Supervision of Orthodontic Therapists

Serious concerns have recently arisen about the supervision of orthodontic therapists and how independently they work. An orthodontic therapist has been told by the dentist who leads her team that she is expected to treat his patients whilst he is away on holiday. She responded that her training had not equipped her to make the decisions that this would involve. This raises a highly important point concerning patient protection and good clinical practice. The GDC policy on this is as stated in Developing the dental team (January 2009 edition), the Scope of practice document and Standards for dental professionals (with supplementary guidance to Standards for dental professionals).

This position statement from the British Orthodontic Society gives guidance on its view of good practice in this area.

Reassessment schedules: The general guidelines for dental team working are set out in the GDC document Principles of Dental Team Working where para 2.5 states that all Dental care Professionals (DCPs) can now work independently from a dentist once they have a treatment plan and do not need to be seen again by the referring dentist until the reassessment date. with this date being set by the referring dentist. For most categories of DCP, e.g. a dental hygienist, the DCP can work for several patient visits without a decision being required about the next step in the overall treatment. However, in orthodontic treatment, the direction and practical details of the next step need to be constantly reassessed by the supervising clinician throughout treatment. The Orthodontic Therapists Curriculum Working Group addressed this problem and specifically advised that all treatments should be undertaken "under the prescription of a registered dentist at every patient visit." This recognizes the truth that diagnosis and treatment planning in orthodontics is not a once only event but is a continuing process which needs to be re-assessed throughout treatment.

The appropriate reassessment schedule in orthodontic treatment is therefore a reassessment at every visit. This does not mean that the supervising dentist has to see the patient at every visit, but that this should be possible. It is clearly not possible if the dentist is not present.

It is worth noting that in the USA where they have long experience of Orthodontic Therapists as part of the team, it is not permitted in any State for a therapist to treat a patient in the absence of the orthodontist. In the UK, the regulations are not specific to Orthodontic Therapists, but are designed to apply in general to all types of PCD.

Orthodontic Emergencies: Paragraph 89 on page 29 of the final report of the Orthodontic Therapists Curriculum Working Group is very clear on this circumstance.

“ In circumstances where a patient presents as an orthodontic emergency, the orthodontic therapist may be required to carry out limited treatment in the absence of a dentist. Instruction should be provided to enable the student orthodontic therapist to identify damaged or distorted orthodontic appliances and to carry out limited treatment in order to relieve pain or make an appliance safe. It is important that the student is made aware of the limits of their own knowledge, skills and expertise and knows when to seek the help of a dentist if a problem is beyond them”.

There will also be instances where unplanned absence of the dentist arises through illness or other similar occurrence and in this situation it will usually be in the patients’ best interest that the therapist should still see the booked patients but be very conscious of the need to work within the scope of their training in the absence of potential supervision.

The competence of Orthodontic Therapists: The curriculum for orthodontic therapy states that it does not attempt to train orthodontic therapists on the skills of diagnosis or in the choice of treatment mechanics and treatment planning decisions which are needed throughout treatment. Instead the curriculum clearly trains the orthodontic therapists to follow the directions and prescriptions of the supervising dentist or orthodontist all the way through treatment. This view was very clearly expressed in the final report of the Orthodontic Therapist curriculum working party Annex 4. Also, para 2.7 in Principles of Dental Team Working clearly states that the DCP “can, within the overall limits of the plan and the limits of their competence, treat the patient (and make any further appropriate referrals) until the next reassessment date.” The important phrase is “within… the limits of their competence” The syllabus and content of the training programmes do not make Orthodontic Therapists competent to make decisions about the next step in treatment. Para 3.6 instructs DCPs to “only make decisions about a patient’s treatment and care when you are confident that you have had the necessary training and are competent to make the decision.”

Raising concerns: In para 3.9 of Principles of Dental Team Working, DCPs are instructed that “As a team member, you have a responsibility to raise any concern you have that patients might be at risk because of… any action you have been asked to carry out that you believe conflicts with your main duty to put patients’ interests first and act to protect them.” In the recent case, the Orthodontic Therapist was of exactly the view that she had a real responsibility to raise such a concern in the interests of her patients.

Responsibilities of Team leaders: It is also highly relevant to note para 5.4 which is addressed to dental team leaders and states “If you employ, manage or lead a team, you should make sure that:…. you do not take advantage of your position if another member of the team says that they do not feel that they should carry out a particular task because they are not trained or competent to do it”

Ethical Practice: Working in the absence of a dentist or orthodontist after the initial treatment plan would be potentially harmful to patients. Members of the GDC Orthodontic Therapists curriculum working party, Orthodontic Therapy training programme directors and the British Orthodontic Society Board of Trustees are very firmly of the view that good clinical governance in this context requires the presence of the dentist or orthodontist at all appointments except in circumstances of emergency.

It is the professional responsibility of dental team leaders and Orthodontic Therapists to be aware of what constitutes good, ethical clinical practice and follow these principles in their care of patients.

About the ONG

The Orthodontic National Group is a specialist group for Dental Nurses within the U.K. and is an affiliated organisation to the British Orthodontic Society.

The Group caters for the interests of Dental Nurses, Therapists and other associated Dental Care Professionals who work part time or full time in the field of Orthodontics.

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Supervision of Orthodontic Therapists

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