According to Mark Richardson, maximising the use of dental therapists is dependent on effective leadership, appropriate delegation, adoption of new ways of working, knowledge of dental therapists' scope of practice, and increased use of skill-mix.

Introduction

The use of dental therapists (DTs) in the delivery of dentistry is not a new concept, with DTs having been reintroduced into the UK in the 1960s and in 1993, the Nuffield Foundation discussed the use of dental auxiliaries to deliver preventive and therapeutic dentistry.1 DTs are used successfully in over 54 countries as way of providing dental care to those communities which have limited dental access.2 Although, within the UK, there has been reluctance to use DTs as part of a new skill-mix delivery models.3

Brocklehurst and Tickle considered that the results of the Adult Dental Health Surveys (1978-1998) suggested that DTs could make a significant contribution to a preventive care and moderate level intervention to large sections of the population.3 Similarly, the Steele Report concluded that much of the routine clinical work historically provided by dentists could be undertaken by suitably trained DTs and the future of dental delivery should include expanding the skill-mix within dental practices.4 Although, Brocklehurst et al. concluded that better alignment between the financial incentives within the NHS dental contract and the use of dental care professionals (DCPs) in role substitution is required and that professional acceptability remains critical.5

Maximising oral health for an agreed level of NHS dental care and mix of resources is an ethical, as well as a financial, imperative for all health service planners.5 This requirement for a new approach to dental delivery, which maximises the use of skill-mix, applies to the Defence Medical Services (DMS) as much as it does to the NHS.6 As a result, a three-year trial, conducted across nine sites, sought to demonstrate the utility of DTs in the UK Military Dental Service.

Methods

For this trial, an explanatory mixed-methods study of sequential design was used with a two-phased approach, with phase one (minor) as the quantitative component using a bespoke self-completion online questionnaire and phase two (major) as a qualitative approach in the form of semi-structured interviews. The use of nonprobability sampling (purposive sampling) was chosen because it is considered the best way to generate the most useful insights into a study's focus7 and is better suited to small sample size.8 Ethical approval was granted by Bedfordshire University's Research Ethics Committee and the Ministry of Defence Research Ethics Committee.

Following development and piloting, a questionnaire was emailed to all dentists (18) and DTs (7) involved in the trial, with a reminder email sent two weeks later. A four-point Likert scale was used and free text boxes were added to each set of questions; participants were requested to add comments, especially if they selected strongly disagree or strongly agree.

The potential barriers to and benefits of using DTs in the Military Dental Service highlighted from the questionnaires were used to develop the interview guide (see online Supplementary Information) for the semi-structured interviews. The interview guide was initially piloted to assess the effectiveness and clarity of the questions and the likely length of the interview.

Questionnaire participants who had given their consent to be contacted and were willing to be interviewed were invited to a semi-structured interview. The semi-structured interviews were organised around a set of six predetermined open-ended questions, an easy opening question and a general question to finish and lasted between 20-25 minutes. All the seven interviews were recorded and personally transcribed within 48 hours of each interview and a copy of their personal transcript was sent to each participant for respondent validation.9

A simple thematic analysis was performed by coding which involved identifying patterns of similar themes/issues within the transcripts. This iterative analysis process reached saturation point10 after seven interviews - four dentists and three DTs. Participants were assured about confidentiality and data protection and any information they shared during the interviews could be omitted upon request any time before it was published.11 All information was confidential and kept securely on a password-protected file and computer.

Results

As only a four-point scale was used, the analysis of the quantitative data was limited to:

  • Reporting of frequency distributions (Table 1)

    Table 1 Frequency distribution responses to questionnaires
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  • Using parametric statistics to compare dentists and therapists for Q1-5 to determine if they differ significantly in their responses (Table 2)

    Table 2 Comparison of dentists' and DTs' responses to the role of DTs (S1-5)
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  • Using parametric statistics to compare dentists trained pre-2000 to post 2000 to determine if they differ significantly in their responses (Table 3)

    Table 3 Comparison of pre- and post-2000 trained dentists' responses to statements on the role of DTs
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  • Using parametric statistics to compare the responses of dentists and therapists to a neutral response (2.5) to determine if their responses are statistically positive or negative (Tables 4 and 5).

