Decision-Making for the Periodontal Team E-Book

Suzanne L. Noble

• Herausgeber: Quintessence Publishing Co. Ltd.
• Kategorie: Fachliteratur
• Serie: QuintEssentials of Dental Practice
• Sprache: Englisch

Seitenzahl: 157

Veröffentlichungsjahr: 2019

Beschreibung

High-quality dental patient management demands an appropriately skilled team. It is the general dental practitioner's responsibility to co-ordinate the team and to take overall responsibility as the team leader. Your team provides all the specialities necessary to achieve a stable, functional, aesthetic masticatory unit, which not only encompasses the management of periodontal disease, but integrates a treatment plan the patient can maintain.

Leseprobe

Quintessentials of Dental Practice – 11Periodontology – 2

Decision-Making for the Periodontal Team

Authors:

Suzanne Noble

Margaret Kellett

Iain Chapple

Editors:

Nairn H F Wilson

Iain LC Chapple

Quintessence Publishing Co. Ltd.

London, Berlin, Chicago, Copenhagen, Paris, Milan, Barcelona, Istanbul, São Paulo, Tokyo, New Dehli, Moscow, Prague, Warsaw

British Library Cataloguing in Publication Data

Noble, Suzanne L. Decision making for the periodontal team. - (Quintessentials of dental practice; 11. Periodontology; 2) 1. Periodontics 2. Dental teams - decision making I. Title II. Kellett, Margaret III. Chapple, Iain L. (Iain Leslie) 617.6′32

ISBN 1850973296

Copyright © 2003 Quintessence Publishing Co. Ltd., London

Figs 1-3, 2-2, 4-2, 5-4, 5-12 by Laura Andrew.

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.

ISBN 1-85097-329-6

Dedicated to our familiesand our patients

Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Chapter 1 The Periodontal Team

Aim

Outcome

Introduction

The Dental Hygienist

Legally Permitted Duties

Permitted Duties of Dental Hygienists and Dental Therapists since the 1986 Dental Auxiliaries Regulations

Local anaesthesia

Local infiltration analgesia

Inferior nerve block regional analgesia

Dental radiography

The emergency placement of temporary dressings and replacement of crowns with temporary cement

Impression taking

Treatment of patients under conscious sedation

Sectors of Dentistry

Ethical Guidance/Maintaining Standards

Key Points of Clinical Relevance

References

Further Reading

Chapter 2 Medicolegal Aspects of Employing Professionals Complementary to Dentistry

Aim

Outcome

The Role of the General Dental Council

The Role of the Employer

Recruitment

Write a job description and a person specification

Arranging the interview

Offer of employment

Document verification

Contract of employment

Employed verses self-employed status

Employee status

Employed or self-employed?

Employment of persons who have not qualified in the UK

Induction of the New Employee

Appraisal

Professional journals

Useful websites

Clinical audit

Key Points of Clinical Relevance

Further Reading

Chapter 3 Working Together

Aim

Outcome

Introduction

The Periodontal Treatment Plan and Referral to a Dental Hygienist

Communication Within the Team

The Dentist as a Prescriber of Treatment

Summary of the role of the dental practitioner as the team leader

The Role of the Dental Hygienist

First phase of treatment

Review with the dentist

Which sites require RSD?

Second phase of treatment

Supportive Periodontal Therapy

When does supportive therapy start?

Case Discussion

Key points of clinical relevance (Fig 3-13)

Further Reading

Chapter 4 Selecting Surgery Equipment for the Dental Hygienist

Aim

Outcome

The Decision-Making Process

The Surgery Layout and Equipment

Posture

Force

Temperature

Radiographic Equipment

Equipment for Patient Education

Equipment for Scaling and Root Debridement

Screening

Monitoring

Scaling

Root surface debridement

Additional instruments for specific sites

Equipment for Local Anaesthesia

Sharpening Equipment

Domiciliary Visits

Dental Nursing Support

Key Points of Clinical Relevance

Further Reading

Chapter 5 Prevention of Oral Disease I: Periodontal Disease

Aim

Outcome

Oral Hygiene Instruction

Education

Motivation

Products in Practice

Individual Instruction

How to give the advice

When should plaque control be carried out?

