Minimum intervention oral care delivery for children: developing the oral healthcare team

MIOC in paediatric dentistry

In England, Wales and Northern Ireland at a population level, the prevalence of dental caries in children is assessed by a national survey performed every 10 years. This Child Dental Health Survey (CDHS) started in 1973 and was last carried out in 2013.⁶ Dental caries is still a public health problem in the United Kingdom with nearly a half of 15 year olds and a third of 12 year olds having caries in their permanent teeth. The pattern follows social gradients, with the most deprived being more affected.⁶ It should be noted that such epidemiological surveys do not use radiographs in detection of caries, as exposing subjects to potentially harmful radiation without clinical benefit is not justified. In other countries where surveys have used radiographs, the caries prevalence increased markedly, as the threshold for caries detection intensifies.⁷

First permanent molars and their occlusal surfaces are the most susceptible to the caries process.⁸ Even current treatments provided for compromised first molars varies⁹ and the minimum intervention oral healthcare (MIOC) framework may provide an alternative pathway for avoiding extractions.¹⁰ Children with caries in their permanent teeth will carry any disease burden into adulthood. Its impact on individuals, and society, is significant both in terms of quality of life and socioeconomic implications.

The traditional mechanistic surgical treatment of carious lesions does not cure the disease process.^11,12 This traditional approach, with an emphasis on ‘drilling and filling’ teeth, which placed the dentist as the most suitable clinician to treat the lesion, should now be replaced with the patient-level MIOC framework with a primary focus on detection, diagnosis, personalized care planning, prevention of lesions and control of the disease process.^13,14 These principles of MIOC can apply to all oral healthcare, not only to dental caries. This offers possibilities for dental (or perhaps better termed, oral healthcare) practices to use DCPs to deliver aspects of oral healthcare (Figure 1).^15,16,17

Benefits would include better long-term clinical care, and an improved patient acceptability. Minimally invasive dentistry (MID) represents one of the four domains of the MIOC framework where, at a tooth level of treatment, all operative interventions are biological, respecting and preserving the dental/oral hard and soft tissues and being as minimally tissue-destructive as possible.

Although the underlying domains of MIOC remain the same for patients throughout their life course, the actual components and their delivery will differ as ‘children are fundamentally different to adults’.¹⁸ A joint ORCA (European Organisation for Caries Research) and EFCD (European Federation of Conservative Dentistry) expert Delphi consensus statement provides recommendations as to how to intervene in children with early childhood caries, and caries affecting the occlusal surfaces of permanent molars. This consensus also highlighted areas where the agreement was weak and the associated research gaps.¹⁹

Creating an oral healthcare team

What can they do?

When designing a practice that focuses on MIOC delivery, it is important to understand fully the scope of practice of each member of the oral healthcare workforce enabling effective integration whether it is in a single surgery practice, a large multi-surgery practice, or an organization which has several practices operating. The roles for each member of the oral healthcare team are detailed in the General Dental Council's (GDC) ‘Scope of practice’.²⁰ Provided the individual is suitably trained, indemnified and working under their GDC scope of practice, some examples of how dental care professionals can be used in the MIOC framework can be seen in Figure 2.

The clinical parameters for each member of the oral healthcare team are outlined and itemized by the GDC the ‘Scope of practice’, describing the items and areas that a registrant has the knowledge, expertise and skills to practice safely in the best interest of a patient.²⁰ In 2013, the GDC enabled direct access for DCPs. Under direct access (excluding NHS care in general dental practice at present), DCPs can now see patients directly for certain treatments without the need for this to be prescribed by a dentist. One aspiration of this change was to enable more access to dental care for the population, including children.

The diagnostic permissions for certain DCP registrant groups originate from this document and the term ‘diagnosis within competence and scope’ is used. This diagnostic list covers caries, periodontal disease, gingival conditions, oral pathology and oral cancer screening. Hygienists and therapists are also taught to recognize endodontic pathology, and would refer this onto their dentist colleagues for treatment. Patients can also access tooth whitening with a prescription from a dentist. At present, hygienists and therapists are applying to hold prescribing rights for certain prescription-only drugs through the medical exemptions framework.

All oral healthcare team members will have a duty to keep full, accurate and contemporaneous patient records when they are carrying out their duties with a patient. Figure 3 shows tasks for the domains of MIOC that appropriately trained and indemnified DCPs can undertake, or be involved in.