    Table 4 Dentists' experiences of the trial (S6-12)
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    Table 5 DTs' experiences of the trial (S13-19)
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Questionnaires

In total, 20 of the 25 questionnaires were returned, giving an overall return rate of 80%, where 14 out of 18 dentists (78%) and 6 out of 7 DTs (86%) responded. All the DTs had qualified within the last ten years with a BSc qualification and could be dually registered (hygienist and DTs), whereas six (42%) of the dentists graduated before 1999 and eight (58%) graduated from 2000 onwards.

Frequency distribution

The frequency distribution results from the questionnaires were expressed as a percentage for each of the three parts and the responses grouped positively (strongly agree/agree) or negatively (strongly disagree/disagree (Table 1).

The majority (95%, 19) of DTs and dentists agreed that DTs could play a significant role within Defence Primary Healthcare (DPHC) and on their suitability to undertake the full scope of a dental hygienist (hygiene work), 90% (18) agreed. However, on the other questions there was less consensus, especially regarding the DTs' ability to undertake routine restorative procedures, with just under half (43%, 6) of the dentists agreeing or strongly agreeing, compared to 100% (6) of the DTs.

In both the dentist and the DT groups, there was little agreement as to whether DTs were better employed in treating new military recruits or fully-trained permanent staff. The dentists differed on their willingness to refer patients for restorative treatment, which was often based on their personal experience of the clinical competency of the therapist with who they worked. This reluctance on the part of the dentists to refer to DTs for routine restorative procedures was substantiated by 50% (3) of the DTs. Most dentists (64%, 9) strongly disagreed or disagreed that DTs could deliver up to 50% of a dentist's clinical output. DTs believed this was due to the dentists' lack of knowledge of their scope of practice and 33% (2) of DTs felt they were not fully integrated into the dental team and indicated that this was because of poor leadership by the dentist.

The dominant themes from the questionnaires were: leadership; delegation; different delivery models; DTs' scope of practice; skill-mix; and utilisation and these themes contributed to the focus of the semi-structured interviews.

Parametric analysis

As the sample size was small, the results only indicate potentially significant differences when comparing the results between dentists and DTs and between dentists pre- and post-2000 qualification. Dentists and DTs generally agree on the role that DTs could play, as indicated with positive Cohen's d scores.12 However, due to the small number of DTs, there are some statements (particularly statement 1 [S1]) where the effect would be moderate (DTs have a more positive opinion than dentists) but there is a lack of statistical significance (Table 2).

There are significant differences between the two dentist groups, with dentists trained post 2000 having a far more positive viewpoint of therapists than pre-2000 dentists for S1 and S2 (large effect), a far more negative opinion on S3 (large effect) and no significant difference for S4 or S5 (Table 3). The overall effect is no significant difference as the positive and negative effects cancel each other out when averaging the scores.

For analysis of statements 6-12, a single sample t-tests on scores compared to a neutral response (2.5) was used to assess the level of agreement between dentists and between DTs. Dentists generally had a positive opinion of the role of DTs for most statements (S6-S12) with significance achieved for statements S6, S7, S8 and S10 (Table 4).

Similarly, DTs generally had a positive opinion of the role of DTs for most statements (S13-S19) with significance achieved for statements S15, S16 and S17 (Table 5).

Semi-structured interviews

Leadership

Leadership was a key factor behind whether the use of a DT was viewed as a benefit or as a barrier. This was highlighted by both dentists and DTs and was perceived to affect the dental centres as well as within Defence Primary Healthcare. One of the interviewees said 'this clinical leadership needs to come from the top. Headquarters and senior dentists […] without this the others will not follow' (Int1). Each direct quote from specific interviews from dentists and therapists is tagged using a random numerical code (eg Int2 = interview 2).

Some DTs were positive about their senior dental officer (SDO), for example 'the SDO offered support if I had concerns, problems or queries about a treatment plan' (Int4). Other DTs did not have such a positive experience: 'I think they [dentists] need to show a certain amount of leadership in motivating the therapist and the rest of the dental team' (Int5).