Continuation of the education process

Reinforcement of the messages

Smoking Cessation

A team approach to smoking cessation

Helping smokers to stop

Taking a smoking history

Advise

Key points to cover with the smoker (Fig 5-16)

Smoking Diary

Assist

Information

Staying stopped

Key Points of Clinical Relevance

Further Reading

Chapter 6 Prevention of Oral Disease II: Diseases of the Hard Tissues

Aim

Outcome

Introduction

Dental Caries

Application of preventive agents

Dental Erosion

Stages in management of dental erosion

Dental Abrasion

Conclusion

Further Reading

Chapter 7 Management of Periodontal Diseases

Aim

Outcome

The Role of the General Dental Practitioner

Clinical Guidelines for Screening

Diagnosis

Classification of periodontal diseases

Periodontal Treatment in the Primary Care Sector

Selection criteria for specialist referral

Non-surgical periodontal therapy

Corrective Therapy

Adjunctive antimicrobial therapy

Monitoring

Key Points

Further Reading

Chapter 8 Orthodontics and Periodontal Health

Aim

Outcome

Introduction

Malocclusion as a Risk Factor for Periodontitis

Adverse Effects of Orthodontic Treatment

Orthodontic Treatment of the Periodontal Patient

Key Points

Further Reading

Chapter 9 Occlusion in Relation to Periodontal Disease

Aim

Outcome

Introduction

Normal Occlusion and the Periodontium

Primary Occlusal Trauma

Clinical Features of Primary Occlusal Trauma

Management of Primary Occlusal Trauma

Secondary Occlusal Trauma (Trauma Within a Diseased Periodontium)

Occlusal features which are relevant to the risk of periodontitis

Treatment for Palatal Damage

Treatment for Lower Labial Damage

Other Occlusal Issues

Occlusal Therapy

Splinting in Periodontal Treatment

Key Points

Further Reading

Chapter 10 Periodontal–Restorative Interface

Aim

Outcome

Introduction

Intracoronal Restorations

Choice of material

Contour

Marginal seal

Crowns and veneers

Material

Margins

Contour

Bridges

Adhesive minimum preparation bridges

Implant Reconstruction

Removable Prostheses

Periodontal-endodontic Lesions

Management of Furcation Lesions

Key Points

Further Reading

Foreword

Decision-making for the Periodontal Team – Volume 11 and the second periodontology book in the Quintessentials of Dental Practice Series, is a timely publication. The dental team is about to come of age with GDC registration of the professions complementary to dentistry, and now is the time to stand back and critically review the quality of the team approach to patient care in your practice. Where better to start than periodontology?

Dental hygienists, not to forget all the other members of the dental team, can substantially influence the oral health of your patients and, in turn, their satisfaction with the service provided by your practice. The extent to which you, as team leader, and your staff plan the care of patients together, and work and communicate as a team, will determine the extent to which your patients’ oral health will benefit from team dentistry. Working together in an appropriate, well-managed practice environment is of fundamental importance to meeting patients’ needs and ever-increasing expectations. This together with sound, evidence-based decisions in relation to treatment can turn a good practice into a highly successful practice in which patients have confidence.

Are you confident in deciding what forms of periodontal care are best for your patients? When do you refer a patient with periodontal problems to a specialist periodontologist? How do other forms of treatment – for example, advanced restorative care, orthodontics and implant therapy – impact on periodontal health and relevant treatment regimes? Above all else, it is your responsibility to avoid the situation where the teeth and restorations have been made good for years to come, but the periodontium is diseased, deteriorating and running the risk of entering terminal decline.

If this brief foreword has touched on issues that have made you stop and think, or you know need to be addressed in your practice, this compact fact-and guideline-filled book will be a very sound investment.

Nairn Wilson Editor-in-Chief

Preface

In order for the dental profession to deliver high quality care for patients, an appropriately skilled team is required. Within recent years the General Dental Council specialist lists have been established and the number of registered dental hygienists has increased. Many general dental practitioners are now in a position to select the most appropriate skilled personnel for specific phases of patient management.

For the care plan to be successful, the patient must be educated about the role each member of the team will take in his or her management. It is the general dental practitioner’s responsibility to coordinate the team and take overall responsibility as the team leader. He or she also has a legal responsibility for procedures delegated to team members who are not registered dentists. It is a professional requirement of each dentist to delegate to professionals complementary to dentistry (PCDs) only those tasks which the person concerned is trained and competent to undertake. Competence implies not only the legal qualification to perform a skilled procedure but the ability to perform that skill to a recognised professional standard without supervision. Members of the team who have not had the opportunity to practise a procedure regularly will become “de-skilled”. General dental practitioners therefore need to be mindful of competence before delegating tasks and to support the continual professional development (CPD) of their team.

The overall treatment plan should not only encompass the management of the periodontal disease, but the integration of other specialities in order to achieve a stable, functional, aesthetic masticatory unit, which the patient can maintain. This book will guide the general dental practitioner through the decision-making process for the periodontal team.

