On the website you can test yourself on the interactive multiple choice and extended matching questions.

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Copyright Information

Several Wiley publications have contributed artwork to this book. We are grateful for permission to use and adapt the artwork.

Dean, M.R.E. and West, T.E.T., 1987, Basic Anatomy and Physiology for Radiographers, 3rd edition, Blackwell Science, Oxford

Ellis, H., 2006, Clinical Anatomy, 11th edition, Blackwell Publishing, Oxford

Foster, T.D., 1990, A Textbook of Orthodontics, 3rd edition, Blackwell Science, Oxford

Hollins, C., 2008, Basic Guide to Dental Procedures, Blackwell Publishing, Oxfordd

Hollins, C., 2009, NVQs for Dental Nurses, 2nd edition, John Wiley & Sons, Oxford

Hollins, C., 2012, Basic Guide to Anatomy and Physiology for Dental Care Professionals, John Wiley & Sons, Oxford

Peterson, O.H. (ed), 2006, Lecture Notes: Human Physiology, 5th edition, Blackwell Publishing, Oxford

Skeet, M., 1981, Emergency Procedures and First Aid for Nurses, Blackwell Science, Oxford

Skeet, M., 1988, Emergency Procedures and First Aid for Nurses, 2nd edition, Blackwell Science, Oxford

Smith, N.J.D., 1988, Dental Radiography, 2nd edition, Blackwell Science, Oxford

Artwork reproduced with permission from third-parties is credited at the end of the appropriate caption.

1

Structure of the Dental Profession

The dental team is now made up of dentists and six categories of registered dental care professionals (DCPs), all of whom work together to provide oral healthcare for their patients. In hospital and clinic environments, some of the dentists may have gone on to become specialists in various fields of dentistry, while dental nurses are now able to train and become competent in various postregistration qualifications as well as ‘extended duties’. With the introduction of a new National Health Service (NHS) dental contract and with a new commissioning system imminent, there has never been a more exciting time for dental nurses to push the boundaries of their profession and become recognised as vital members of every dental team, in every dental workplace.

An overview is given below of the roles of the various registrants, and that of the dental nurse is covered in detail in Chapter 2.

The dentist

Dentists undergo 5 years of undergraduate training at a university dental school. On passing their final examinations, students are awarded the degree of Bachelor of Dental Surgery (BDS), but they cannot use the title of dentist or practise the profession until their names have been entered onto the Dentists Register. In addition, dentists who have qualified in member states of the European Union may also join the Register, although they must have an adequate level of written and spoken English. Dentists from non-European Union countries must have their skills and knowledge assessed for equivalence with that required for UK dentists before they may work here.

The Register is kept by the General Dental Council and contains the name, address and qualification(s) of every person legally entitled to practise dentistry in the United Kingdom. Such persons may describe themselves as dentist, dental surgeon or dental practitioner – there is no difference between these titles. Dentists may also use the courtesy title of Doctor but must not imply that they are anything other than dentists. Following qualification, all dentists are legally required to continue their professional education until their retirement from practice, in order to maintain and update their skills.

Registered dentists have a wide choice of opportunities within the profession.

• General practice.
• Community dental service.
• Hospital service.
• University teaching and research.
• Industrial dental service.
• The armed forces.

They may also take additional higher qualifications and become specialists in a particular branch of dentistry. Some examples of such qualifications are as follows.

• Fellowship in Dental Surgery (FDS).
• Master of Science (MSc) in a specialty.
• Membership in the Joint Dental Faculties (MJDF).
• Membership in Paediatric Dentistry (M Paed Dent).
• Membership of the Faculty of Dental Surgery (MFDS).
• Diploma in Dental Public Health (DDPH).
• Diploma in Dental Radiology (DDR).
• Diploma in General Dental Practice (DGDP).
• Diploma in Orthodontics (DOrth).

These qualifications are provided by the joint dental faculties of the Royal Colleges of Surgery.

Having obtained the relevant higher qualifications, dentists may then join the Specialist List of the Register for their particular specialty, which includes the following areas.

• Oral and maxillofacial surgery.
• Surgical dentistry.
• Dental and maxillofacial radiology.
• Dental public health.
• Oral medicine.
• Oral microbiology.
• Oral pathology.
• Orthodontics.
• Periodontics.
• Prosthodontics.
• Restorative dentistry.

The General Dental Council

The General Dental Council (GDC) is the regulatory body of the dental profession and its duties are set out in legislation. It aims to promote high standards of professional education and professional conduct among dentists and DCPs, throughout their working career. It thereby ensures that the status of the profession in the general community is upheld and that a proper code of conduct is maintained, for the protection of the public. In essence, its remit is to:

• protect patients
• regulate the dental team.