Delegation

In this study, the age of the dentist did make a difference to the willingness to refer. One interviewee stated 'the younger ones [dentists] were more receptive to referring patients' (Int1), whereas another stated that 'in the older dentists there seemed to be a mindset that was against therapists' (Int5).

One DT remarked that 'I think the older dentists were used to doing everything themselves, like to be in charge of all aspects of the treatment' (Int4). However, some dentists in the trial were happy to delegate:

  • 'I thoroughly enjoyed working with dental therapists and I was more than happy to refer my patients to them' (Int3)

  • 'I personally was happy to refer to the therapist' (Int2).

'New ways of working'

This willingness to adopt new ways of working was not universally popular among the dentists:

  • 'They were quite old-fashioned in the way of working and hadn't necessarily kept on track with the way the dental profession is developing' (Int5)

  • 'If you hold on to old-fashioned ways of working [...] and you are not open minded to new ways of practice then [...] it will not work' (Int1).

Some dentists did embrace the new way of working and understood the benefit DTs could bring to their practice in terms of efficiency, saying 'as the therapist is able to do some cons [conservation treatment (restorative)], the dentists were able to focus on doing the inspections. So, this helps me achieve the required KPIs [key performance indicators]' (Int3).

Scope of practice

From a DT perspective, lack of knowledge of their scope of practice by dentists was a barrier to full utilisation of DTs. It was reported 'that some of the dentists were not familiar with the scope of practice of the therapists and so just randomly referred patients, probably the ones they didn't want to treat themselves' (Int5).

The need for dentists to have a good understanding of the roles and responsibilities of their team, including scope of practice, was recognised by a dentist who said, 'the dental officer needs to be approachable and to recognise the role that therapists can play in the team approach to dental delivery' (Int6).

Skill-mix

The awareness of dentists to the benefits of skill-mix is key to successful integration of DTs within the dental team:

  • 'The younger dentists, some who will have trained with therapists, are more familiar with the work of therapists and the concept of skill-mix' (Int5).

This organisational benefit was highlighted by one of the interviewees, who said 'another benefit would be to the organisation as we would be seen to be embracing skill-mix and leading the way within general dental practice as a whole' (Int7).

Utilisation and recruitment

One interviewee said 'I think if they [DTs] are utilised wisely in the right practice and with the right team, then I think it is an amazing opportunity' (Int4) and another said 'they [DTs] are just as productive as some of the dentists and so with costing less, they are more cost-effective to the military' (Int6).

However, failure to recruit a DT who can work to their full scope of practice was seen by some as a barrier, for example 'the therapist I worked with was not very productive […] and suffered from skill fade' (Int2).

Discussion

Although the small sample does raise the issue of how representative these findings are, especially as the Military Dental Service is quite different to the NHS-funded contract, the results do collaborate the findings from other similar studies.13 So, despite the limitations of sample size, the broader findings in relation to clinical leadership, use of dental skill-mix and new ways of delivering dentistry have resonance within UK dentistry.

One of the main barriers was related to the size and type of the dental practice in which the DTs worked. This issue of size of practice and suitable patient base is like the findings of Cowpe, Barnes and Bullock14 and de-skilling concerns have been raised as a potential barrier to use of DTs.15 This importance of the practice size has also been highlighted by Gallagher and Wright16 who suggest that larger group practices may be the best place in which to employ a DT. Harris and Burnside17 also report that, while skill-mix may be effective in improving efficiency, this is limited to conducive situations - situations which, as this trial suggests, include a dental centre with enough patients and with appropriate treatment needs.

Within the dental practices, the largest barriers revolved around the dentists' lack of knowledge of DTs' scope of practice and subsequent reluctance to delegate which chimes with the findings of Csikar et al.18 More disappointingly was the dentists' nonavailability and unwillingness to provide supervision, poor attitude to skill-mix and lack of belief in teamwork and team management. These barriers are the same as those highlighted by Bullock et al.13 and according to the General Dental Council,19 this apparent lack of leadership and teamwork is counter to what the patient expects, that is, to be fully informed of the different roles of the dental professionals involved in their care and that members of the dental team will work effectively together.

