Fiona Ellwood asks if it is time for a new conversation regarding oral health improvement practitioners.

Abstract

Dental nurses have a longstanding relationship with collaborative and caring work at all levels, and across multiple settings. Their role has evolved with time, but has accelerated since mandatory registration in 2008. Against this backdrop, the following question must be asked: is it time for a different narrative? There is a need to explore the role of the dental nurse and consider opportunities in allied fields, given the stark reality of the continued prevalence of dental and oral diseases and inequalities. There is also a need to foster different ways of thinking and working, and I argue that dental nurses who become oral health improvement practitioners (OHIP) have a greater part to play in intervention and prevention and, as such, should be permitted to work to their full scope of practice. Beyond this, OHIPs should be encouraged to advance their skills and to deliver the practice of oral health within their communities. The following discussion in response to the question ‘Is it time for a different narrative when it comes to oral health practitioners?’ concludes with the work of Steele (2009a) and that of the Dental Dean (HEE, 2017a), who embraced Steele’s work. The narrative centres on the current capacity and yet the confinement of the dental nurse, who is trained as an OHIP, with an eye on the future and its possibilities.

The prime focus in this instance is on the dental nurse in the primary care setting, and how they can best take part in the broader health promotion strategies.

Introduction

Although this discussion has a central focus on the period of dental nurse registration and beyond, there are some key points from a historical perspective that help to set the scene and quickly demonstrate the acceleration of the role as a result of mandatory registration with the General Dental Council (GDC), (2008).

Ross et al. (2008) assert that the journey to registration is firmly seated within the 1993 Nuffield Report. In short, recommendations were made that dental nurses/dental surgery assistants (the titles were often utilised interchangeably) should be, “properly qualified and registered” (Nuffield Foundation, 1993). On the point of titles, before moving away from this historical space, dental nurses were known by many different titles, and not all appeared to be complimentary. For example, subordinates and street hires (Ellwood, 2014). Some of their early duties were to simply act as a chaperone and undertake administrative duties. These, of course, are a far cry from the role today, but do still form part of the modern dental nurses’ duties.

Having taken a snapshot to look at the journey to mandatory registration, which must not be dismissed as insignificant, the real focus of the discussion will move to the modern-day dental nurse (the registrable title of the dental nurse is now applied in isolation). It will also look to explore the influence of the learning outcomes designed by the GDC and those relative to the field of oral health, health promotion and population-based healthcare. It will then look to bring in the NICE Guidelines (2015a) and the Delivering Better Oral Health Toolkit (2021a) whilst continuing to focus on the dental nurse in the primary care setting, and their potential to contribute to the bigger picture.

The dental nurse registrable qualification

As with any dental registrable group, the primary qualification must map succinctly to the GDC learning outcomes recorded in the Preparing for Practice document (GDC, 2015a) and be relative to the professional group, recognising these will soon change. The learning outcomes are grouped against four domains:

  • Clinical
  • Communication
  • Professionalism
  • Management and leadership

GDC 4 Domains (adapted from preparing to practice)

Table 1. GDC dental nurses learning outcomes relevant to oral health (GDC, 2015).

Interestingly, the field of oral health sits predominantly across the clinical domain, and only three of the learning outcomes relate directly to community or population level health. There is some crossover within the other domains but from different perspectives, such as communication. Table 1 presents the learning outcomes that link to oral health, both on an individual and community/ population basis.

What is not as clear, perhaps, is to what level, breadth, and depth these areas are taught, for what purpose, and what level of understanding the tutor has so that the subject is well delivered and received. What is known is that for each of the dental nursing primary qualifications, providers have a common set of standards that generally sit within the vocational level three framework. Those providing the more recent and higher-level qualifications look beyond work-related activities and include wider issues.

Many dental nurse tutors have been awarded the Oral Health Education certificate, which provides added support for many who hold the certificate. Those teaching higher-level courses have commonly engaged in university learning, looking to evidence-based practice and appear to encourage their students to do the same.

This is soon to be replaced by the new ‘Safe Practitioner’ framework that will come to fruition this year (GDC, 2024). The domains will then move to a framework based on behaviours and outcomes for dental professional education entitled Clinical Knowledge and Skills, Interpersonal Skills, Professionalism, and Self-management (Figure 1).

Dental nurses recalled being introduced to the basic principles of the social determinants of health (Wilson & Mabhala, 2009) in their primary qualification, but very few acknowledged being introduced specifically to the structural, intermediate or proximal determinants of health – or linking those to any planning or potential outcomes. One explanation is possibly that these may well be a feature of the post-certification award in oral health. Some reported not making use of the oral health training they received as part of their primary qualification, whilst others recorded that the heavy workload and lack of time and resources meant that oral health was not a key priority in the practice and not part of their role.

