Article
To answer this question, as is so often the case, it is perhaps more pertinent to consider what it is not! It is not routine dentistry, very definitely not ‘cosmetic’ or ‘aesthetic’ dentistry and is not those elements of primary care dentistry presently deemed as only deliverable in the private sector.
This misconception has to some extent been fuelled by the expansion in recent years of various courses and training programmes designated as ‘Restorative Dentistry’ but promulgating cosmetic dentistry, implants as an early alternative to natural teeth, and the potential mutilation of healthy dental tissues in the pursuit of an aspirational cosmetic ideal at odds with preservation and protection of natural tooth tissue.
This results in it often being misunderstood at all levels, not only by the general public as patients, but also colleagues within the profession from primary care even to those working in some of the other specialties and, particularly in more recent times, those commissioning dental services.
Restorative Dentistry is a wide-ranging dental specialty encompassing an extensive variety of clinical and diagnostic skills. It is perhaps best described as ‘the study, diagnosis and integrated effective management of diseases of the oral cavity, the teeth and supporting structures and the rehabilitation of the teeth and the oral cavity to functional, psychological and aesthetic requirements of the individual patient, including the co-ordination of multi-professionals working to achieve these objectives’.
It is one of the 13 dental specialties currently recognized by the UK General Dental Council. It is unique insofar as it is a single specialty but encompasses the scope of practice of three other recognized specialties, sometimes referred to as the restorative monospecialties, namely prosthodontics, endodontics and periodontology. It utilizes all forms of restoration of teeth and the supporting tissues, from management of the periodontal tissues to the endodontic tissues, and replacement of teeth (and facial hard and soft tissues) by way of fixed bridgework, removable dentures and osseointegrated dental implants.
Scope of clinical practice for the Restorative Consultant
The aspects of practice unique to Restorative Dentistry are those which involve integration at a specialist level of all these disciplines. This particularly encompasses multidisciplinary provision of care integrated with other disciplines in dentistry and medicine, such as dental oncology and its associated rehabilitation, management of developmental defects, such as cleft lip and palate and hypodontia, and of dental aspects of trauma. It does, however, have a significant interface with dentistry at the generalist level as it is in some respects an extension of much of what is undertaken in general dental practice into the specialist realm.
Consultants and Specialists in Restorative Dentistry, as well as carrying out treatment at a specialist level, provide advice, support, training and education for colleagues in the primary care setting. Their scope of practice varies dependent upon their location and the skill mix of the consultant teams within which they may work. For those working within dental teaching institutions, they may develop areas of sub-specialization among different members of a team, but all who are Consultants in Restorative Dentistry train to a standard that allows them to provide a broad base of treatment and advice across the discipline in a cost-effective and integrated manner. This broad skill base is particularly pertinent to those restorative specialists working in an acute hospital or community setting, as they may be single-handed within their specialty or members of a small team. Consultants often work as core members of multidisciplinary teams with other specialties, such as oral and maxillofacial surgery, orthodontics and other surgical and oncological colleagues for management and care of cleft lip, hypodontia or cancer patients.
Interface with colleagues
Advice is available via referral to consultants, based predominantly but not exclusively in dental teaching hospitals, but also in acute hospital settings and occasionally community-based units. This can facilitate a shared care aspect to patient treatment, with troubleshooting of specific problems and more advanced elements of care being provided by consultants or specialty trained or training staff. All are conscious of working, where possible, within overall treatment plans which are potentially deliverable in primary care under NHS provider contracts or, if not, in the private sector being provided for colleagues in that setting. As part of that advice, Restorative Consultants strive to educate colleagues in current evidence-based management of their patients, in providing realistic, cost-effective and manageable care for their patients.
Routine referral management
Consultants receive referrals from colleagues in primary care dentistry but also from general medical practice and other hospital specialists. This is an area of their practice which can, and often does, take up a substantial element of their clinical time. It is clear from audit of activity by colleagues around the UK that the range and volume of referral can vary considerably. There requires to be some level of consistency of approach in quality and acceptance of referrals in different units to avoid a ‘postcode lottery’ of service delivery.
Equally, it is clear that there can be a variation in the quality of referrals. This can be led by uncertainty of the appropriateness of treatment plans, patient demands requiring the reassurance of a second opinion, a need to consider treatment to repair or correct previous poorly completed or failing work and, increasingly, economic issues related to the current primary care contract.
The latter two issues are of particular concern as, while failing restorations may result after a lengthy period of time, it is noted by consultants on a frequent basis that some items of treatment (particularly endodontic and periodontal) are often not managed to an adequate standard in primary care, usually because they are time consuming items of treatment which do not fit well with the current UDA tariff contract. It is clear from discussion with some patients and colleagues in primary care that there is an element of ‘gaming’ that goes on, with patients being advised that any ‘more advanced’ treatment (eg periodontal root surface instrumentation) requires to be delivered as a private treatment. When patients indicate concern about this, they are then referred to local consultants in the hope that treatment may be delivered by them, a team member, or in teaching institutions by students, if it is deemed potentially suitable for educational purposes.
These matters raise the question of who should be responsible for the delivery of care not appropriate for specialist management and which is not being delivered by colleagues in primary care. The matter of contract quality assurance is vital and in times past was monitored on an ongoing and regular basis by reference dental officers (RDOs) who were employed by the Dental Estimates Board to review practice activity on a randomly allocated basis. There are now structures in place which review activity in primary care by analysing basic activity data and looking for patterns of over- or under-activity in items such as extractions, root canal treatments and inlay provision. However, it is suggested that these are insufficiently robust at present to police service provision adequately.