Effective clinical leadership is required to grasp this opportunity and make the necessary changes to maximise the skill-mix and ensure DTs and all DCPs are able to use all their skills.

Those dental practices and dentists that embraced new ways of working, for example, increasing skill-mix use by effectively delegating to DTs, were able to free up more qualified staff for the complex treatments, could deliver system efficiency savings and increased productivity.20 This ability to delegate not only improves organisational effectiveness, but can be a real staff motivator21 and it also fits well with the government's expectation that the skill-mix within the dental team will evolve to allow DCPs to undertake more of the dentists' routine work.22

Although some research has suggested that the social acceptability of being treated by a DT is not high,23 initial findings suggested that military patients are not concerned by the prospect of being treated by a DT and it was notable that no instances of negative patient feedback were reported from any trial site and that individual DTs reported multiple instances of positive verbal and written patient comments.

However, as with any large organisation, effecting skill-mix change can be difficult24 and as Bullock and Firmstone25 concluded, education and training are required to maximise the benefits of increased skill-mix. So, interprofessional education should be embraced by organisations and clinicians to underpin innovative approaches to service delivery. Employing DTs is not only beneficial in terms of delivering high-quality patient care, but it enhances key elements of leadership, management, professionalism and communication.26

Conclusion

The key to maximising the benefits and overcoming the barriers associated with employing DTs is leadership. Effective clinical leadership is required to grasp this opportunity and make the necessary changes, both clinically and professionally, to maximise the skill-mix and ensure DTs and all DCPs are able to use all their skills within their scope of practice. Although Walsh et al.27 have argued that there is little evidence for clinical leadership and its dental impact, the link between leadership and improvements in quality of healthcare has been underlined by various reviews and reports, but less attention has been given to the role of leadership within the dental profession.28 Mutual trust, understanding and clinical confidence are key components of good working relationships29 and so clinical responsibilities and scope of practice of the dentist vis-a-vis that of the DT must be clear and complimentary and dentists need to show leadership, management and supervisory talents as team coordinators.30

Effective leadership is crucial to employee engagement and organisational success31,32,33 However, the healthcare industry has placed little emphasis on the leadership development of healthcare professionals. Although frequently required to lead healthcare teams, clinicians are often left to rely upon an unpredictable apprenticeship model.34 Therefore, development of leadership should be started early in a clinician's career, especially given the fact that leadership is of growing importance more generally for the clinical professions given its impact on quality.28

So, the conclusions of this study are that DTs do have utility within the Military Dental Service but the organisation and specifically the dentists, need to take a more proactive leadership role. New models of high-quality, preventively-oriented dental care should be delivered by dental teams in a professional manner and involve managed clinical networks of care across organisations and systems, underpinned by effective leadership and professionalism locally and nationally.26

Future implications

  • Findings from this study would suggest that there is scope to utilise a small number of DTs as a skill-mix enhancement, providing site suitability criteria are met and that this benefit does not come at the expense of reduced clinical delivery, a disproportionate focus on periodontal care and reduced clinical flexibility. This latter point is particularly relevant in the wider military context where being able to efficiently undertake high-volume recruit dental inspections, sometimes in conjunction with immediate restorative care, is critical to ensure that poor oral health does not prevent military personnel from effectively fulfilling their military role.

  • Therefore, to maximise the benefits of employing DTs within the Military Dental Services, the following recommendations have been made:

  • Defence Primary Healthcare, as an organisation, needs to engender a workplace culture and ethos that facilitates and encourages the adoption of new ways of dental service provision

  • Clinical leadership training for all dental clinical staff that promotes teamwork, embraces skill-mix and improves the provision of oral healthcare

  • A change management programme needs to be implemented at potential recipient sites to generate the staff buy-in required to ensure DTs are correctly utilised

  • Use of DTs should be part of the wider work strand looking at employing other DCPs in such a manner that they are able to utilise all their skills within their scope of practice.

This article was originally published in the BDJ in Volume 232 pages 232-238, 25 February 2022.