In the performance of these duties, the GDC must be satisfied that courses of study at dental schools and the qualifying examinations are adequate, and the same applies to postgraduate education and to the register-able qualifications for all the DCP categories.

It is the policy of the GDC for all dentists, after qualification, to complete a year of foundation training (previously called vocational training) before starting independent practice. Such training schemes are already in force in NHS general practice, the community and hospital services, and also on a voluntary basis in non-NHS practice. As soon as adequate resources and facilities are available, it is likely to be mandatory for all newly qualified dentists to undergo foundation training soon after qualification.

The GDC is empowered to remove or suspend from the Register any dentist or DCP who has been convicted of a criminal offence or is guilty of serious professional misconduct. It may also suspend any registrant whose fitness to practise is seriously impaired because of a physical or mental condition. These issues are discussed further in Chapters 2 and 3.

Apart from registered dentists, the only other persons permitted to undertake dental treatment are registered dental hygienists and dental therapists, and registered clinical dental technicians may provide and maintain full dentures to edentulous patients. The GDC is responsible for these dental care professionals in much the same way as for dentists. The expected level of their competences by the time of their qualification is laid out in the GDC document Preparing for Practice, while those additional duties possible after a period of suitable training and assessment are laid out in its document Scope of Practice. This has particular relevance to dental nurses, and all GDC documents can be downloaded at www.gdc-uk.org.

The dental team

Dentists’ training enables them to undertake, without assistance, all treatment necessary for patients, including construction of their dentures, crowns and bridges, provision of restorations and root fillings, extractions, etc. Except for the actual treatment performed within the mouth, much of the work which a dentist is qualified to do can be performed by other members of the dental team. For example, a chairside dental nurse provides an extra pair of hands for preparing and mixing filling and impression materials, and for helping with suction, retraction and illumination to keep the operative field clear and dry for the dentist and comfortable for the patient. A dental technician can make dentures, crowns and bridges ready for the dentist to fit, while dental hygienists and therapists are permitted to undertake limited forms of dental treatment.

By utilising all this assistance, a dentist becomes the leader of a team which can practise in the most efficient way. Dentists carry out all the treatment which they alone can perform, while the other members of the team – hygienist, therapist, dental nurse and technician – perform all the work which a dentist can delegate. Compared with a single-handed dentist, the dental team can provide far more treatment each day with less effort and fatigue for all concerned, and thereby give a better total service to the patient and the community. Dental team working is discussed in more detail in Chapter 3.

The full group of registered dental team members will eventually comprise:

• dental nurses
• dental hygienists
• dental therapists
• orthodontic therapists
• dental technicians
• clinical dental technicians
• maxillofacial prosthetists and technologists.

All except the last group are already required to be registered with the GDC, and must have specific training programmes, extended duties and professional responsibilities for continuing professional development and professional conduct similar to those of dentists. The issue of professionalism and its relevance to all dental team members is discussed in detail in Chapter 3.

Further information is also available at www.gdc-uk.org.

Dental care professionals

This is the new professional title for all members of the dental team besides the dentist. They were previously referred to as professionals complementary to dentistry (PCDs).

Dental nurse

This whole text is aimed at dental nurses and their training requirements, and their invaluable role and position in the dental team are discussed in detail in Chapter 2.

Dental hygienist

After 2 years’ training at a dental hospital or in the armed forces, hygienists used to be awarded a Diploma in Dental Hygiene and could then become registered by the GDC. Dental hygiene training has now been combined with that of dental therapists as a dual qualification, so that all those who qualify have a much wider range of skills and competencies.

Hygienists are permitted to undertake a number of dental procedures for which they have been trained, under the prescription of a dentist. These duties include:

• scaling and polishing teeth
• use of infiltration local anaesthesia
• application of fluorides and fissure sealants
• treating patients under conscious sedation, provided that a dentist is present in the room
• emergency replacement of dislodged crowns, using a temporary cement
• removal of excess cement
• application of a temporary filling if one becomes dislodged while under their treatment
• taking impressions.

Apart from their treatment role, hygienists are also trained to be proficient dental health educators.

Dental therapist

Dental therapists undertake a 2-year course at a dental hospital and now become qualified in both hygiene and therapy. They are awarded a Diploma in Dental Therapy and Hygiene and can carry out a wider range of treatments once they have obtained GDC registration. They are permitted to carry out all of the same duties as a hygienist, and all of the following additional duties:

• simple fillings
• pulp treatment of deciduous teeth
• extraction of deciduous teeth
• fitting preformed crowns on deciduous teeth
• dental radiography (when taught as an integral part of the training course).

