Memorandum by David G Hillam (DS 04)
Following closure of three dental schools in
the 1980s, there is now a shortage of dentists to manage the increasing
demand and need from an aging population requiring complex dental
treatments (restorative and periodontal). Good preventive care,
such as can be provided by hygienists, could reduce the need for
simple treatments. However, current trends are for the training
of more dental therapists to perform these more simple treatments,
at the expense of hygienist training. Furthermore, the duties
of therapists are extending to permit much of the work of the
general dentist and there are moves for them to work independently.
Quality of care will ultimately suffer if therapists are allowed
to work as independent "dentists" with only 102 weeks
training. The numbers of hygienists should be increased, not reduced.
At present one of their roles is advice on smoking cessation.
This could be formally extended to include dietary and other advice
on obesity and on alcohol intake.
The submitter of this written evidence was a
Consultant in Restorative Dentistry specialising in periodontology
(diseases of the gums and supporting structures of the teeth)
for 25 years, a post that was combined with Directorship of a
training school for dental hygienists. He is also a former General
Secretary and President of the European Federation of Periodontology
and former President of the British Society of Periodontology.
Other positions he has held include Clinical Manager of a Dental
Hospital, chairmanship of the national Panel of Examiners for
dental hygienists (GDC) and membership of numerous dental advisory
and other committees at local and national level. He retired from
active practice in 2001.
1. The parts of the committee's remit that
I wish to comment on are:
(a) The work of allied professions, (dental
hygienists and therapists).
(b) The extent to which dentists are encouraged
to provide preventative care.
(c) The quality of care provided to patients.
2. Up to the late 1950s, there were two
training programmes for dentists, a four-year course leading to
the LDS qualification in addition to 4.5-year and five-year programmes
leading to the more academic BDS qualification. The LDS was phased
out in favour of the, longer, more comprehensive courses.
3. Dental hygienists were introduced by
the RAF during the war, followed by an experimental civilian scheme
in the 1950s. This proved to be a success and national training
programmes began throughout the UK in the 1960s and 1970s. Approximately
200 were trained each year. Their work includes the treatment
of periodontal diseases (these rival tooth decay as a cause of
tooth loss), the prevention of all oral diseases, taking radiographs,
etc. Their course of training is currently two years long (minimum
90 weeks study).
4. Also in the 1960s, when levels of decay
in children were very high, therapists were introduced to do simple
restorative and preventive treatments for children.
5. Towards the end of the 1960s, the introduction
of fluoride toothpastes reduced levels of decay over the next
decade and it was feared that there would be an over-supply of
dentists. As a result, three UK dental schools closed in the 1980s
despite some of us warning that the British public had become
accustomed to restorative dentistry (as opposed to extractions
and dentures) and the aging population will require more complex,
difficult restorative work to maintain their heavily restored
dentitions. This proved to be true, and at the present time there
is a large need and demand for crowns, root canal treatments,
bridges, implants, etc. Not only this, but with more teeth being
preserved, more teeth are exposed to the risk of periodontal diseases
leading to a greater demand for hygienists and dentists.
6. There has been an expansion of the role
of therapists so that they are now permitted to undertake most
of the more routine tasks of dentists after only 2.25 years training
(minimum 102 weeks study1). Their work is no longer restricted
to children and they are now permitted to work in all areas of
7. There is a lack of clarity on what therapists
are permitted to do, causing confusion to therapists and dentists
alike. In addition to "simple" procedures, the
GDC states that they must "Have a knowledge of advanced
restorative techniques for both dentitions", ie children
and adults. "Knowledge" is defined as "A sound
theoretical knowledge of the subject but may only have limited
clinical/practical experience"1. Furthermore, the same
document states "there should be no barrier to prevent
PCDs [including therapists] expanding their range of skills"
and they are "Permitted to practise in respect of those responsibilities
for which they have received education and training . . . and
for which they have received authorisation from a registered dentist".
It would appear from this that therapists may practise the whole
range of dentistry, so long as they convince themselves and a
dentist that they have received training and are competent.
8. Moves are now afoot to allow diagnosis/prescription
by hygienists and therapists and for them to be allowed to set
up independent practice. Indeed, the regulations have already
been changed that will ultimately enable them to set up their
own businesses. As a result, I foresee the possibility of a grade
of "dentist" appearing in the "High Street"
with training of only 102 weeks. (Compare this with the phasing
out of four-year trained dentists referred to in paragraph 2 above.)
9. The training of therapists is being progressively
combined with that of hygienists. There are now very few places
for the training of hygienists only.
