There have been significant changes in the way in which orthodontics has been delivered since the last major workforce study was undertaken. The major change has been the introduction of orthodontic therapists in the UK. This paper aims to outline for the general dental practitioner the role of orthodontic therapists, including their scope of practice, along with discussion regarding their integration into specialist orthodontic practice in both the primary and secondary care setting, illustrated in part from the authors' experience.
Clinical Relevance: This article aims to outline how orthodontic therapists work as part of the orthodontic team, the procedures they can undertake, along with discussion regarding their integration into specialist orthodontic practice in both the primary and the secondary care setting.
Article
Trevor Hodge
Since the last major workforce study was conducted and published in 20051 there have been significant changes in the delivery of care. One of the major changes has been the increase in manpower and improved access to specialist led orthodontic care due to the introduction of orthodontic therapists. Working under appropriate supervision2 and following a prescription, orthodontic therapists are permitted to undertake numerous reversible orthodontic procedures, as detailed in the GDC Scope of Practice documentation.3 The specific capabilities of orthodontic therapists are listed along with all other dental registrants in the GDC Preparing for Practice and Dental Team Learning Outcomes for Registration documents.4
History
Orthodontic therapists are a recent addition to the Dental Care Professionals group of GDC registrants and have, in a short space of time, proved to be important members of the dental team. They are permitted to undertake a number of orthodontic procedures under prescription from a dental surgeon.
The first orthodontic therapists qualified in 2007 having undertaken courses approved by the GDC and with adherence to the principles set out in the GDC document, Developing the Dental Team: Curricula Frameworks for Registerable Qualifications for Professionals Complementary to Dentistry (2004).5 However, the documents Preparing for Practice and Dental Team Learning Outcomes for Registration (2011)4 replace this 2004 publication and list the specific capabilities of all divisions of dental care professionals. By May 2014, over 360 orthodontic therapists were registered with the GDC. Currently, there are eight centres offering training courses in the Diploma in Orthodontic Therapy (Table 1).
Location
Awarding Body
Bristol
Royal College of Surgeons of Edinburgh
Edinburgh
Royal College of Surgeons of Edinburgh
Leeds
Royal College of Surgeons of England
London (King's College)
Royal College of Surgeons of Edinburgh
Manchester
Royal College of Surgeons of Edinburgh
Preston
Royal College of Surgeons of Edinburgh
Swansea
Royal College of Surgeons of England
Warwick
The University of Warwick
The role of orthodontic therapists and nurses – scope of practice
The skills of an orthodontic therapist are defined, as for all registered groups, by the GDC. These explicitly state what a therapist can and cannot do, although it is recognized that, as the practice of orthodontics develops, the role of the orthodontic therapist will also evolve and change.4 Since the introduction of orthodontic therapists, the role of dental nurses has also changed the clinical practice of orthodontics, with additional tasks now undertaken including:
Intra- and extra-oral photography;
Pouring, casting and trimming study models; and
Tracing cephalographs.
Supervision
The GDC only specify that orthodontic therapists work within their clinical capabilities and within the limits imposed by the Scope of Practice documentation3 (Table 2). Whenever practicable, however, best practice is that patients are seen with the supervising dentist or orthodontist present. Obviously, this is not always practical or desirable, but the supervising dentist should see the patient at least every other visit – this is a recommendation from the British Orthodontic Society (BOS) and the Orthodontic National Group.2 This document also states that an orthodontic therapist should see a patient unsupervised only where the dentist writes a clear prescription in the notes and that this should not be changed by the orthodontic therapist. In the event of any query, treatment should be postponed. A further appointment should then be made to see the supervising dentist. After the treatment planning appointment, the orthodontic therapist can place fixed appliances to the precise prescription of the dentist. The prescription should include:
The bracket system, including the type and prescription;
Any special instructions for specific bracket positioning;
Specific archwires to be used;
Instructions regarding use of auxiliaries and requirements for ligation;
An appropriate interval until the next visit. The notes should indicate all that is required including when the patient needs to be seen next.