Prior experience as a dental nurse and possession of the relevant dental nursing qualification are requirements for admission to dental hospital training courses for dental hygiene and therapy training.

Dental technician

Dental technicians are highly skilled craftsmen and women who construct dentures, crowns, bridges, inlays, orthodontic appliances, splints and replacements for fractured or diseased parts of the face and jaws. They work to the dentist’s prescription in a dental laboratory. Training consists of a full-time course in a dental hospital or technical college; or an apprenticeship with part-time attendance at a technical college.

Clinical dental technician

Clinical dental technicians are specially trained to provide and maintain full dentures for edentulous patients, and may do so without the involvement of a dentist.

Maxillofacial prosthetists and technologists

Maxillofacial prosthetists and technologists are technicians who have specialised in jaw and facial reconstruction and replacement, and work closely with maxillofacial surgeons in a hospital environment.

The National Health Service

Dental treatment in the United Kingdom is provided either privately or through the NHS. Private patients obtain treatment from a practitioner of their choice and pay a fee to the practitioner for professional services given, or they join one of the private registration and capitation schemes and pay a monthly or annual subscription to cover the majority of their treatment charges.

National Health Service dental treatment differs from private practice in the range of treatment provided and the method of payment for such treatment. Certain types of treatment available in private practice are currently restricted in the NHS (such as tooth-coloured fillings and crowns on posterior teeth), while payments to the dentist are set and controlled by the NHS, with patients’ contributions ranging from nil to a set maximum.

Currently, NHS treatment available to the public is split into three bands, as follows.

• Band 1 – simple treatments such as examinations, radiographs, scaling.
• Band 2 – routine treatments such as fillings, extractions, root treatments.
• Band 3 – complex treatments involving laboratory work such as crowns, bridges, dentures.

A set fee is charged to the patient for each of the bands, regardless of the amount of treatment carried out, so for instance the same fee is paid for one filling or 10 fillings, if provided during the same course of treatment.

However, the system is due to change in the very near future, and while the final decision is not yet made on the replacement system to be introduced, it is highly likely that more emphasis will be placed on the role of DCPs within the dental team. The dentist will still be the only team member capable of providing all care and treatment for a patient, but much will be delegated to those DCPs with suitable training and qualifications to be carried out instead. So, dental workplaces may eventually consist of fewer dentists and more DCPs, but with the ability to carry out the same range of dental treatments between them.

The cost of the NHS is borne by the state, and the government department responsible for it is the Department of Health. This delegates operational management of the service to the NHS Executive. For administrative purposes, the country is divided into a number of large strategic health authorities for overall planning. These are currently subdivided at a local level into a large number of smaller authorities, called NHS trusts for hospital services and primary care trusts (PCTs) for community clinics and general practitioner services. PCTs have the responsibility of deciding the level of need for NHS dentistry in their area, as well as providing emergency out-of-hours dental care to the public.

In April 2013, PCTs are due to be replaced by another system of commissioning medical and dental care in their localities, and although the final details are unclear at this time, it is likely that local councils and general medical practitioners (GPs) will take responsibility for commissioning healthcare in their areas instead.

Community dental service

This was formerly called the school dental service, providing examination and treatment for children and expectant and nursing mothers. It still meets the same needs but has acquired additional responsibilities. These vary according to local demand but can include treatment for special needs patients of all ages, emergency treatment for patients without access to an NHS dentist, treatment of the elderly (especially those unable to attend a dental workplace), provision for general anaesthesia and conscious sedation, and dental health programmes for the community at large.

The community dental service is administered by the NHS trust or PCT and co-operates with hospital staff and general practitioners in planning and co-ordinating all dental services in the ­district. Salaried community dental officers provide treatment in clinics with equipment and ­materials supplied by the trust or PCT.

Hospital dental service

Hospitals are administered by an NHS trust. Dental services are provided by consultant oral and maxillofacial surgeons and orthodontists. They give specialist advice and treatment for patients referred by practitioners outside the hospital, and for patients referred from other departments of the hospital. They are also in overall charge of dental care for long-stay inpatients. In addition, most consultants provide postgraduate courses and part-time training posts for ­general practitioners.

General dental service

This is the general practitioner service which provides a significant share of all dental treatment in the UK. It is currently administered by the local PCT which holds dentists’ NHS contracts and is responsible for NHS disciplinary procedures.

The Dental Practice Division of the Business Services Authority (previously the Dental Practice Board) authorises payment of NHS treatment fees to practitioners. It can also arrange for patients to be examined by its dental reference officers (DROs).

