References
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Scope of Practice. 2013;
Preparing for Practice. Dental Team Learning Outcomes for Registration. 2011;
van der Linden FPGM. Three years postgraduate programme in Orthodontics: the final report of the Erasmus Project. Eur J Orthod. 1992; 14:85-94
Huggare J, Derringer KA, Eliades T, Filleul MP, Kuipers-Jagtman Kiliaridis S The Erasmus programme for postgraduate education in orthodontics in Europe: an update of the guidelines. Eur J Orthod. 2014; 36:340-349
O'Neill J Whose case is it anyway?. 2007;
Onabolu O, McDonald F, Gallagher JE. High job satisfaction among orthodontic therapists: a UK workforce survey. Br Dent J. 2018; 224:237-245
Rooney C, Dhaliwal H, Hodge T. Orthodontic therapists – has their introduction affected outcomes?. Br Dent J. 2016; 221:421-424
Dugdale CA, Ahmed F, Waring D, Malik OH. Scope of practice and supervision of orthodontic therapists in the United Kingdom: Part 1: a national cross-sectional survey of orthodontists. J Orthod. 2018; 45:29-37
Ahmed F, Dugdale CA, Malik OH, Waring D. Scope of practice and supervision of orthodontic therapists in the United Kingdom: Part 2: a national cross-sectional survey of orthodontic therapists. J Orth. 2018; 45:38-45
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Brexit: the Implications for Health and Social Care. 2017. https://www.kingsfund.org.uk/publications/articles/brexit-implications-health-social-care
Training and scope of practice for orthodontic auxiliaries: where does the uk sit within europe?
From Volume 11, Issue 3, July 2018 | Pages 93-99
Article
Dental auxiliaries are defined as people involved to a greater or lesser extent in the practice of dentistry, but are not qualified with a degree or diploma in Dentistry. Orthodontic auxiliaries are those specifically involved in assisting or providing orthodontic care (Table 1).
| Dental Auxiliaries | Orthodontic Auxiliaries |
|---|---|
| Dental nurse |
Orthodontic nurse |
The advantages of auxiliaries in the orthodontic team were first reported in 1999 and include:
The training, regulation and role of orthodontic auxiliaries in the UK
The training, qualification, registration and scope of practice for all orthodontic auxiliaries in the UK has been agreed between the General Dental Council (GDC) and the British Orthodontic Society (BOS). Auxiliaries must be registered with the GDC to practise and the roles of all dental registrants in the UK are laid out in the GDC Scope of Practice documentation.2 Standardized training and certification to denote competency are required for registration with the GDC for all dental auxiliaries (Table 2). Standardized training is advocated to improve patient safety, quality of care and promote understanding of competencies and subsequent appropriate use of skills.
| Orthodontic Auxiliary | Qualification |
|---|---|
| Orthodontic nurse | National Examining Board for Dental Nurses: |
| Orthodontic technician | BTEC National Diploma in Dental Technology |
| Orthodontic therapist | Diploma in Orthodontic Therapy of Royal College of Surgeons England |
Designation of clinical duties should reflect adequate training and demonstration of competency.3 For example, the scope of practise for orthodontic nurses can extend to include oral hygiene instruction and full orthodontic records, including radiographs, impressions and clinical photographs, providing adequate training has been completed to ensure competency. Orthodontic dental nurses and therapists are supported by the Orthodontic National Group (ONG), an affiliated organization to the BOS that aims to act on their behalf in progressing standards, developing roles within the team and obtaining extended duties. The Orthodontic Technician Association (OTA) advocates for orthodontic technicians with a role in development and education and acts as an advisory body to institutions and individuals regarding the use of orthodontic laboratory techniques and the scope of practice for orthodontic technicians. Both the ONG and OTA participated in the GDC Consultation process for the GDC Scope of Practice guidance.2
Orthodontic therapists
The development of Orthodontic therapists (OTs) arose as a potential solution to problems arising from the discrepancy between demand for orthodontics and number of providers. A pilot training programme for therapists was undertaken in Bristol in 1999 based on an existing successful Vancouver programme. Training was undertaken over 4 weeks using multiple methods covering 17 modules. The results were excellent and this was used as a basis to develop training courses in Bristol and Leeds,1 from which the first cohort qualified in 2008. Subsequently, a National Standard was developed to enable training, leading to qualification through the Diploma in Orthodontic Therapy accredited by the Royal College of Surgeons. Alongside Bristol and Leeds, a further six universities now provide approved training to prepare for the Diploma examination; Cardiff, Edinburgh, Manchester, Warwick, University of Central Lancashire and King's College London. The programme takes 12 months with 4-week intensive training, a number of study days and work-based training in primary or secondary care. In December 2016, there were more than 350 orthodontic therapists registered with the GDC.