Team development

Use of a structured, conscious approach may help to aid the development of a team from a fledgling group of individuals to a high-performing team proficient in the delivery of MIOC. In 1965, Bruce Tuckman identified stages for effective team development (Figure 4).²²

Forming: the stage where a group comes together, but tries to avoid conflict. Members try to get to know each other, but are cautious. Here the overall vision of MIOC and MID is communicated, a plan is drawn up and an acknowledgement of the resources needed is agreed.

Storming: here conflict is present. Issues such as authority, responsibilities, regulations, remuneration and appraisal systems need to be addressed.

Norming: at this stage the team starts to become an organized unit. Working together with a sense of purpose and shared vision. A feeling of togetherness and trust is established and morale is good.

Performing: the team is now showing good productivity with goals and performance indicators, such as access to care, being met, members are supportive towards each other, which allows a degree of autonomy and creativity.

Current use of DCPs

Currently there are approximately 69,300 DCPs on the dental register in the UK, with the majority consisting of dental nurses (Table 3).²³

Limitations of the data collected mean that it is not possible to assess the extended duties roles of the registrants, and the practices that each undertakes. There is an acknowledgement that DCPs are not being used to their full scope of practice. This represents, potentially, a waste of useful resources, as well as a waste of expenditure on training and development.

In delivering oral health education, for example, team members must try to offer the same advice/message/encouragement, but differing perspectives and delivery modes may prove helpful to the receiver (Figure 5). When managing children and their parents, all members of the oral healthcare team have a responsibility to build rapport. This is crucial because oral hygiene instruction, dietary advice and encouragement for regular attendance will be more effective when the parents/carers are engaged and fully supportive of the value of the care messaging that they are receiving. The role of the team is to help children and parents to value, modify and improve their own behaviour. The didactic provision of information by itself is not sufficient to accomplish this. The child and parent need to have the capability, opportunity and motivation to help behaviour change and subsequent adherence to change.

Access to care

The use of the wider oral healthcare team to deliver MIOC may help to improve access to care for populations. Where resources are scarce, and access to care is suboptimal, the delegation of tasks to DCPs may help deliver more interventions, by either substituting or freeing up dentists to concentrate on more complex operative cases. This can result in more preventive services being provided while maintaining patient acceptance of the service.²⁴ In theory this sounds plausible, but in general dental practice there may be several other factors that affect such implementation.²⁵

Clinical/cost-effectiveness

There is a lack of definitive evidence to demonstrate that use of the wider oral healthcare team to deliver care in general dental practice in the UK is more clinically effective in tackling disease.²⁶ Some studies show that the use of DCPs in specific contexts can improve completion of courses of treatment. However, these were not in the context of GDP in the UK.²⁷ Studies have shown that DCPs may be just as efficacious in diagnosing common oral diseases, such as caries, periodontal disease and oral cancer.^28,29 However, further research is warranted to support improved clinical and cost effectiveness of MIOC in NHS primary care.

Knowledge, skills and attitudes

The delivery of MIOC requires all oral healthcare professionals to have an understanding, knowledge and familiarity of the subject. Research has shown wide variation in knowledge and in the decision-making process by dentists.^30,31,32 Questionnaire-based studies of dentists have concluded that UK general dental practitioners' knowledge of MIOC is relatively poor.³³ Schwendicke et al, in their paper on closing the gap between evidence base and practice, also state that getting dentists who have been trained according to a traditional approach to change attitudes and move to a MIOC care pathway is challenging. ³⁴ However, the proportion of traditionally trained professionals who make up the oral healthcare workforce will decrease with time, and this may become less of an issue.

Proponents argue that using the wider oral healthcare team, especially more recently qualified members, may well help to support the delivery of a modern MIOC approach.³⁵ Given that in the UK, current mandatory CPD requirements do not expressly state that professionals need to undertake training in developing interventions, such as selective carious tissue removal, the use of newly qualified DCPs may help steer practices to a more minimally invasive approach. Using the wider skillsets of team members can give individuals a sense of ownership and recognition of the value of their work. A variety of tasks and role development can improve overall work satisfaction and performance.³⁶ Having a wide team composition will also mean greater interdependence. This can bring into play factors both easily identifiable (such as training, age), but also more intangible deeper-level constructs, such as personality.³⁷

Child and parent/carer-focused oral healthcare

Patients who are used to seeing a dentist only, may well feel that their care is being compromised by having a dental professional with less scope of practice, such as a DCP, delivering interventions. However, studies have shown that most patients tend to accept care by a DCP without any major concerns.³⁸ A review by Dyer and Robinson in 2016 on the acceptability of care provided by DCPs concluded that while most adults would accept such care, ‘care for children was seen as less acceptable’.³⁹ MIOC and MID may require more visits than the traditional approach, which may affect the acceptance by carers of children. A systematic review showed that the majority of research on children has included them as objects only.⁴⁰ Further research looking into the acceptability of MIOC should involve them as much as possible and gather their perspectives using qualitative methods.