General practitioners set up and equip their practices at their own expense and are entitled to have private patients as well as NHS patients. However, if involved in NHS care of patients, they must also demonstrate compliance with various quality assurance measures, as follows:

• clinical governance
• clinical audit/peer review
• information governance.

There is no reason why a fully private practice cannot have the same quality assurance systems in place also, although they are only required to abide by any relevant legislation, rather than having to abide by NHS rules.

Clinical governance

This requires every NHS practice principal to have a quality assurance system for the practice, in order to ensure a consistent quality of care. It must cover the following areas to ensure the safety of its patients:

• infection control (Chapter 8)
• all legal obligations of health and safety law in the practice (Chapter 4)
• all legal obligations for radiation protection (Chapter 4)
• compliance with GDC requirements for continuing professional development (Chapter 3).

The practice must also:

• appoint a member of the staff to be responsible for operating the system
• display a written practice quality policy for patients
• provide the PCT with an annual report on the quality assurance system.

Clinical governance is discussed further in Chapter 3.

Clinical audit and peer review

Clinical audit is an essential feature of clinical governance that came into force for NHS dentists in 2001. Its purpose is to ensure that individual dentists assess different aspects of their practice, make changes where necessary, and thereby improve service and care for their patients. The running of quality assurance programmes within the dental workplace can often be delegated to suitably trained dental nurses, an example being retrospective clinical audits of dental radiographs.

Peer review is an optional alternative to clinical audit for dentists who prefer to undertake their practice assessments within a group of other dentists and thereby share the benefit of the group’s combined experience.

As these are now clinical governance requirements, rather than optional activities, funding is no longer available to dentists for their completion.

Information governance

This is a quality assurance system that has been implemented for healthcare, corporate and information technology (IT) organisations that sets out to ensure the safety and appropriate use of personal and patient information. It is therefore linked to patient confidentiality, data protection and the freedom of information passing between various organisations and bodies.

The Department of Health has charge of the implementation of the system for healthcare organisations, including all dental workplaces, and has developed sets of information governance requirements in a toolkit (referred to as the IG Toolkit), which enables NHS healthcare providers to measure their own compliance.

Information governance is discussed further in Chapter 3.

British Dental Association

The British Dental Association (BDA) is the professional body representing the majority of dentists in the UK. It publishes the British Dental Journal (BDJ), and many compendiums, toolkits and other literature to provide its members with up-to-date information and advice on the business of dentistry. It runs annual dental conferences which provide further update advice, as well as many continuing professional development (CPD) events aimed at the dental team rather than just dentists. The Association also negotiates for the profession with the government and other bodies, such as local dental committees, where dental interests are concerned. Membership of the BDA is voluntary, it is open to all dentists and allows its members access to a huge source of dental literature and research material.

Resources

www.gdc-uk.org.

General Dental Council, 37 Wimpole Street, London W1G 8DQ

Tel: 020 7887 3800

Fax: 020 7224 3294

Further resources are available for this book, including interactive multiple choice questions and extended matching questions. Visit the companion website at: www.levisonstextbookfordentalnurses.com

2

The Dental Nurse

History

Until 2008, any person wishing to work as a nurse or assistant in the dental surgery environment could do so without undertaking any form of training or passing any examination. Since 1943, the National Examining Board for Dental Nurses (NEBDN), previously called the National Examining Board for Dental Surgery Assistants, had been setting and running its voluntary examination for any persons working as nurses (assistants) in the dental workplace. Qualification in the National Certificate examination showed that successful candidates had achieved a set basic standard in dental nursing, were able to work unsupervised alongside the dentist and could call themselves a ‘dental nurse’ (previously a ‘dental surgery assistant’).

More recently, City & Guilds (C&G) introduced its Level 3 NVQ in Dental Nursing, as an alternative qualification for those students wishing to follow a vocational rather than a more academic career pathway to becoming a dental nurse. Both qualifications ran successfully alongside each other, and were open to any students wishing to take them. In Scotland, students were able to access a Scottish equivalent of the NVQ, as well as the National Certificate.

In the last 5 years, dental nurses, along with all other dental care professionals, have gradually been brought under the regulatory umbrella of the General Dental Council (GDC). Following a period of ‘grandparenting’, during which unqualified but well-experienced dental nurses were allowed to register with the GDC without prior qualification, compulsory training and qualification for all were introduced.