Orthodontic training across Europe
The training pathway for specialist orthodontists is largely standardized across Europe. In 1992, van der Linden and co-workers applied for an Erasmus grant of the European Union (EU) to develop a commonly accepted programme for the education of specialists in orthodontics. Fifteen University Professors from 15 different European countries collaborated to identify and agree the essential matters for the programme, such as the main objectives for specialty education in orthodontics, course contents, time requirements and pre-clinical/clinical work and research. The programme became known as the Erasmus Programme for the Specialty Education in Orthodontics.4 The Erasmus Programme is not formalized by the EU as the role of the EU is only to provide directives for minimal length and overall content of programmes without providing specific details. However, the Programme has been implemented in most European countries and incorporated in the law of several countries. This standardization has been an important factor in regulating training and consequently the standard of orthodontic care throughout Europe. The Erasmus programme is regularly reviewed and updated.5
For orthodontic auxiliaries no such standardization exists and training, registration and scope of practice are thought to be highly variable across individual countries. This may be a potential source of difficulties within the European Economic Area (EEA) where freedom of exchange of professionals is permitted among the Member States who were participating in the EU before 1st May 2004. Dental care professionals from the EEA are able to work in the UK as long as they hold a primary qualification specified in the relevant EC Directive and are registered with the GDC. With the increasing role of orthodontic auxiliaries and the freedom of movement of EEA workers, it has been questioned whether standardization of the training and scope of practice may be timely.
A previous study by one of the authors in 2007 used a questionnaire distributed to Angle Society of Europe members to request information relating to the training and role of nurses, dental hygienists and orthodontic auxiliaries. The response rate was low (33%) but findings indicated that formal orthodontic auxiliary training was uncommon and the delegation of tasks was highly variable.6
Survey of training and scope of practice for orthodontic auxiliaries across Europe
Paucities in existing evidence about the training and use of orthodontic auxiliaries across Europe prompted the current study. The study aimed to evaluate training and registration requirements, scope of practice and supervision of clinical work for chairside orthodontic auxiliaries across Europe.
A cross-sectional survey design was used. Sampling aimed to gain representation from multiple orthodontists across 32 European countries to enable comparison of practice within and across countries. Initial recruitment involved 193 Heads of Orthodontic Schools across Europe and 23 members of the European Federation of Orthodontic Specialists Association (EFOSA) who were sent an electronic version of the survey via email link in December 2015. Due to a low response rate, including only 19 respondents (9%) from this approach, further opportunities for additional recruitment were identified. Questionnaires were distributed to 100 members attending the Angle Society of Europe (ASE) meeting in January 2016 and 31 members attending the EFOSA meeting at the European Orthodontic Society meeting in June 2016.
The questionnaire was developed by the authors with sections to cover three areas of interest:
The introduction to the survey clarified that the questions related only to chairside auxiliaries and this was defined as including anyone working within the surgery to provide direct clinical care. The questionnaire was piloted with UK and overseas postgraduate students to assess readability and clarity in questions. The preliminary questionnaire was developed using an online survey tool (LimeSurvey) for distribution via emails lists. Subsequently, a paper version of the survey was also developed to enable alternative methods of distribution (Figure 1).
The survey was not judged to require approval from a Research Ethics Committee. Consent was implicit by return of the questionnaire and no incentives were offered for participation. Participants were reassured that participation was voluntary and all results would be kept confidential, stored securely and reported anonymously. Personal data was stored only for the duration of the study to prevent duplication in distribution.
Results
Despite the multiple approaches taken for recruitment, response rate to the survey was disappointingly low. Only 59 complete surveys were returned (Table 3) and not all countries were represented (Table 4). The low response rate was considered during interpretation of the results.
| Method of Distribution | Number Distributed | Number of Responses | Response Rate (%) | |
|---|---|---|---|---|
| Electronic | 216 | 19 | 9 | |
| Direct to members | ASE | 100 | 22 | 22 |
| EFOSA | 31 | 31 | 100 | |
| Number of responses | 72 | |||
| Incomplete responses | 13 | |||
| Total for inclusion | 59 | |||
| Represented (Number) | Not Represented |
|---|---|
| Austria (1) |
Bulgaria |
The majority of respondents (58/59) indicated that training was the responsibility of orthodontic specialists. General dentists and orthodontic auxiliaries were reported to provide training for orthodontic auxiliaries by 18 (31%) and 13 (22%) of respondents, respectively. Standardization of training of auxiliaries was reported by 22 of the 59 respondents (37%). There was high variability in training for chairside orthodontic auxiliaries; 25% reported no formal training, 51% reported a general dental auxiliary qualification and 41% reported specific orthodontic auxiliary training. The differences may in part be attributed to the variation in how the term chairside orthodontic auxiliary was interpreted. Participants reported that chairside orthodontic auxiliaries could include nurses with or without extended competencies, orthodontic therapists and technicians.