It is clear that patient demands have also risen and a wish to retain a functional and cosmetically acceptable and pain-free dentition into older age is increasingly common. This is supported by the pattern of dental health seen over the last few adult dental health surveys, with decreasing edentulousness and evidence of toothwear in partially dentate situations. This pattern is also contributing to changing patterns of advanced dental treatment need and demand for specialist restorative dental intervention.
Worryingly, most consultants also see cases referred for advice or treatment where the plan is apparently obvious but the referrer indicates that provision of it lies ‘outwith their skillset’. This is an increasing trend and it is difficult to be sure what the drivers are for it. Undoubtedly, there is an understandable concern in some cases, in times of increased litigation and referrals to the GDC, to seek reassurance of an appropriate treatment plan. However, there are many cases where, if it is not an economically driven referral on the part of practitioner or patient, it appears that the practitioner does not appear to have insight into the problem and its management, often in cases where it can be evident to senior undergraduates how management should progress.
Accordingly, over recent years, Consultants in Restorative Dentistry have witnessed an increasing volume of referrals of this type and this impacts adversely upon their core business and their ability to deliver care to the patients identified as lying most within their remit.
Teaching and training
Many consultants regularly run courses aimed at updating colleagues on a range of topics within the field of restorative dentistry, from treatment planning to skills courses on all aspects of restorative techniques. Such skills courses are at present relatively infrequently run ‘in-house’ within the units where the consultants work. However, there is scope for expansion of such courses with a strong hands-on element, if appropriately funded, to allow clinicians at various levels to work alongside specialty trained colleagues to observe, develop and ultimately deliver skills which can be translated to their own workplace.
This is perhaps particularly pertinent at the present time, as NHS England looks at ways to manage the dental contract and service provision in a new era of contracting and commissioning services. There is an aspiration to develop three tiers of service provision, with tier 2 being at the level of what has previously been termed ‘dentists with enhanced skills’.
In order that this is properly and effectively quality assured, it would seem prudent to provide training for colleagues aspiring to such a role, with a common level of expertise, in a manner similar to the way specialty training does at present.
Training in Restorative Dentistry is overseen by the regional branches of Health Education England (the ‘Deaneries’). It is also managed via the Royal College of Surgeons of England and its Specialty Advisory Committee (SAC) for Restorative Dentistry. Trainees undertake an approved training programme in the specialty, following a curriculum developed by the SAC and approved by the GDC.
Entry on to the specialist list in Restorative Dentistry is also possible at present by application to the GDC and provision of information on training indicative of equivalence with that expected by the training programme for UK trainees. This allows colleagues who have trained overseas and whose experience is appropriate to seek inclusion in the specialty. There remain issues, however, regarding the assessment of this equivalence as quality assurance of programmes not complying with the Gold Guide and SAC curricula is difficult to provide.
Upon completion of training, Consultants or Specialists in Restorative Dentistry may work in the publically funded health service, or the private sector, or commonly a combination of both.
A new model of specialist clinical care delivery
It is suggested that a nationwide initiative requires to be put in place to ensure that an equitable delivery of appropriate care at a suitable level is delivered to our population. This is indeed under consideration by way of these new ‘tiers’ of dental professionals and care delivery.
There are, however, concerns as to the delivery of this tiered service. The nature and level of training necessary for tier 2, or dentists with enhanced skills, and the type of specialist skills necessary to deliver this care is presently under debate. Delivery of training to enhance skills and to maintain them in the longer term will have to be provided from somewhere and resourced appropriately, both in terms of funding and location, while the remuneration to colleagues trained to provide this care will need to be commensurate with those enhanced skills and the time taken to train.
Equally, the need to manage and assess the level of skill required to deliver the treatment a patient requires has to be provided by colleagues with appropriate specialist skills. It has been suggested that as such colleagues presently exist as Consultants in Restorative Dentistry, then appropriate managed clinical networks should be instituted under the guidance of Consultants in Restorative Dentistry. This then may allow a more appropriate level of care to be delivered to the population. It will impact on the relatively small number of consultants presently around the country as they will then be required to provide a service which encompasses those areas of specialist expertise and multidisciplinary working identified above, provide training for colleagues aspiring to DES status, monitor ongoing delivery of care by those colleagues, provide advice to those tier 1 colleagues, where appropriate, and treatment of a specialist nature, if this is not deliverable by colleagues holding a specialty qualification in the monospecialties.
Additionally, they will be required to continue to deliver training to specialty trainees within their institutions, undergraduate and postgraduate students, where this is appropriate, and perform management roles within their units to ensure efficient service delivery in association with health service managers.
Restorative Dentistry Consultants are led by their specialty association (RD-UK – Association of Consultants and Specialists in Restorative Dentistry), senior members of which group are involved in the various Department of Health and Royal College initiatives to develop these matters.
Summary
This paper has been intended to review the nature and scope of ‘Restorative Dentistry’ in the UK. It has identified what the specialty, as defined by the GDC specialist listing, is about, how and by whom it is delivered and how it is envisaged that it might change in coming years.
It is clear that there are significant changes foreseen in dental health care delivery in coming years and Consultants in Restorative Dentistry are well placed, by the nature or their training and experience, to take a leading role in this.
It is important, however, that their role is fully recognized and opinion sought, where appropriate.