Auxiliary Workers in the Dental Practice of the Future
Identifieur interne : 005671 ( Istex/Corpus ); précédent : 005670; suivant : 005672Auxiliary Workers in the Dental Practice of the Future
Auteurs : Richard Miller YardleySource :
- Perspectives in public health [ 1466-4240 ] ; 1985-12.
English descriptors
- KwdEn :
- Chairside care, Clinician, Dental, Dental care, Dental disease, Dental hygienist, Dental practice, Dental surgeon, Dental team, Dental therapist, Dental treatment services, General practice, Growth areas, Hygienist, Many instances, Oral hygiene, Particular group, Particular problem, Patient care, Plaque control, Restorative dentistry, Technical ability.
- Teeft :
- Chairside care, Clinician, Dental, Dental care, Dental disease, Dental hygienist, Dental practice, Dental surgeon, Dental team, Dental therapist, Dental treatment services, General practice, Growth areas, Hygienist, Many instances, Oral hygiene, Particular group, Particular problem, Patient care, Plaque control, Restorative dentistry, Technical ability.
Url:
DOI: 10.1177/146642408510500602
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ISTEX:ADD23E1E381DC88630F0FBA0CD5817CCF9ABACBELe document en format XML
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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Yardley</surname><given-names>Richard Miller</given-names></name><degrees>O.B.E.</degrees><aff>24 Bore Street, Lichfield, Staffs WS13 6LL</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>12</month><year>1985</year></pub-date><volume>105</volume><issue>6</issue><fpage>195</fpage><lpage>197</lpage><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>195 Auxiliary Workers in the Dental Practice of the Future SAGE Publications, Inc.1985DOI: 10.1177/146642408510500602 Richard Miller Yardley O.B.E. 24 Bore Street, Lichfield, Staffs WS13 6LL henever one makes an attempt to look into the future, it is always sensible to look back a little into the past and to see the way the dental team, as we now know it, has developed. When I look back to my childhood living in my father's quite progressive dental practice, I remember well the mechanics' workshop with its high technology equipment of a high pressure vulcaniser for dental rubber, the sand casting equipment to make zinc dies and lead counters for the swageing of gold 1 plate and the steam pressure casting equipment. I remember the starched green and white uniform of the surgery maid, who answered the front door and the telephone, mixed fillings, washed up the instruments and put them in the hot water steriliser, and did many of the things about the surgery which the modern DSA still considers to be part of the normal routine of daily life. It is a tragic fact that so often great strides forward in many spheres of endeavour are triggered off by the winds of war, and it was, of course, the advent of World War 2 that stimulated the Royal Air Force to lead the way in Europe in training hygienists, a concept of a dental auxiliary imported from the United States to assist the hard-pressed dental surgeon in improving and maintaining a high standard of oral health necessary in the combatant forces. I remember being indoctrinated by my father, who had of course experienced the incorporation of the 1921 dentists into the profession, that there was a great danger that standards would be lowered if anybody but a fully trained clinician were to be allowed access to the mouth. I took with me when I was called up, this prejudice into the Royal Air Force. However I am happy to say that it only took a very short while - about three days - for ' me to appreciate the immensely high standard of care and the benefits thus accruing to both the patient and the dental surgeon. Within a short time the profession was faced not only with an undreamt of demand for dental care with the advent of the National Health Service in 1948, but concomitant with this came means of high-speed tissue cutting, which totally reorientated the time/work pattern of operative dental treatment. There are probably few in this room who can remember being restricted to the preparation of all cavities by dry-cutting hard tissue with ordinary carbon steel cutters. Thus the immediate activity around the patient in the chair was accelerated in such a way that to provide a more cost/time effective method of treatment four-handed dentistry first became not only a reality but an actual necessity. From that time it was but a short step, especially when treating a sedated patient, to a concept of six-handed dentistry. One cannot help being reminded of one's earliest days in the hospital gas-room, when the definition of an efficient exodontist was one who managed to have at one and the same time a tooth in the forceps, a tooth in the air and one entering the bucket. Restorative dentistry had entered a similar phase. It was at this stage in the manning of my own practice that we had on staff serving six dentists five technicians, a hygienist, twelve DSAs, a receptionist and a secretary. Such staffing was related to a high output of both conventional restorative and prosthodontic work, and an appointment book which on average contained between thirty to forty patients a day, all of whom received active clinical treatment. On reflection the biggest single quantum leap within the practice organisation at that time was the engagement on staff of a full-time hygienist. Her duties then consisted, as it now seems to me, to be principally of routine scaling and polishing, sometimes the treatment of acute ulcerative gingivitis in new patients, and, as I now appreciate, the routine re-removal of considerable amounts of calculus at six-monthly intervals from quite a considerable number of patients. It was not long, however, before the standard of oral hygiene of an increasing number of our regular patients began to improve dramatically, and I make no secret of the fact that this improvement occurred where previous routine periodontal care by the dental surgeon had