This book can be read separately from the other four in the periodontal series. However, reference will be made to the other books, as the series is designed to develop certain aspects and concepts and to reinforce these throughout the process.

Acknowledgements

The authors are grateful for the help of the following people. In Birmingham, Marina Tipton helped with the photography and Helena Smith with the manuscript. Thanks to Stewart Hawkins for proofreading Chapter 2 and to Pharmacia Limited for guidance on the Nicorette® products and for providing Fig 5-14. Thanks to Dr Adrian Shorthall for use of Fig 9-7. In Leeds, thanks to Mr PA Cook, Mr JK Williams and Mr L Boyle for loan of clinical slides, to Ian Smith for scanning electron microscopy and to John Walker for photographic assistance.

Chapter 1

The Periodontal Team

Aim

This chapter aims to provide the general dental practitioner (GDP) with an insight into the development and role of professionals complementary to dentistry within the context of the management of periodontal diseases.

Outcome

As a result of reading this chapter the practitioner should have an understanding of how the periodontal team has evolved and the legally permitted duties of dental hygienists and dental therapists.

Introduction

It is in the primary care setting that the vast majority of periodontal disease is diagnosed and managed. The team involved in patient care may be small, involving only the dentist, dental hygienist and dental nurse. Conversely, the team may work together in a large polyclinic where periodontal care is one of many specialist dental services offered. In such situations the periodontal specialist will be available for the diagnosis and management of the more complex cases.

In its broadest sense, the dental team reaches beyond the high street surgery to include the secondary care services in hospital periodontal departments where the consultant in restorative dentistry and his or her team will offer advice and, where appropriate, treatment of referred cases.

In order to obtain the most appropriate care for an individual patient the GDP will refer the patient to other team members to utilise their skills, knowledge and experience to achieve the desired treatment outcomes. Rather than this referral process being considered as a hierarchical model, it is suggested that it be considered in a circular form with the GDP at the centre. It is the GDP with whom the patient is registered and it is the GDP to whom the patient returns for continuing care (Fig 1-1). The role of the GDP is an infinite one! The other team members have important skills to offer, but their roles are finite ones, clearly defined by the practitioner’s referral request or treatment plan.

Fig 1-1 Members of the periodontal team.

By co-ordinating the referral process the practitioner plays the key role in consolidating the treatment and ensuring that the patient is informed of the reasons behind the referral. The role of the practitioner as the team leader is explored further in Chapter 3, but by way of introduction to “working together” this chapter will focus on the evolution of the professionals complementary to dentistry and the skills these team members have to offer.

The Dental Hygienist

Although dental hygienists were first trained in the United States in 1913, there was no formal training in the UK until 1943, in the Royal Air Force. During the next 20–30 years schools of dental hygiene were founded and attached to dental schools, but they trained relatively few hygienists compared to dentists. Enrolment with the General Dental Council (GDC) became mandatory in 1957.

The original concepts of patient education and prevention of periodontal diseases remain the linchpin of the dental hygienist’s role, but the range of permitted duties has expanded in recent years in line with the current concepts of team management for patients with oral diseases. Dually qualified dental hygienists/therapists now receive education to diploma and degree levels in universities alongside undergraduate dental students. This enhances the periodontal team concept within the workplace.

The changing patterns of oral disease and the increasing public awareness and demand for oral health was the driver behind the Nuffield Inquiry into Education and Training of Personnel Auxiliary to Dentistry in 1993. This extensive inquiry examined the role of dental auxiliary personnel, and stimulated widespread debate on a number of key issues surrounding the development of the dental team. Following this the GDC set up the Dental Auxiliaries Review Group (DARG), to prepare appropriate recommendations in relation to all classes of dental auxiliary. The committee reported in 1998, setting out proposals on permitted duties, entry requirements and registration. It was also recommended that the team concept for future practice should be promoted through the training of dentists and dental auxiliaries in close association with each other.

Subsequently, in 1999, the GDC announced a new era for professionals complementary to dentistry. The council supported statutory registration of all members of the dental team and the widening of clinical roles after appropriate education and training. Although the term dental hygienist remained protected, as it was a role with which the general public was familiar, the dental hygienist became incorporated into a wider group subsequently named Professionals Complementary to Dentistry (PCD). The GDC emphasised that entry to the register would be on the basis of appropriate education and that each PCD should practise only under the delegated authority of a registered dentist.

It was the expressed intention of the GDC that all PCDs should continue to work within the dental team within which the dentist would remain responsible for diagnosis, treatment planning and the quality control of the treatment provided (Fig 1-2).