10. The recent scarcity of dentists has
brought with it the need to import dentists from overseas, the
training standards of whom are not monitored by the GDC in the
same way as home-educated dentists. Many of the countries from
which we import these dentists cannot afford the exodus of their
personnel. I believe that we should be exporting our skills to
less well-developed countries, not vice versa. Also, the GDC's
Fitness to Practise hearings seem to be dominated by overseas
trained dentists who have failed to match up to expected standards.
11. I fear that the quality of care provided
to patients is in jeopardy because of the short training of operating
dental personnel (hygienist-therapists) and the need to import
overseas dentists whose training has not been monitored by the
12. The risk is enhanced because of lack
of clarity in the regulations. There is no longer a "red
line" that must not be overstepped. I believe there will
always be unscrupulous practitioners who will be tempted to work
beyond their level of competency and the situation will be impossible
13. There is taking place a serious reduction
in the number of dental hygienists who play such a major role
in the prevention of oral diseases. This is to be deplored.
14. I believe that the profession tends
to attract two main personality types. They are, of course, not
mutually exclusive but are a guide to those aspects of their occupations
that provide greater job satisfaction:
Type 1. Perhaps the more traditional type.
They are motivated by an attraction to the practical aspects of
dentistry; intricate fillings, crowns, bridges, implants, aesthetic
improvements to the teeth. The "precision engineering"
Type 2. These are motivated by a more "biological"
approach; prevention, the treatment of gum diseases, care of the
soft tissues of the mouth and the general health of the patient.
15. I believe that the current trend towards
therapists is attractive to Type 1 individuals, perhaps those
that cannot achieve the requirements to become dentists. This
trend is at the expense of hygienists (Type 2), many of whom do
not want to perform the extended duties of a therapist but who
gain their job satisfaction by successfully treating periodontal
diseases and motivating patients to prevention rather than by
undertaking restorative treatments.
16. There is anecdotal evidence that some
applicants for hygienist-therapist courses do not want to do therapy,
but are forced into it because of the lack of places for hygienist
training. Also, there is a high demand from preventively-minded
dentists for the very limited supply of hygienists, not therapists.
It could be argued that their preventive methods are so successful
that they do not need therapists to undertake simple work.
17. Diversion of resources to ensure that
the UK has sufficient, well-trained, general dental practitioners
to undertake most of the increasing amount of complex work needed
for the aging population (restorative and periodontal), and also
to encourage more preventive dentistry.
18. Improved referral services for cases
of advanced periodontal diseases, by introducing consultant posts
in periodontology, fully supported by hygienists. The present
Consultant in Restorative Dentistry has to cover; restorations,
root canal therapy, bridges, implants, dentures, etc. (Type 1),
as well as the whole range of periodontal diseases (Type 2). It
is just not possible to keep up with all the new knowledge and
maintain expertise in all these areas of dentistry.
19. Expansion of the numbers of dental hygienists,
sufficient to provide a comprehensive dental prevention service
to the whole population as well as supporting the general and
specialist dentist in the treatment of periodontal diseases. If
preventive services improve sufficiently, there will be less need
for therapists. In other words, there should be a reversal of
the current trend to train therapists at the expense of hygienists.
20. Amongst other duties, the work of hygienists
(a) The removal of calcified bacterial deposits
firmly attached to teeth within deep gum pockets where gums have
detached from teeth following bone loss. This is technically a
difficult, time consuming task and can only be done at its best
by people whose skills are maintained by spending a high proportion
of their time doing it.
(b) The giving of preventive advice to patients
on thorough tooth cleaning (especially important and difficult
in patients with periodontal diseases).
(c) The application of solutions to teeth
to prevent decay and also to treat tooth sensitivity.
(d) Giving advice on smoking cessation. (Smoking
is linked to oral cancer.)
(e) Giving dietary advice for the prevention
21. This could easily be extended to include:
(a) Dietary and other advice on obesity.
(b) Advice on alcohol intake.
22. The training of all groups (dentists,
hygienists and therapists) must include experience in all environments
where they may practise in future. At present, there is a trend
for training to be predominantly (in some cases exclusively) in
"outreach". In this environment, students are not exposed
to difficult, referred cases and may be less able to recognise
or cope with the treatment needs of this group of vulnerable patients,
or to provide adequate support to consultants, without additional
D G Hillam BDS, MDS, FDSRCS
1 GDC Publication. Developing the Dental Team. Curricula
Frameworks for Registrable Qualifications for Professionals Complementary
to Dentistry (PCDs). September 2004. Back