ADA takes scope of practice battle to the web

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The ADA has launched an online petition to express its concerns about proposed changes to scope of practice.
The ADA has launched an online petition to express its concerns about proposed changes to scope of practice.

This week the Australian Dental Association has rallied its members to sign a petition, and to write to the Dental Board of Australia and State Health Minister, opposing the DBA proposal to alter the Scope of Practice Standard for dental practitioners to allow auxiliary dental practitioners to work without supervision and to undertake additional procedures.

The petition is on a dedicated website entitled Hope for Scope. As of yesterday morning, the petition had gathered 2266 signatures.

The ADA says on the site that “the Dental Board’s recommendations for changes to the Scope of Practice Registration Standard undermine the role of the dentist and potentially jeopardise the quality of the dental care that Australians will be receiving in the future.”

The site lists their concerns as:

* Practising ‘without supervision’ introduces unacceptable risk; adding that the Dental Board’s proposal eliminates the current level of public protection that the existing Standard ensures. The risk of misdiagnosis or failure to recognise a dental problem would increase.

* Expanding scope needs to be supported by formal 
education and training; The site says that with only partial training in oral conditions and treatments, there is a heightened risk of auxiliaries diagnosing and treating within the limits of their knowledge, without being required to consult a fully qualified dentist and thus not providing a complete diagnosis of all conditions.

* Definition of dentistry; If an all-inclusive definition is adopted the public will have difficulty differentiating between who is a dentist and who is a ‘dental practitioner’.

* Defining dentistry will hold back progress; The ADA believes that including a static definition would restrict innovation and the breadth of practice that may develop over time in response to technological and scientific advances. These changes would effectively be excluded from the practice areas allowed by the Standard and prevent dentists who are at the forefront of development from employing new techniques and treatments.

Scope of practice is a hotly contested issue in the profession at present. An article on the same topic in News Bites a month ago led to a fierce debate in the comments section which has continued up until recently.

Not everyone agrees with the ADA’s concerns. Dental Hygienists Association of Australia (DHAA) president Hellen Checker says, “Endorsing dental hygiene services in this way will remove one of the most significant barriers to direct public access to preventive oral health services, which would in turn help to reverse the decline in public oral health.

“The scope of practice standard to facilitate delivery of primary health care is the first step in the paradigm shift necessary for economically responsible dental service delivery and workforce training and utilization. The Comprehensive Primary Health Care Model is highly adaptable to community settings and congruent with the scope of practice requirement for supportive structured professional relationships to expedite the cross referral process. The standard and guidelines need to vigorously emphasize a preventive model with direct access to primary preventive dental providers such as dental hygienists and oral health therapists working in unsupervised community settings. Denying this, or giving only lukewarm support as an add-on to restorative services, is to deny long-suffering population groups the right to oral health. Dental hygienists, dental therapists and oral health therapists are autonomous professionals who work collaboratively when required as part of the professional dental team. It needs to be made clear, both to dental practitioners and the public, that dental hygienists, dental therapists and oral health therapists are extensively trained professionals, properly qualified and registered and possessing the expertise needed to perform their roles.

“Many countries around the world recognize the value of preventive dental care and place a high community value on preventive dental services. Many encourage direct access, meaning citizens may see a dental hygienist without first having to see a dentist. In Ontario, Canada, Bill 171 was introduced in 2007 which allows the public to access the dental services of registered dental hygienists. Other counties with similar legislation the United Kingdom, Netherlands, New Zealand and Scandinavian countries including Sweden and Norway and many states in America, where dental hygienists have recently celebrated the centenary of their profession. The recent recommendations from the Australian parliament are in keeping with international, evidence- based trends.”

 

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10 COMMENTS

  1. The ADA seems to think changes in the Standard will put the public at risk. Perhaps there is another agenda here. I understand it is the role of the Dental Board of Australia and the Australian Dental Council to ensure patient safety and quality is of a high standard. To claim that dental hygienists, dental therapists and oral health therapists are not adequately trained and qualified to diagnose and treatment with their scope of practice is a blatant challenge the accreditation functions of the Board, the Dental Council, and all the Universities and higher education organisations that offers training to these dental practitioners. Australia lags behind international standards, and sadly the ADA’s directions is a barrier to improving public oral health in Australia.

  2. The ADA are not claiming Hygenists, Therapists or OHTs are not adequately trained to diagnose and treat within their scope of practice.

    They are saying they are not qualified or trained to diagnose/treatment plan/refer patients beyond their scope of practice.

    As auxiliaries are by definition not educated as broadly or as in depth as dentists their role remains as a member of the dental team specializing within their scope of practice.

    Auxiliaries are not trained as extensively as dentists, and as demonstrated by their limited scope do not have the breadth and depth of knowledge required to accurately diagnose and refer.

    The fact remains dentists are the most qualified member of the dental team and as many OHTs have commented before this model works and affords each member the respect for skills and autonomy they deserve within their limited scope of practice.