Orthodontic Therapists Can:
Orthodontic Therapists Cannot:
Clean and prepare tooth surfaces ready for orthodontic treatment
Remove sub-gingival deposits
Identify, select, use and maintain appropriate instruments
Give local analgesia
Insert passive removable orthodontic appliancesInsert removable appliances activated or adjusted by a dentist
Re-cement crowns
Remove fixed appliances, orthodontic adhesives and cement
Place temporary dressings
Identify, select, prepare and place auxiliaries
Place active medicaments
Take impressionsPour, cast and trim study models
They do not carry out laboratory work other than previously listed as that is reserved for dental technicians and clinical dental technicians
Make a patient's orthodontic appliance safe in the absence of a dentist
Diagnose disease, treatment plan or activate orthodontic wires-only dentists can do this
Fit orthodontic headgearFit orthodontic facebows which have been adjusted by a dentistTake occlusal records including orthognathic facebow readingsTake intra- and extra-oral photographs
Additional skills which orthodontic therapists could develop during their career include:
Place brackets and bandsPrepare, insert, adjust and remove archwires previously prescribed or, where necessary, activated by a dentist
Applying fluoride varnish to the prescription of a dentist
Give advice on appliance care and oral health instruction of orthodontic appliances
Repairing the acrylic component part
Fit tooth separators
Measuring and recording plaque indices and gingival indices
Fit bonded retainers
Removing sutures after the wound has been checked by a dentist
Carry out Index of Orthodontic Treatment Need (IOTN) screening either under the direction of a dentist or direct to patients
Make appropriate referrals to other healthcare professionals
Keep full, accurate and contemporaneous patient records
Give appropriate patient advice
It would be inappropriate for the orthodontic therapist to make a decision on the type of appliance and then place the appliance of his/her choice and complete the treatment with no further input from the supervising dentist/orthodontist.
Procedures that require clear written prescription but no direct supervision also include:
Fitting bite opening blocks and turbos;
Taking alginate/PVS impressions;
Fitting aligners and pressure/vacuum-formed retainers;
Taking records (including X-rays if suitably qualified);
Repairing appliances hence making them safe and the patient pain free;
Debonding fixed appliances when agreed in advance.
Orthodontic therapists should have direct supervision by the dentist for the following procedures:
Fitting or adjusting steel/TMA archwires;
Fitting bonded retainers;
Designing, fitting or adjusting headgear;
Fitting active removable appliances adjusted by a dentist;
Changing or fitting elastics or space opening/closing springs and other active auxiliary components;
Fitting space opening springs;
Debonding of an orthodontic appliance if not agreed in advance.
Orthodontic emergencies
In circumstances where a patient presents as an orthodontic emergency, the orthodontic therapist may be required to carry out limited treatment in the absence of a dentist in order to relieve pain or make an appliance safe.
Access to dental care professionals
In May 2013, The General Dental Council removed its barrier to Direct Access for some dental care professionals after considering the impact on patient safety.6
Chair of the GDC, Kevin O'Brien said:
‘This decision has been made with patient safety as an upmost priority. Registrants treating patients direct must only do so if appropriately trained, competent and indemnified. They should also ensure that there are adequate onward referral arrangements in place and they must make clear to the patient the extent of their scope of practice and not work beyond it.'
It should be remembered that:
All registrants must be trained, competent and indemnified for any tasks they undertake;
All registrants must continue to work within their scope of practice regardless of these changes;
All registrants must continue to follow the Standards for the Dental Team set by the GDC;7
Dental care professionals do not have to offer Direct Access and should not be made to offer it.
With regards to the orthodontic therapist, this guidance will have had less impact compared to the independence given to other categories of dental care professionals. This is in part due to the continual need for re-assessment of the orthodontic patient throughout the length of his/her treatment. What has changed is that orthodontic therapists can now carry out Index of Orthodontic Treatment Need (IOTN) screening without the patient having to see a dentist first. One of the authors is currently undertaking research looking at whether orthodontic therapists, along with other dental registrants, can use the IOTN accurately.
Integration into specialist orthodontic practice
Since the Yorkshire Orthodontic Therapy Course (YOTC) started in Leeds in 2007 (the first in the UK), therapists have been trained and employed within both the primary and secondary care settings. A brief summary of how they are employed and paid is illustrated in Table 3.
Primary Care
Secondary Care
Type of Employment
Employed - salariedSelf employed
Employed - salaried
Pay
Hourly rate
Fixed according to Agenda for Change (AfC)
As of May 2014, approximately 360 orthodontic therapists have qualified in the UK and they are now a part of specialist orthodontic practice, both in primary and secondary care. They are undertaking a full range of activities appropriate to their clinic skills and experience, under the prescription of a dentist. Their employment in the team maximizes the skill mix available to the orthodontist. This enables the orthodontist to devote more time to treatment planning and treating difficult and complex cases, with more routine appointments being undertaken by the orthodontic therapist under either prescription or direct supervision. In addition, the skill mix in recent years has been further enhanced with the addition of dental nurses being trained with additional skills, such as in photography, impression-taking, radiography and oral health education. All of these factors allow better utilization of the orthodontist and therapist time whilst providing career progression for the dental nurse.
What have we learnt?
An audit was carried out of the trainers of students on the first four intakes of the Yorkshire Orthodontic Therapy Course, which revealed the following information:
The ratio of therapists trained in hospital: specialist practice was 2:5;
Once qualified, therapists were being employed to undertake a wide range of duties they had been trained in with the exception of the fitting of headgear and the pouring, casting and trimming of study models;
The hourly rate of pay range in specialist practice was £16–£24. The banding of therapists in hospital ranged from 5 to 7 under Agenda for Change (AfC) with most being on the band 7 scale;
All therapists in hospital practice were employed, whilst in specialist practice the employed to self-employed split was 4:1;
The majority of trainers supervised no more than 1 or 2 therapists whether supervising only or treating patients at the same time. One orthodontist, however, supervised 3 whilst also treating patients and one managed to supervise 4 under the same conditions.