Delegation

To delegate effectively requires team understanding and a knowledge of the scope of practice of each team member. The introduction of dental therapists into the workforce is a relatively recent concept in the UK. Research has also shown that dental professionals are not very confident in knowing the scope of practice of other dental professionals.⁴¹ As such, effective delegation may not be straightforward or readily accepted. A qualitative study by Nilchian et al concluded that a variety of factors influenced the delegation of paediatric patients for fissure sealants to dental hygienists and therapists, including payment mechanisms, remuneration factors, child and parent attitudes, and the perceived role of the DCP.²⁵

The referring dentist needs to have confidence in the ability of the team member to whom they are referring a patient. Dentists may find the ‘loss of control’ in delegating is a factor that hinders their willingness to use a team-based approach for MIOC. Ongoing sustainability will require good leadership, staff training and development, access to and undertaking continuing professional development, as well as effective business management. Extended duties dental nurses could be used as part of the detection stage of the MIOC care pathway taking radiographs and clinical photographs (Figure 6). Non-clinical attributes of a team may also play a significant role in achieving objectives in MIOC care for children.

Environmental factors

MIOC delivery and a team-based approach implies more patient contacts with different team members. This may initially place extra burden on a patient and their carers in attending appointments, and may be especially poignant in the context of a pandemic when contacts may be encouraged to be minimized. Further, increased appointments places additional draw on practice resources. However, in the long run, as the MIOC approach controls disease and reduces disease risk, fewer appointments will be required from the patient. A full cost-efficiency analysis is required to answer this question fully.

One potential avenue to reduce this initial physical load may be the use of teledentistry for oral health promotion and screening.⁴² Teledentistry may have value for remote consultations for those with reduced access to care and diagnosis in high-risk, preschool children. The use of digital resources including social media may also widen access to resources and information.

Medico-legal liability

Dentists may potentially have concerns about delegating interventions to DCPs as part of a personalized care plan. Where a clinician is employed, then the practice owner will undoubtedly have liability for any oversights or negligent performance.⁴³ This vicarious liability may well deter practices from using the wider skills of DCPs, especially if the practice owners indemnity does not extend to cover this. Of course, this could be addressed by legislation, which aims to promote effective and efficient healthcare. The use of clinical photography, which can be carried out by a DCP, can help with clinician and child/carer communication (Figure 6) reducing the risk of litigation. The keeping of contemporaneous and accurate dental records is vital for maintaining good practice and may reduce risks of future litigation.

Regulation and remuneration

Although there is an acknowledgement and an upstream drive to integrate DCPs, regulation and remuneration may continue to be obstacles to be overcome in the UK to enable effective implementation of DCPs into NHS primary care. As described earlier, although direct access was approved by the GDC in 2013, this is still not currently available in NHS general dental practice. Hence NHS dentists are still responsible for the overall course of treatment, and patients still must be seen by a GDP before care can be delivered by the DCP in an NHS dental practice. This may consume extra practice resources, and the authors recognize that due to limited scope of practice of DCPs, to entirely remove this contact will need further discussion and acceptance. Also, given that remuneration for treatment generally favours surgical interventions,^44,45 practice owners and associate dentists may hesitate to employ DCPs if satisfactory remuneration mechanisms for prevention are not in place.²⁵

Conclusions

Dental caries in children still remains a significant public health problem, with high prevalence, morbidity and associated costs. Access to dental care can still be problematic. The use of DCPs, and effective use of their full scope of practice, has potential to increase the access to, and efficiency of, MIOC framework delivery, and help meet the needs of untreated oral diseases in a modern, biological, evidence-based approach. The factors discussed in this article may also apply to the use of the skill mix in general oral care, and is not limited to MIOC. In order for practices to implement the wider skill mix effectively in MIOC for children, present and anticipated challenges will need to be overcome, both at the local and the national level. This will require acknowledgment of the barriers, and a pragmatic discussion to overcome them.