    OHTs are NOT trained to refer or diagnose at the same level as dentists are, hence the concern by the ADA of a lowering of standards.

    The agenda missed here is the pressure being put on the DBA by the HWA to reduce the costs of dental care by allowing lesser trained auxiliaries to practice independantly on the basis of a flawed and poorly written attempt at research and social engineering, shown here: https://www.hwa.gov.au/sites/uploads/hwa-oral-health-review-report-201208.pdf

    For a critique of this report some of the many rebuttals are linked here: http://www.synstrat.com.au/PDFs/dentistarticles/Dental Reform Agenda article Graham Middleton.pdf

    http://www.ada.org.au/app_cmslib/media/lib/1211/m452643_v1_105_du_october_12.pdf

    http://www.synstrat.com.au/PDFs/dentistnews/Dental Reform Agenda or Social Engineering October 2012.pdf

    Unfortunately the OHT community has been convinced by the HWA and previous federal government their profession is the shining hope of affordable dental care, meanwhile actual affordable public health measures such as water fluoridation, targeted intervention in high risk groups, investment in incentives for rural practitioners and oral health promotion are left by the wayside.

    Although some efforts have been made i.e. the Voluntary Dental Graduate Year Program and the Dental Relocation and Infrastructure Support Scheme some have suggested total dental health spending has decreased since the government disbanded the chronic dental health scheme leaving large gaps in the funding of disabled and senior patients with serious dental problems.

    It remains to be seen what changes will occur to the delivery of dental services to Australia and as always is the case the ADA will deliver informed and well researched and affordable suggestions as they are operate independent of the latest political milieu and have the public’s interest at heart and are not trying to skew public opinion to get re-elected.

  3. WITHIN THE PERAMETERS OF YOUR TRAINED SCOPE OF PRACTICE are the key words here. If I, as a dental hygienist, foolishly advice a patient or diagnose a patient outside my trained scope of practice, then the Dental Board has the authority to re-educate me, discipline me or strike me off. How exactly is that different from any other professional registered with the Dental Board? A.D.A., please trust us to be as professional as you. The evidence of litigation and disciplinary action, shows that we can be trusted.

  4. To all Dentists out there complaining about the scope of practice changes with therapists, do you have concerns about your general dentist colleagues performing treatment well beyond their undergrad training? The proposed changes are minuscule compared to dentists performing block grafts, sinus lifts, implant surgery and restoration, apicoectomy, fixed ortho, sleep apnoea devices and full mouth rehabs. I don’t recall any of that being covered in undergrad training. CPD has enabled a broadened scope of treatment options for dentists which we all enjoy and passionately defend, yet in the same breath we seek to deny the opportunity for progression of therapists. As an aside, if you actually ask some therapists how they feel about the proposed changes, I think you will be surprised that it is not met with overwhelming support from them.

  5. How unfortunate that as a student you are demonstrating ignorance about the work that Dental Hygienist, Oral Health Therapists and Dental Therapists currently do. Having worked in this profession for 25 years, I am fully aware of my scope of practise and my obligations to refer to Dentists for conditions outside of this scope. I have always done this and under the proposed change this would not change. I am currently responsible for my patients and they only see the Dentist if I refer them. My experience means that I am more then capable of recognising dental conditions within the mouth, even ones I am not trained to treat! I don’t diagnose these conditions, but I do refer them! This will not change. Dentistry is such a dynamic field that I am constantly learning and regardless of the scope of practise now and in the future, I hope as a student, when you graduate you will value the experiences of all those around and and continue to learn from them as well.

  6. Terri, nobody is calling you incompetent or suggesting your level of expertise is inadequate. How could I know whether you are unqualified without knowing anything about you in the first place.

    If you read the byline of the ADA it is entitled “Don’t give good auxiliaries the power to make bad decisions” which sums up their argument.

    I can confidently say most of the best students in dental science at Griffith are OHTs, and their experience shines through in practical and theoretical examinations. There is no animosity towards OHTs as a group as even dental students can see your value and contribution to dental practices.

    What dentists don’t want is diagnosis outsourced to the cheapest possible provider who hasn’t been as comprehensively trained in all aspects of dentistry as diagnosis requires the integration of knowledge from a variety of fields within dentistry.

    This is not to say dentists are infallible or created equal, however when creating a standard for care regulatory bodies rely on accreditation from the ADC as a minimum standard to provide unsupervised practice.

    We are not saying all dentists are more knowledgeable than all OHTs, or vice versa, for public safety standards however these practitioners have met the requirements to operate unsupervised and have attained a level of competence deemed suitable for this.

    Giving OHTs the opportunity to practice independantly and perform oral diagnostic services they have not been formally trained for introduces the opportunity for misdiagnosis.

    What is the legal remedy for a patient who has undiagnosed pathology from a practitioner who has not been trained to diagnose their condition?

    Nobody is saying dentistry and auxiliary fields are not gaining experience and knowledge over time, and I least of all would suggest I am any more qualified than a graduated OHT or dentist who has been practising for some time.