Impact on other members of the team
Obviously, the addition of orthodontic therapists into the workplace has not been without consequences. Both general dentists, working within orthodontic practices as assistants, as well as specialist orthodontic associates, have felt the impact. Currently, it is difficult to obtain more than anecdotal evidence for this, but the authors suggest that the number of general dentists working within specialist orthodontic practice, and within the hospital service as clinical assistants, has reduced following the introduction of orthodontic therapists and the changes to the contract in 2006. This will be largely down to financial reasons as the costs of employing an orthodontic therapist will generally be less than that of a general dentist working as an orthodontic assistant.
The experience of specialist orthodontists employed or working as self-employed associates has also been affected since the introduction of orthodontic therapists. The affects include:
An increase in NHS contract allocation from principles with an opportunity to purchase the services of orthodontic therapists (effectively paying their full income) to help fulfil their additional Units of Orthodontic Activity (UOA);
The use of separate waiting lists with more complex NHS cases being allocated to the specialist orthodontists;
An increase in the percentage of their gross income paid to them as supervision of the orthodontic therapists has been undertaken;
The allocation of free orthodontic therapist hours to help with their contract when supervision has been provided elsewhere.
Unfortunately, in a state-funded health service with a cap on overall expenditure in place, the expansion of the workforce with orthodontic therapists has, in some geographical locations, reduced the need for specialists to be taken on as either assistants or associates. This has, not infrequently, manifested as a reduction in hours or percentage income for specialist providers who are not practice owners. In the audit mentioned above involving trainers from the first four intakes of the YOTC, it was found that 50% in specialist practice had not taken on new specialist orthodontists since the introduction of orthodontic therapists that they would have previously done and, indeed, 20% had replaced some orthodontist hours with employed orthodontic therapists.
The future
In addition to the effects on those dentists and specialist orthodontists already in the workforce, there is a continued impact on the employment of newly qualified specialists and clinical assistant dentists. Future workforce issues need re-assessing regarding the numbers of specialists being trained by the NHS. This responsibility lies with the Centre for Workforce Intelligence (CfWI), with input from the BOS. Together, their remit will be to investigate whether potentially smaller numbers of specialists will be needed to be trained in the future or whether there needs to be a reduction in the number of orthodontic therapist training providers. It is interesting to note that, unlike the recruitment of both dental students to undergraduate dental courses and applicants to orthodontic postgraduate programmes, the numbers of orthodontic therapists in training is demand led. For each institution offering Orthodontic Therapist training, applications for places are dual in nature, requiring both a willing trainee and a training provider with capacity and, as such, numbers entering the workforce is self-limiting. Indeed, in the last two years, not every Orthodontic Therapist course has received sufficient applications to run its programme.
There may then also be a potential impact on secondary care orthodontics if fewer specialist trainees are available to provide service commitment in current departments providing significant amounts of training. In addition, a reduction in numbers of training posts leading to specialization also reduces the pool of trainees available to undergo further higher training to fill consultant posts made available with the departure of existing incumbents of such posts. There may also be a concomitant reduction in the number of consultant trainers required for the existing specialist training programmes if a reduction in NHS training numbers is not in part replaced by the training of self-funded trainees, such as those from overseas.
Conclusion
The use of orthodontic therapists in an extended orthodontic team model has been successful since their introduction in 2007. The team approach best utilizes the skills of each individual in the team and potentially allows greater access to specialist orthodontic care for patients, although this is limited in the UK by funding for NHS orthodontic treatment, which is unlikely to increase in the current climate of austerity.
In the authors' opinion, the introduction of orthodontic therapists working under prescription under the supervision of a dentist has had a positive influence on the specialty, although more research is required to quantify exactly what the impact has been. Indeed, one of the authors is investigating the effect of qualified orthodontic therapists on the quality of outcomes with reference to the Peer Assessment Rating.
It has allowed specialist orthodontists to concentrate their time on diagnosis, treatment planning and the treatment of more complex malocclusions, whilst still maintaining a specialist led service for more routine cases. This is in the best interests of the patient. In some geographical areas where there has been a historical shortage of specialists, it has improved access to a specialist led orthodontic service. The introduction of orthodontic therapists has also given a definitive career pathway for dental nurses with an interest in orthodontics, keeping this knowledgeable resource within the specialty.
Newly qualified specialist orthodontists have suffered, with reduced job opportunities, as the number of orthodontic therapists has increased within the practice of orthodontics and this will ultimately need to be addressed through future workforce studies and the probable reduction in the number of specialists being trained.