appeared to have little long-lasting impact. Together with this change there was I known an improvement in the standards of restorative care by the dentist himself. Other changes soon began to take place. Firstly the introduction of high technology techniques into the laboratory together with the retraining of technicians to provide higher standards of technical ability, especially in the field of fixed prosthodontics began to change the horizons of care available to the patients, and quite soon the concept of one amalgam carrier in the well, one in the air and one in the mouth began to become as outdated as the previous concept of the flying tooth. Within the last ten 'years and especially within the laboratories, change within ,the pattern of dental disease itself has had and is having enormous effect upon the present and obviously the future pattern of dental care. The profession now must happily accept that dental disease is no different from other diseases of mankind in that it can not only be controlled, but in many instances eliminated. The effect of such a change must, I suggest, have an enormous impact upon the way we staff the dental treatment services of the future. It would, I think, be true to say that most professions eventually react to events and perhaps it might be refreshing, to say the least, if we in dentistry were able to anticipate the needs of our patients in the future and to be properly equipped as a team to cope with those needs. My brief is to discuss developments within general practice, though I must confess the more one looks at it, any trends there will probably be reflected in the dental treatment services as a whole. Let me start with what must be numerically the largest group within the team. In 1980 it was estimated that there were some 35,000 in the United Kingdom. Of these some 12,000 hold Certificates of the Based on a lecture given to the Royal Society of Health. 10196 Association of British Dental Surgery Assistants and there are, of course, a small number who also have Certificates from dental teaching schools without having sat the ABDSA examinations. I see two factors affecting this group. Firstly there will not be any spectacular growth in the numbers employed because of the change in the pattern of chairside care. I do see, however, an increase in the general standard of person occupying this position within the team. Traditionally, of course, the DSA is female and I can see no reason why that should change. A considerable step forward was brought about when the ABDSA Certificate required a comparatively modest educational requirement before an applicant could sit the examination. In spite of repeated attempts to remove that educational hurdle, I personally am happy to see that it is being retained and in fact experience shows that throughout the length and breadth of the country girls applying for this type of work are in fact now holding educational qualifications well in excess of minimal requirement. This can only have a beneficial effect on the ability of this member of the team to assimilate more readily advanced chairside and surgery disciplines. One particular aspect comes readily to mind and that is in an ageing population, a problem which I shall touch on later, chairside care of the elderly and even resuscitation will become sadly an increasing responsibility of this member of the dental team. The advent of new materials used in restorative dentistry, together with their widely varying chairside techniques, will require constant updating of the DSA's training, and it is significant that certain commercial houses are now interesting themselves in providing peripatetic tutors to facilitate this concept. One other aspect that cannot be ignored is the change in administrative patterns within dental practice, which must inevitably take account of the revolution in information technology and I foresee a time when a proportion of practice administration will be channelled through computer systems. Again it is patently obvious that efficient use of such systems will best be carried out by personnel educationally trained above a certain standard. One should also take into account that in certain parts of the world in particular the USA and DSA carries out within the mouth certain reversible procedures and I speak personally when I can see such activities being quite reasonably within the scope of properly trained and supervised personnel. To give a simple example I see no reason why the DSA should not assist in the care of the ortho- dontic patient by taking routine impressions and the administration of fixed appliance therapy, for it is patently obvious that one of the growth areas within the dental treatment pattern of the future will be that of ortho- dontics, and it is perfectly ludicrous to deny the highly trained clinician adequate assistance to facilitate the orthodontist's potential. I also see no reason why the DSA should not be trained to place the rubber dam, for the increasing number of clinicians now using this aid. Let us now consider the role of the dental technician. There has been over the past twenty years an inexorable movement towards the establishment of both small and large laboratories serving a wide number opf dental practices. Some of us, I think quite rightly, regret the loss of close contact between the clinical and the technical side of dental care and it is perhaps significant that where the highest standards are achieved, a close proximity of the two services often exist. However, simple commercial and logistical considerations suggest that for the great majority of clinicians the present pattern will continue. The problems, as I see it, are twofold. One is the poor standard of communication between the clinician and the technician, and on the other the immensely variable standards of technical ability which exist to service the clinical sector. It is true to say that the profession as a whole and the training schools in particular have been especially concerned