Registration

Since 2008, any person wishing to work as a dental nurse has had to undergo a period of ­supervised training, and then pass a formal examination before being allowed to register with the General Dental Council. All unqualified dental nurses must be supervised and ‘in training’ to be able to work directly with patients, and all qualified dental nurses must be registered on an annual basis with the GDC, to be able to continue to work with patients unsupervised.

As with the other dental care professionals (DCPs) listed in Chapter 1, the necessity of registration for dental nurses has raised their role to that of a professional in the eyes of both the public and other members of the dental team. In addition, it has brought all members of the dental team into line with other healthcare professionals in the United Kingdom, so that all are now ­accountable to a regulatory body.

In line with other regulators, the purpose of the GDC in its regulatory role is to maintain the list – or Register – of those persons deemed suitable to work as healthcare professionals at their level of qualification. This is correctly termed their ‘fitness to practise’.

As with all other GDC registrants, dental nurses are required to pay an annual retention fee to maintain their place on the Register, having behaved in a professional manner throughout the previous 12-month period. In other words, the GDC has to ensure not only that anyone joining the Register is fit to practise at the point of initial qualification but that they remain so throughout their career. Consequently, the GDC’s own aims are summarised throughout its publications as: ‘Protecting patients, regulating the dental team’.

Role of the General Dental Council in dental nurse training and qualification

To ensure that dental nurses are adequately trained and qualified to a suitable level in their chosen dental career, the GDC describes the learning outcomes that each student must be able to demonstrate by the end of their training, to be able to join the GDC Register. Originally, these outcomes were published in the GDC document Developing the Dental Team but they are now covered in the updated publication Preparing for Practice – Dental Team Learning Outcomes for Registration. This updated document has also superseded the equivalent publication for dental ­undergraduates, The First Five Years. All GDC publications can be viewed or downloaded by accessing its website at www.gdc-uk.org.

In summary, then, the GDC has a vital role to play in the regulation of the whole dental team, including dental nurses, from the time that they enter a formal course of training as a student, right through their professional career until they leave the GDC Register. The GDC’s functions as a regulatory body and the way that this affects the dental nurse are as follows.

• Set standards to be followed – in relation to behaviour, education (pre- and postregistration) and ethics.
• Handle fitness to practise issues – in relation to poor health, poor professional performance or professional misconduct.
• Remove individuals from the Register and prevent them from practising as dental ­professionals, if they are considered to be ‘unfit’.

In carrying out its role as a regulatory body for the dental profession, the GDC also promotes its own aims to.

• protect patients
• regulate the dental team
• promote public confidence in all dental professionals
• quality assure dental education for all dental professionals working in the UK
• ensure that all dental professionals maintain an up-to-date level of knowledge
• assist patients with serious complaints against dental professionals.

These fundamental aims of the GDC affect the working lives and careers of every dental professional on a day-to-day basis, and represent the standards that should be achieved by all. The GDC has conveniently published these principles and standards in booklet format, General Dental Council Standards Guidance, and made them available to all registrants. They are discussed in detail in Chapter 3. All student dental nurses are expected to be familiar with the detailed contents of these booklets by the time they sit their qualification examinations.

Learning outcomes and qualification

As mentioned previously, the GDC has set out the outcomes that dental nurses must be able to demonstrate by the end of their training period, in order to become a registrant and be deemed ‘fit to practise’. Within a training course, demonstration of these outcomes is met through ­education, training and assessment, and they are therefore referred to as ‘learning outcomes’. They are derived from the GDC’s own Standards for Dental Professionals document, and include the ­requirements set by the GDC for lifelong learning to be achieved. In the UK, student dental nurses can meet the training requirements by following an approved course and passing either the NEBDN National Diploma examination or the City & Guilds Level 3 Diploma in Dental Nursing examination.

The GDC learning outcomes have been developed so that a student who achieves them can be said to be competent – they can practise safely, effectively and professionally as a dental nurse. The vast majority of the learning outcomes are actually set, word for word, for each dental professional category, from the dentist through to the dental technician. Once achieved, they demonstrate that the student has the knowledge, skills, attitudes and behaviours required to become a GDC registrant.

To understand what is required from student dental nurses during their training, education and assessment, the following interpretations of these key terms may be useful.

• Knowledge – the underpinning, theoretical information gained from learning or experience, which gives the student understanding of a subject.
• Skills – the special abilities acquired by learning and practice to be able to complete a task, often manually or verbally.
• Attitudes and behaviours – the moral and ethical beliefs held by the student which ­demonstrate their values and priorities, and guide their actions.

Students must exhibit all of these attributes to be considered as professional dental nurses after qualification, and be entered onto the GDC Register. They must then maintain and improve upon these qualities throughout their working life, to stay on the Register.