Certainly, few early career dental nurses reported understanding the difference between oral health education and oral health promotion. Some suggested they were the same, but simply provided by different members of the dental team. At this stage in their careers, many shared concerns about having specific conversations around smoking and alcohol as so called ‘safe beginners’, although this appeared to be part of social history taking, rather than providing support and guidance. Those who did engage in health work reported not feeling confident in approaching subjects such as smoking and alcohol, or to refer patients on.

Figure 1. GDC, 2024 (Table 2).

Dental nursing post-registration

Two key documents aimed at supporting those in primary dental care are briefly discussed, although there are many more. The first is the Oral Health Promotion: General Practice NICE Guidelines (2015a) document, and the second is the Delivering Better Oral Health Toolkit (OHIDa, 2021). These two documents are written from an evidenced-based perspective and can support the dental nurse to continue to contribute to oral health strategies and the wider public health picture. There are also useful infographics designed by the former dental public health office, which are referenced by several dental nurses, and they were regarded as helpful. Many of the infographics appear to inform the work of the oral health educator in the dental setting.

1 NICE guidelines

These guidelines are aimed at supporting those in primary care and are readily available online and downloadable. The general focus is on oral health promotion, and the introduction to the document clearly suggests that, “when exercising their judgment, professionals and practitioners are expected to take this guideline fully into account” (2015b). The guidance sets out who it applies to, providing several recommendations and links to further supporting documents. This allows team members in the primary care dental setting to access them with ease, including the dental nurse. The document also gives direction in offering oral health advice that professionals can give to patients, and makes suggestions of when it can be given. It also links to the core oral health messaging that comes from the Delivering Better Oral Health Tool Kit (OHIDb, 2021). Furthermore, it discusses how the dental team can adopt a patient-centred approach, and how they can be involved in the decisions about their care.

So, it was surprising to discover from the survey that many dental nurses had heard of the 2015 NICE guidelines for oral health in dental practice, but few had ever taken the time to read it or had been knowingly involved in applying it. There may be multiple reasons for this, but as previously noted, time and workloads seemed to be key factors.

2 The Delivering Better Oral Health Toolkit (Table 2)

Again, this toolkit makes clear it is evidence-based to support dental teams. Earlier iterations arrived in National Health Service (NHS) dental practices, whilst some would find their way to the dental team, while others were tucked away safely. The current edition and the individual chapters, plus summary tables, are downloadable and easily accessible. It has 13 chapters, but all are available independently and are specific to an oral health subject. These are listed below.

According to the survey, most dental nurses were familiar with the Delivering Better Oral Health Toolkit, and many had accessed it on several occasions. Many of those who have studied oral health as a post-certificate award were familiar with the earlier iterations and have visited the latest online edition. Some have gone a step further and accessed the NICE Guideline Oral Health for adults in care homes (NICE, 2016), as there appears to be a trend to break away from traditional working styles from registered dental nurses with special interests in areas of oral health and wellbeing.

Having drawn upon core supportive guidance for the primary dental care setting and dental nurses, it has become clear through the survey that there are many differences and deviances from the ideology of delivering effective and efficient oral health interventions.

In more general terms, it appears that any interventions delivered by dental nurses within their current roles are predominantly geared towards individual change, a concept supported by Watt et al. (2000).

Table 2. Contents adapted from DBOH 2021.

Dental nurse oral health education certification

Returning to the original question, dental nurses can expect to receive some education relating to oral health and the wider context in their primary qualification, which is commonly aimed at level 3 (Table 1). The short survey suggests that this is not often followed through, and unless a further award is undertaken, the population level aspects of oral health promotion frequently appear to be omitted. Notably, dental nurses are not required to undertake this post-registration certificate to engage in oral health activity.

The following list shines a light on the subjects covered in one of the traditional oral health education certificates available to dental nurses:

  • Maintaining good clinical practice.
  • General health and disease.
  • Patient assessment and treatment planning.
  • Patient management.
  • Health promotion and disease.
  • Health promotion and disease prevention.
  • Management, leadership and working with others.

The higher-level oral health programmes appear to have more of a focus on community oral health work, with projects that link to more extensive research, drawing on existing literature and evidence. They simply appear to be part of the shift to embrace oral health promotion in the broader sense.

What becomes clear in this very surface-level view of the oral health input and outputs relating to dental nursing and oral health, is that there is an intention in the primary qualification to arm dental nurses with a basic understanding of oral health matters for individual patients. But from there on, the learning is patchy, as is the uptake of post-registration certification. One suggestion is that this could be related to a lack of opportunity in the dental practice if this career path is followed.

Dental nurses who leave the profession to take up different oral health roles appear to go to local council authorities or embark upon private enterprise work, with very few gaining posts in the public health sector, and others working in secondary care to make the best use of their skills. In line with the survey, the shift to establish oral health care and the desire to do more appears to be one of the many drivers that could potentially see a reduction in dental nurses exiting the profession.