over recent years as to the training patterns for both undergraduate and graduate level clinicians. Because of the participation of the General Dental Council, together with pressure from the profession through our British Dental Association, considerable progress is now being made in this area. Sadly, as I see it, no similar umbrella organisations exist within dental technology, though one must pay tribute to the efforts of such disparate groups as the NJC, the DLA, City and Guilds, and more recently BTEC for their efforts in this field. One must also bear in mind that because of the high technologies now coming into everyday use, the industrial sector itself is playing a larger part in the specialised training of technicians. I am particularly happy to be able to report that at long last it would appear a centralised body under the aegis of a General Dental Council is interesting itself in this particular problem, and my sincere hope is that the profession as a whole recognise the total interdependence of these two groups within the general concept of patient care. By using the argument of increasing total patient care, a group wishing to introduce the Denturist auxiliary is currently pressing its case, and the Office of Fair Trading is' at the moment concerning itself with the debate. The case for the introduction of such a class of auxiliary can be considered by studying the claims of the pressure group itself, and in the light of international experience. The principal claims made are that a prosthesis prescribed, made and fitted by the same person is inherently better than one made by those specially trained in the separate disciplines, and that it would be a less expensive to the patient. In the first case there is no demonstrable evidence that this is true, and with the shift in the age group who are going to use removable prosthesis in the future, the necessity for the clinician to have an even wider knowledge of the biological aspects of prosthetic treatment will grow. This suggests that the overall complexity of care may be greater than it is at present. In the second case, there is ample evidence that in the countries where Denturists exist or have recently been introduced (with the exception of Denmark), there has not been in existence a comprehensive state backed Dental Health care system - with all that that implies. As far as costing is concerned data shows that after an initial honeymoon period, Denturists not only employ laboratory technicians to manufacture the appliances provided,' but the cost to the patient is comparable to that of a service by a fully qualified team. Any such debate must in the long run hinge on the ultimate benefit to the patient, and the availability of appropriate care provided through traditional channels. One might make two further comments. Firstly a comparison with the recent change in Optical Services might be made, - and there, there is no question of the technical service actually being directly involved in patient care; and secondly should it be shown that the denturist is required, then the control of this service must lie with that body whose statutory duty is to look after the interest of the patient, - The General Dental Council. Now, may I now come to that member of the dental team whom I think must have an increasingly important role in the clinical environment of the practice of the future, the dental hygienist. I have said earlier that dental disease is preventable and that it is only with the adequate expansion of this particular group of auxiliaries that truly preventive care can be provided for all those who seek treatment. Again at the beginning of this decade there were in the UK some 1,200 hygienists. Their utilisation in general practice is patchy across the country and even now 11197 many dentists do not see a need for their service, which on the one hand is a tragic reflection on the undergraduate training of the profession and on the other, in 1984, where the majority of treatment patterns are still, if I could use the word, traditional, dentists are finding that with the dramatic fall-off in dental disease which requires mechanical intervention, some clinicians are utilising their time to carrying out what has become, in general, the clinical sphere of the hygienist. I believe this particular problem is inexorably bound up with the method of remuneration currently used to fund general dental service dental care. Dental disease can be said to originate in the presence of dental plaque. Plaque control is therefore the prime factor in its elimination. Plaque control is carried out by the patient trained and supervised by the dental team, principally, in so many instances, through the agency of the hygienist. As out patients become better motivated, and this is now being seen in many practices throughout the UK, as indeed is becoming more commonplace in Northern Europe, as well as across the Atlantic, the pattern of practice for the dental hygienist will change. Advice and supervision will become an increasingly important part of their activities in contradistinction to the actual physical removal of large quantities of soft plaque. , There are, however, two growth areas, for which the profession must cater. The first are quite obviously the 40% of the population who do not receive the type of treatment that we have been discussing and I believe the change in this figure will only come about as the younger generations come to maturity with a normal expectancy of a high standard of dental care. The other and more exacting problem which faces the hygienists' corps, as well as the dentist himself, is the rapidly increasing number of geriodonts, the elderly dentate patient. People who in yesteryear would have almost without exception have expected to be edentulous by the time infirmity struck, but now are entering the autumn of their lives at least partially dentate and in increasing numbers with complicated restorative dentistry present in their mouths, the integrity of