    What the ADA is saying and what I support is the provision of services in line with the scope of practice you have been trained for.

    If you have been trained within a limited scope of practice such as OHT or dental technology, it is logical your practice not extend to oral diagnosis or providing informed consent on treatment modalities as you do not have the breadth and depth of training to give advice on these services.

    Obviously there are extensions of every specialist practice however dental students are adequately trained in all modalities to extend their capabilities through CPD training, and have a broad understanding of the implications their practice can have on other facets of oral health.

    Specialists themselves are general dentists who extend their practice beyond general dentistry, however they require the basic knowledge of a general practitioner to correctly diagnose the source and contributing factors to dental pathology.

    A MD is trained to identify pathology and treat or refer to specialist practitioners just as a dentist remains the primary referring physician to provide treatment planning and referral for dental problems.

    As many have noted before you would not go to your local nurse to see whether they can refer you for skin cancer, a non healing abscess or a damaged ligament etc…

    The same goes for TMJ dysfunction, orofacial pain, soft tissue lesions & suspicious growths, planning for fixed or removable prostheses, this planning is conducted by a dentist because they are trained in all modalities and are able to diagnose based on this training.

    Re the talk of a lack of litigation as evidence of OHTs competence, they are all under the protective wing of a supervising dentist, how could an OHT be liable for not diagnosing a condition they have not been formally trained to identify?

  7. Letting auxiliary Dental Practitioner practices without supervision reminds me of this similar situation, where Building designer can design house without architect’s signature.

    I don’t know about dentistry, but in architecture, it definitely lowers the standard of the building design. A house designed by a building designer has no soul; but because it is cheaper, developer will hire building designer instead of architect. As a result, the quality of design the general public get is lower.

    As a result, it drives real passionate architects out of the industry. And the only winner is the developer. Both the public and architects lose.

    For example, an architect sees a house as somewhere people revitalise themselves. They will see how the orientation, elevation, ventilation, views, transitional space etc … work out to give the best to the inhabitant; On the other hand, a building designer simply think of how he can put 2 bedrooms, 1 kitchen, 1 living room into a box at a lowest building cost to sell the highest market price.

    Similarly, I would think that a dentist will be able to associate a pain in the mouth to other more serious problem in the body (eg nasal problem, neurology problem etc), just like a doctor, whereas an auxiliary just can’t because they are not trained like a doctor.

  8. To Someone concerned – While I do appreciate your argument, it is still a very limited view of my occupation. As a tutor and as a practicing Dental Hygienist, I strive at all times to view and teach a view of the mouth in a wholistic way. We learn to know all the shades of normal and periodontal conditions very, very well so that when doing an oral cancer exam (on every patient, every 6 months), we will recognise “not normal”. “Not normal”- regardless of how insignificant it seems, is always referred. In my career of 36 years, I have detected two life saving stage one scc (one very tiny in the floor of mouth, one behind an upper molar),a tongue tumor (fatal)and a number of invasive but benign lesions that were monitored, the results of which I do not know. I diagnosed none of these but referred “not normal”for diagnosis. This is what our training teaches. I beg to suggest, that our tissue exams are more thorough than the average dentist as we look at soft tissue constantly. In regard to other areas, again I look at the whole picture and speculate on possible causes. Is this straight perio? Are systemic factors a possibility? Is a traumatic occlusion a factor? Is the dentistry or dentition complicating things? Would this person benifit from smoking cessation, medical, dietary or lifestyle referral? Then – I refer. In fact, I would at all times if working unsupervised, recommend to the patient to get a dental exam every 6-12 months by a dentist. Isn’t it time we trusted each other to do our prescribed jobs and trusted the public to follow our advise and see a dentist too?

  9. Auxillary dental staff such as dental therapists and dental hygienists are a precious commodity to the dental industry. I dare to imagine what it would be without an experienced hygienist to work with. However if they are allowed to practice without supervision, I think forget applying for dentistry, or completing primaries or even applying for pediatric dentistry. Its much cheaper (not easier) and time wise less taxing to apply for dental therapy. Why do 5 when you can do 3?

  10. Oh my goodness what an awful lot of scaremongering by the ADA.
    My expert and extremely comprehensive study to become an OHT was provided by the same highly qualified personnel as the dentists. Don’t tell me my supervisors and tutors held back on what they taught me just because I’m an OHT and not a dentist?
    Over the past 28 years I have never had a dentist stand over me, beside me or even in the same room/building just to supervise my work! They have however been at the other end of a phone call or email when and if necessary. ‘Supervision’ has not been necessary and will not be necessary as I am fully qualified to examine,diagnose, treatment plan (including referral)and carry out treatment all within my highly qualified scope of practice. That is what I have been doing and what I hope to continue to do, working within a structured and professional relationship with a referring dentist.
    Do not deem me or my co-workers by hiding behind those very shallow words….”don’t give good auxiliaries the power to make poor decisions”.

    Dental hygienists, dental therapists and oral health therapists are not the ones on a power trip here.

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