More recently, more innovative work has been noted, with dental nurses working with care homes and allied medical teams to train staff to look after residents' oral health. Some are self-employed and building a business, in speaking for schools and mother and toddler groups, as well as working with speech and language teams. But if the clock was turned back and the great work of Professor Steele (NHS, 2009b) was revisited, how much of this discussion in relation to the question posed would truly be new? Indeed, it might well be asked what has actually been achieved.

On the back of Professor Steele’s report (NHS, 2009c), Taylor (HEE, 2017b) presented two impactful infographics in the first round of Advancing Dental Care, the first showing a vision of who could do what against the Steele model (Figure 2) and a second showing this against the GDC Scope of Practice fields (Figure 3) and they remain influential today.

Interestingly, Health Education England has since published other reports, the last being Advancing Dental Care Phase ll: Future Oral and Dental Workforce for England (HEE, 2019). This report laid bare the workforce believed necessary to meet the oral health needs in dentistry for England, with a central tenant of prevention-orientated care across the life course. The actions from the report are noted as being carried forward through a dental educational reform programme over four years at the time of publication.

Interestingly, and perhaps poignant to this question— there is much reference to the postgraduate field, an acknowledgement to skill-mix, and also a nod to the need for an increase in knowledge and skills leading to role satisfaction and the laying down of a blueprint. What it fails to acknowledge are the higher-level qualifications that some dental nurses already have, those that are available to them, and any inference of how dental professionals can contribute to the dental public health arena and oral health promotion— rather than oral health education. However, it does point to an apprenticeship programme, and it will be interesting to see how this is deemed to be a better fit or, indeed, a link between the oral health fields and how the broader reach of community and population health will feature. It is at this point believed by many, that it is well worth revising the report.

Figure 2. HEE, 2017 with permission (Based on the Steele Report, 2009)

Going it alone

The progress and milestones, no matter how small or significant, continue to move forward for dental nurses regarding oral health. In 2021, an international group of dental nurses came together to form the Oral Health Coalition (SBDN, 2021). Following this, they continued to participate in an award through the University of Glasgow, presented at the Global Oral Health Conference at COP26 (U of G, 2022). The central focus of their work was around the United Nations Sustainable Development Goals (2019) and the provision of oral care for older people in both developed and developing countries.

The call to action from the presentation was related to equitable oral and general care for older people, the need for the world to be more age-friendly, and finally, for investment in the workforce and communities so that there is a match, not a gap, between skills and health needs of the population. The request was that there was an inward look at working more efficiently in communities regarding delivering sustainable local dental care. Dental nurses, at that point in time, had never presented on such a platform.

The reaction from the Oral Health Coalition when the World Health Organization published the draft discussion paper Global Strategy on Oral Health (2021) in the section titled Oral Health Care Systems, at point 14, dental nurses were mentioned for the first time. That moment and mention was incredibly uplifting and beyond our expectations. The attention of the strategy then turned to the need to focus on training community oral healthcare workers and mid-level providers. Could this be the gap and the new narrative? We know it could certainly contribute to reducing the inequalities in oral health.

In conclusion

It certainly appears that it is time for the narrative to change for OHIPs. Dental nurses are well placed and valued members of the dental team. It is acknowledged that they are key to delivering succinct oral health messages and care, but it is time to think bigger and outside the box. With a structured career path, many would opt to follow a dental public health pathway and be able to contribute more extensively. Those who simply wish to do more in their current capacity certainly need to be assured that they have the tools and resources at their fingertips, and that they are valued and able to contribute to future bodies of work.

There is clearly a gap between general dental practice oral health activity and associated qualifications and awards for dental nurses. There is also a further identified gap between oral health qualifications and awards, and public health strategies and implementation programmes in the dental setting. There is a clear desire and will to do more from the dental nursing/OHIP camp, with a vision for dental public health strategies to be inclusive to dental nurses. Long gone are the titles of ‘subordinates’ and ‘street hires’, and by being courageous and creative, dental nurses can become part of a new narrative as functioning OHIPs, contributing to the reduction of oral health inequalities. This will, however, require a workforce with a vision and a shift in regulatory frameworks.

References

  1. Ellwood F. (2014) ‘Dental Nursing Careers’ [PowerPoint presentation] CPD for dental nurses. Available at www.sbdn.org.uk Accessed June 2022.
  2. General Dental Council (2008) Dental Nurse Registration. Available at [WWW] https://www.gdc-uk.org Accessed July 2022.
  3. General Dental Council (2024) Safe Practitioner. https://www.gdc-uk.org/docs/default-source/education-and-cpd/safe-practitoner/spf-dental-nurse.pdf?sfvrsn=a4546c3_3 Accessed November 2024.
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