Fig 1-2 The team and team leader.

Legally Permitted Duties

Until such time as the GDC is able to register all PCDs, dental hygienists and dental therapists may practise dentistry to the extent of the Dentists Act 1984 and the 1986 Dental Auxiliaries Regulations, with amendments in 1991 and 2002. It is an offence to practise outside these limits.

They are permitted to work “under the direction of a registered dentist”. This implies that the dentist has examined the patient and indicated in writing the course of treatment to be provided. The dentist need not necessarily be present on the premises at the time the hygienist or therapist is carrying out the treatment. This legislation formed part of the 1991 amendment to permit hygienists to carry out domiciliary visits.

The supervisory role of the dentist varies in differing clinical situations and it is the dentist’s responsibility to be aware of these parameters. In the case of treatment of a patient under conscious sedation by a hygienist or therapist, the dentist must be in the surgery with the patient throughout treatment. Whilst inferior dental nerve blocks are being administered the dentist must be on the premises but not necessarily in the room. With the introduction of expanded duties from 2002, many practitioners will be involved in workplace post-qualification training for additional skills for hygienists and therapists, and the recommendations are for close personal supervision of a designated number of procedures.

Dental hygienists are permitted to carry out the following kinds of dental work:

Cleaning and polishing teeth.

Scaling teeth (i.e. the removal of deposits, accretions and stains from those parts of the surfaces of the teeth which are exposed or which are directly beneath the free margins of the gums, including the application of appropriate medicaments).

The application to the teeth of such prophylactic materials as the GDC may from time to time determine.

Giving advice within the meaning of section 37(1) of the Dentists Act 1984 such as may be necessary for the proper performance of the dental work prescribed.

The taking of dental radiographs.

The administration of local infiltration and inferior dental nerve block analgesia for the purpose of scaling or root debridement.

The taking of impressions for diagnostic purposes.

The emergency placement of temporary dressings and replacement of crowns with temporary cement.

The treatment of patients under conscious sedation.

Depending upon the date of primary qualification, there may be additional skills obtained and certified by course attendance and workplace supervision. In clinical practice the dental hygienist’s skills include:

The removal of supra- and subgingival calculus.

Closed root surface debridement (RSD).

Appropriate oral hygiene advice.

The application of local delivery antimicrobial agents as an adjunct in periodontal therapy (under the Medicines Act 1968 the dentist must prescribe the drug to be used).

Management of dentinal hypersensitivity with appropriate medicaments.

Prevention of dental caries by the application of topical fluoride.

Fissure sealing (the use of filled resins in minimally prepared cavities is not permitted).

Polishing dental restorations.

Dental therapists may carry out all the duties listed for dental hygienists with the addition of:

Extraction of deciduous teeth.

Simple fillings.

Pulp therapy to deciduous teeth.

The placement of prefabricated crowns on deciduous teeth.

Permitted Duties of Dental Hygienists and Dental Therapists since the 1986 Dental Auxiliaries Regulations

Local anaesthesia

Local infiltration analgesia

Dental hygienists who hold the Diploma in Dental Hygiene awarded after 1992, or dental therapists who hold the Diploma in Dental Therapy (formerly the Certificate of Proficiency) may carry out scaling under local infiltration analgesia. This competency was included in the hygienists’ core curriculum from 1992 onwards. Therefore hygienists qualifying after that date will not hold separate certification.

Dental hygienists who qualified before 1992 must to be able to demonstrate competency by presentation of a certificate proving post-qualification training in local infiltration analgesia. Following legislation passed on 1 July 2002, the dentist does not have to be on the premises whilst the dental hygienist is administering local infiltration analgesia. Under these circumstances a third person with current training in cardiopulmonary resuscitation must be on the premises.

Inferior nerve block regional analgesia

Following the July 2002 amendments to the regulations, dental hygienists and therapists are permitted to carry out their statutory duties under the administration of an inferior dental block that they have personally administered. The recommendations are that the training period must include 10 closely supervised procedures in the workplace before certification by the awarding authority is issued. Following this, a registered dentist must be on the premises whenever an inferior dental block is administered by a dental hygienist or therapist.

Dental radiography

Dental hygienists and dental therapists may take dental radiographs provided they have received training according to the Ionising Radiation Medical Exposure Regulations IR(ME)R 2000.

Since July 1992 dental radiography has been included in the core curriculum for dental hygienists. Those persons who qualified prior to this date must undergo the recognised training and have evidence of certification to be legally permitted to take radiographs. The courses of training are similar to those undertaken by dental nurses.

The emergency placement of temporary dressings and replacement of crowns with temporary cement