which is totally dependent upon scrupulous maintenance of oral hygiene. A state which becomes increasingly difficult to achieve with the onset of old age and its accompanying problems, starting possibly with arthritis in the hands, lack of muscular co-ordination due to general senility and often exacerbated either by such conditions as Parkinson's disease, minor cerebral episodes, or simply failing eyesight, which inevitably reduce the degree of manual dexterity which is required to maintain reasonable oral hygiene. These patients may need not only more regular supervision and actual physical treatment than the normal patient, but will in increasing numbers be, I believe, unable to attend the normal dental surgery. It is these patients, as I outlined in a paper presented to the Auxiliary Personnel Committee of the British Dental Association in 1981, who will be living in, at the best, sheltered accommodation, who will require domiciliary care to be provided by a dental hygienist. I envisage dental hygienists working to some extent in the same way as the Health Visitor or District Nurse, providing on the direction of the dental surgeon, the supervision and care that will be required for this particular group of patients, sometimes as frequently as once per week in order that a practical standard of oral hygiene can be maintained, because as every clinician knows, to render a patient edentulous at 80 onwards is not only traumatic for the patient, but presents almost insuperable prosthetic problems for the clinician. May I now finally consider two further groups within the dental team, both small in number and with apparently widely differing responsibilities. Firstly the Dental Therapist. I suppose the cynic may say that these were a vital group of workers who came too late upon the scene and now the problem for which they were originally created has gone away, and as we know, the Government has accepted in the broadest terms the recommendations of the Dental Strategy Review Group and has closed the New Cross school. I know that many are appalled that there has come into existence in the London area a training scheme for further dental therapists, and I think it can be argued that if there is a need for dental therapists to provide the treatment that they traditionally supply, then it is certainly not in the south-east. Experience shows that people who either come from, or more into the South East for training, tend not to move out to those areas of the country where there might be a need for their services. It can be argued that there still are areas of the United Kingdom where child caries, especially in deprived groups within society, requires the additional clinical power of the therapist group. If that can be demonstrated to be so, then I believe therapists should be trained alongside dental students, as recommended by Nuffield, in the areas where they might eventually work. But in the long term I do not believe that the traditional role of the dental therapist is one that needs now to be continued. What I do feel, however, is that those who have been trained in this discipline can best be utilised not as up-market hygienists but as local supervisors of dental health education programmes, working of course under the direction and in close co-operation with the appropriate supervising Dental Officer. This brings me very conveniently to that somewhat nebulous group known as the Dental health Educator, who might be anyone from the therapist, hygienist, DSA, to a willing volunteer at local level in the form of a 'Mum', who is prepared to go into primary schools and give to children of her own child's age group parental advice as how best to look after their teeth. Such people, of course, would of necessity have taken special training in this limited field and although in my own view almost without exception such people should have some direct clinical experience of the provision of dental care, this might not always be possible. In conclusion, we have seen within the last decade the positive change of direction which the dental health team must accommodate in its formulation of the planned dental care of our society in the future. It is my belief that this care cannot adequately be given without a totally integrated team on the lines I have tried to predict.</meta-value></custom-meta></custom-meta-wrap></article-meta></front></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Auxiliary Workers in the Dental Practice of the Future</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Auxiliary Workers in the Dental Practice of the Future</title></titleInfo><name type="personal"><namePart type="given">Richard Miller</namePart><namePart type="family">Yardley</namePart><namePart type="termsOfAddress">O.B.E.</namePart><affiliation>24 Bore Street, Lichfield, Staffs WS13 6LL</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">1985-12</dateIssued><copyrightDate encoding="w3cdtf">1985</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><relatedItem type="host"><titleInfo><title>Perspectives in public health</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">1466-4240</identifier><identifier type="eISSN">1757-9147</identifier><identifier type="PublisherID">RSH</identifier><identifier type="PublisherID-hwp">sprsh</identifier><part><date>1985</date><detail type="volume"><caption>vol.</caption><number>105</number></detail><detail type="issue"><caption>no.</caption><number>6</number></detail><extent unit="pages"><start>195</start><end>197</end></extent></part></relatedItem><identifier type="istex">ADD23E1E381DC88630F0FBA0CD5817CCF9ABACBE</identifier><identifier type="ark">ark:/67375/M70-0XLQWKJN-6</identifier><identifier type="DOI">10.1177/146642408510500602</identifier><identifier type="ArticleID">10.1177_146642408510500602</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/ADD23E1E381DC88630F0FBA0CD5817CCF9ABACBE/metadata/json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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