All participants provided a named regulatory body for dentistry in their country. Registration was reported to be compulsory by the majority of respondents for orthodontic specialists (58/59) and general dentists (51/59), however, this was considerably lower for orthodontic auxiliaries (20/59). Despite respondents providing information about the regulatory body, a register of dental care professionals is not accessible in many countries. The GDC do not provide data to estimate the number of overseas professionals working in the UK and, as a result, it was not possible to determine the movement of orthodontic auxiliaries within Europe.
The majority of respondents (83%) reported working alongside orthodontic auxiliaries, yet there was notable disparity in opinion regarding which procedures auxiliaries should and do perform, and expectations for supervision. Table 5 summarizes the general trends in opinion regarding each procedure. The results of the present survey provide a similar picture to those from the 2007 survey, despite the increase in use of orthodontic auxiliaries in the UK, and most probably in other parts of Europe.
| Procedures Widely Accepted as Appropriate | Conflicting Opinion Regarding Appropriateness | Procedures Rarely Considered as Appropriate |
|---|---|---|
| Oral hygiene instruction |
Impressions |
Assessment |
The low response rate presents significant challenges for interpreting and using the findings of the survey. Two key limitations in the study were identified. Firstly, auxiliary is an ambiguous term and without clarification on an individual country basis it is difficult to create a valid Europe-wide survey. Uncertainty in the survey questions and intention may have reduced participation, particularly for the electronic survey. Secondly, informal feedback during survey distribution to members at meetings highlighted that the topic was seen to be politically sensitive and this inhibited participation.
Future challenges to the appropriate use of orthodontic therapists in the UK
Orthodontic therapists (OTs) were introduced to improve access and quality of orthodontic care. The success and popularity of the training programme is evident in the high number of applications each year and the opportunity for further training and career development is valued by OTs, who report a high level of job satisfaction.7 Evidence supports that excellent standards of care can be delivered by orthodontic therapists working in primary care8 with appropriate supervision and adherence to the GDC ‘Scope of Practice’.
Anecdotal evidence suggests that the greatest challenge to OTs in the UK presently is ensuring adequate supervision and support. In 2018, a two-part survey was undertaken to investigate the scope of practice and level of supervision of OTs in the UK. The first part, involving GDC registered orthodontic specialists, found that the majority of orthodontists provide a written prescription for the OT, however, 42% were aware that their prescription did not contain the necessary information stipulated by the GDC.9 The second part, targeting OTs through the BOS, found that the majority of OTs reported working from written prescription without direct clinical supervision.10 A further survey undertaken with OTs supported the findings that most clinical procedures by OTs are performed under prescription but unsupervised,8 however, around 1−2% of more complex procedures, such as fitting bonded retainers and adjusting archwires, are being undertaken without either prescription or supervision. These surveys are beginning to highlight a possible misuse of OTs, which could be both damaging to patient care and the reputation of the specialty as a whole. Consideration needs to be given to mechanisms for identifying poor practice and supporting OTs where concerns arise. A further area for development is inclusion of information and training about effectively working with OTs in the training for orthodontists. Current lack of training and knowledge has been identified as a possible cause of poor supervision and delegation practices.11
Should orthodontic auxiliary training be standardized across Europe?
Despite the poor response rate from the survey, it seems fair to suggest that training, registration and the role of orthodontic therapists is highly variable. However, whether standardization is needed is a more complex question. Registration is the responsibility of individual countries and will be determined by the governing body responsible for dentistry. The role of auxiliaries needs to fulfil service need and this will vary between countries. Accordingly, the scope of practice must reflect service need and this might prevent the feasibility of standardizing training. The general feeling from orthodontists across Europe appears to be that current models for training and use of orthodontic therapists are working well in individual countries and there is no desire to complicate this with EU wide regulation.
Brexit poses a significant challenge to many areas of healthcare provision, including staffing and workforce planning.12 It now appears likely that, following withdrawal from the EU in March 2019, migration of EU nationals will be subject to UK law, although precisely what this means is unclear. With such uncertainty ahead, the UK is not in a position to lead decisions regarding European training at this time and any further discussion arising from this survey should be instigated and driven by those members of orthodontic societies remaining in the EAA.