what a CDT does is purely down to the CDT themselves not promoting themselves properly or by past associations’ failure to educate the wider dental profession.
Educate the dentist
In my experience, most dental professionals know what a CDT does, but if they don’t then the individual CDT could educate the dentists that they would like to work with to avoid any confusion. When dentists understand the many benefits of working with a CDT, they will be happy to see your patients and will happily refer the majority of their denture cases to the CDTs.
This will free up their diaries, making more appointments for their other patients, enabling them to do more profitable work. Another by-product of that relationship is that they may gain extra work.
If, on the rare occasion, a dentist flatly refuses to provide a prescription, then my suggestion would be to talk to the dentist in question. If there is still an issue, then look for a dentist who is prepared to work with you, as a CDT. There are so many dentists out there who are more than happy to work with CDTs.
Enhancing patient safety through expanded SOP
Regarding the adherence to best practice care, I am not really sure what the authors mean. I would like to see the evidence based care and data that prioritises safety and effectiveness.
OFT review 2012
The proposal also references Office of Fair Trading (OFT) calling to allow patients to see hygienists, therapists and CDTs directly without seeing a dentist first.
Currently CDTs are allowed to see a patient first. If a patient phones a CDT for some dentures, the CDT can see that patient to discuss types of treatments available. This could be dentures, but it is also the CDT’s duty of care to explain that there are alternatives – implants or crowns and bridges.
Once the CDT has seen the patient for a consultation, the CDT can then refer the patient to a dentist to carry out an oral health check, carry out any treatment needed and give a prescription. The patient is then referred back to the CDT who can start their denture treatment.
The GDC SOP for CDTs states:
- Patients with natural teeth or implants must see a dentist before the CDT can begin treatment
- Carry out clinical examinations within their SOP
- Give appropriate patient advice
- Recognise abnormal oral mucosa and related underlying structures and refer patients to other healthcare professionals if necessary.
Lack of medical expertise
In my opinion, I totally disagree with the remarks made by the authors about how CDTs are viewed and treated.
I just wanted to share in my experience as to why the current SOP for CDTs does work and why I feel it does protect the patient.
I had a patient recently who had an submerged wisdom tooth. It had been there for over 20 years, had never caused a problem and this was the message from the dentist after I had referred her: ‘I have removed her infected and submerged LL8. This was her last remaining tooth. I had to remove a little bone and there was a bit of an abscess under the tooth’.
The patient had told me that it wasn’t causing her any problems. Would a CDT with an increased SOP have the knowledge to diagnose this? And that is the point of my article.
Dentists are trained to degree level with a superior knowledge of teeth, gums, medicine and all things tooth related than we are. In my opinion, there is no point in just saying ‘we should be allowed to make dentures for patients with natural teeth without them having to see a dentist first’.
Education is the way forward
If CDTs want to see patients directly, then education is the only way forward and, therefore, CDTs will need to be trained to the same level of expertise and knowledge as dentists. This would require extra time and cost of that education as well as the increased cost of a CDT’s indemnity insurance which would rise significantly. Additionally, you would have the extra cost of updating the CDT clinic to include X-ray equipment etc. The list and costs will escalate.
If you ask most CDTs if they have the extra time to see patients or carry out X-rays or examinations etc, I am sure most would say no.
Surely what makes far more sense is, with the shortage of appointments currently on the NHS and the lack of good prosthetic dental technicians, for CDTA UK to put their time and resources into educating more dentists and explaining the benefits of working with a CDT. You could even include a dental appointment into the cost of your denture treatment, meaning the CDT pays the dentist for the patient’s prescription.
That way you can find a great referral pathway, and when they see the benefits of all the additional new patients you are sending them who will need additional treatment, the dentists will refer their patients back to you for their dentures, therefore freeing up more of their appointments.
We are not educated to the same level as a dentist which the GDC was fully aware of when it first registered CDTs in 2007. Nothing had changed because the CDT education hasn’t changed or expanded.
SOP frustrations
The only thing I would agree with the CDTA UK is that it is frustrating for us to tell patients in hospitals and care homes that we cannot treat them until they have been seen by a dentist. In most instances, dentists will not visits patients in care homes and community dental services are extremely stretched.
This then does open patients up to looking for alternatives which is usually seeking the help of a dental technician who is untrained, not indemnified and working out of their SOP if they treat the patient. This in my opinion is definitely an area that needs to be looked at more closely.
My advice to the CDTA UK is to go back and get a lot more evidence-based research that gives you a much stronger argument when putting across a successful case to the GDC for increasing the SOP for CDTs. Our current SOP, although not perfect, does do the most important thing, protect the patient.
Joint approach
Lastly, I will finish my article with a few comments from a dentist I worked with (who has since retired) and why I think that our SOP works well and, most importantly, provides the best protection for the patient with patient centred care…
They said: ‘Andrew’s new found freedom to work directly with patients has lead to a more streamlined service with enhanced outcomes for these patients. We discuss which treatments are the most appropriate, allowing the patients the benefits of an integrated team to their treatment.
‘I am proud to say that this joint approach has not only resulted in better outcomes for our patients but we are increasingly converting many patients who “have given up on their teeth and dentistry” to take more interest in their oral health.
‘We have gained the trust of many of these patients, allowing them to consider better treatment options and retain more natural teeth. As a result of involving all appropriate professionals at the treatment planning stage, we are able to assimilate the various components for the preventive and restorative process.’
What are your thoughts? Do you think the scope of practice of CDTs should be expanded? Contact [email protected]
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