From Volume 45, Issue 10, November 2018 | Pages 947-951
The last decade has seen the orthodontic workforce transformed by the introduction of orthodontic therapists. This article aims to highlight how they have changed the provision of orthodontic treatment and how the orthodontic profession has caught up with general dentistry where task delegation to dental therapists and hygienists has been commonplace for many years.
By 2007, changes to the Dentist Act meant that the General Dental Council (GDC) permitted the training of Orthodontic Therapists (OTs). Therefore, at this time, the first courses began training this grade of Dental Care Professional (DCP).
The introduction of OTs was in response to a high level of orthodontic treatment need within the UK (estimated at 50% of 11-year-olds requiring orthodontic treatment1) but a poor orthodontist to patient ratio. Discussions about the role of OTs, initially known as orthodontic auxiliaries, began as early as 1973. A pilot study was conducted at Bristol Dental School in the mid-nineties where dental nurses undertook a four-week training programme, which taught a range of appropriate orthodontic skills. At the end of this pilot, it was found that the students not only had a high level of clinical and theoretical knowledge, but that they also had practical abilities that were closer to orthodontic postgraduate students and thus far surpassed the course organisers' expectations.2 The foundations of the training programme for OTs were based on this pilot study and, in 2017, 10 years after the first orthodontic therapist courses started, there were more than 500 orthodontic therapists registered with the GDC in the UK. Typically, courses leading to registration are one year in length and comprise two parts – an initial 4–week core course with additional study days throughout the year based at the training centre, and workplace training in an approved orthodontic practice or hospital orthodontic practice. After completion of the course, including satisfactory workplace reports, success in formative assessments, etc, the student can apply to sit the Diploma in Orthodontic Therapy examination. The minimum requirements stated by the General Dental Council are that the student can be a dental nurse with a recognized qualification, a qualified dental hygienist or dental therapist, or a dental technician with appropriate clinical experience. The local trainer must be on the orthodontic specialist list.
The composition of the UK workforce delivering orthodontic treatment has changed greatly over the past decade since the introduction of OTs.3 This change in skill mix is significant due to the scope of practice of OTs4 (Table 1). This has meant that orthodontists are now able to delegate many more clinical tasks to orthodontic therapists, enabling each member of the orthodontic team to use his/her time efficiently. In places it has led to the following:
| Orthodontic Therapists Can | Orthodontic Therapists Cannot |
|---|---|
| Clean and prepare tooth surfaces ready for orthodontic treatment | Remove sub-gingival deposits |
| Identify, select, use and maintain appropriate instruments | Give local analgesia |
| Insert passive removable orthodontic appliances |
Re-cement crowns |
| Remove fixed appliances, orthodontic adhesives and cement | Place temporary dressings |
| Identify, select, prepare and place auxiliaries | Place active medicaments |
| Take impressions |
They do not carry out laboratory work other than previously listed as that which is reserved for dental technicians and clinical dental technicians |
| Make a patient's orthodontic appliance safe in the absence of a dentist | Diagnose disease, treatment plan or activate orthodontic wires – only dentists can do this |
| Fit orthodontic headgear |
Additional skills which orthodontic therapists could develop during their career include: |
| Place brackets and bands, prepare, insert, adjust and remove archwires previously prescribed or, where necessary, activated by a dentist | Applying fluoride varnish to the prescription of a dentist |
| Give advice on appliance care and oral health instruction | Repairing the acrylic component part of orthodontic appliances |
| Fit tooth separators | Measuring and recording plaque indices and gingival indices |
| Fit bonded retainers | Removing sutures after the wound has been checked by a dentist |
| Carry out Index of Orthodontic Treatment Need (IOTN) screening either under the direction of a dentist or direct to patients | |
| Make appropriate referrals to other healthcare professionals | |
| Keep full, accurate and contemporaneous patient records | |
| Give appropriate patient advice |
Historically, a significant proportion of orthodontic treatment has been carried out by GDPs in the UK. In 2005, the workforce report5 (Figure 1) revealed that 17% of orthodontic providers had no orthodontic qualification and, in six areas (Shropshire, Staffordshire, Trent, North and East Yorkshire and Lincolnshire), the majority of orthodontic provision was carried out by non-specialists. From the author's (TH) personal experience in East Yorkshire, the introduction of OTs has led to an increase in access to specialist-led orthodontic treatment. As local GDPs with orthodontic experience have retired, the employment of OTs has allowed commissioners to redistribute funding amongst the small pool of existing local specialists cost-effectively.
The role of the orthodontic consultant in secondary care has traditionally centred on five domains:
With resources in the NHS stretched and pre-eminence being given to achieving the clinical and management roles of the post, OTs can help allow consultants to meet current challenges of the increasing clinical and management demands, while still fulfilling the other key roles. OTs allow for a better use of skills mix through task delegation: as permanent members of the team they provide continuity of care; under the supervision of a clear prescription they can provide some clinical cover in the absence of the consultant; and they improve efficiency and clinical throughput once trained. An example of the improved efficiency can be found by looking at a hypothetical model of two consultants working without OTs, each having a job plan based around one new patient clinic and seven treatment sessions. Based on a consultant seeing 10 patients per treatment session, and working on clinics on average 44 weeks per year, 6160 follow-up appointments will be provided. Now compare this to a scenario where there are the two consultants on the same job plan, but working alongside three OTs, with the consultants working alone for 50% of the time and supervising OTs 50% of the time. If the OTs work nine sessions with 10 patients a clinic for 46 weeks in the year, the net number of follow-up slots increases to 15,500. This represents a 250% increase in output, but is still a consultant-led service. This is based on the experience of one of the authors (SL) in a busy district general hospital in the north of England.
At the Consultant Orthodontist Group Symposium in Liverpool 2016, a survey was conducted examining the use of OTs within secondary care. The main reasons cited for not employing OTs included lack of finances, lack of management interest and lack of capacity to accommodate them. In addition, while many of the delegates said that they would like to train an OT, many stated that they had no time to do so. However, a large proportion of the delegates also said that waiting list and financial targets were not being met at their hospitals. Given then the potential to increase productivity of the orthodontic workforce with the inclusion of an OT in the team, there is likely to be an underutilization of this group of DCPs within the hospital setting. It is estimated that only 10–15% of the current OTs in the UK work in secondary care.
Working with OTs has the potential to offer similar levels of increased efficiency in primary care as those described in secondary care. While there is no published evidence on the ideal model of working with orthodontic therapists in the UK, anecdotally, most practitioners report either supervising 3 OTs and having no personal list of patients or, alternatively, working alongside 2 OTs whilst also treating some patients.6 As well as a sensible ratio of orthodontist:OT, efficiency is likely to be affected by the nature of the clinical tasks being undertaken, as well as the competency and experience of the OT. Most providers choose not to involve OTs in the management of new patients as they are specifically not taught about diagnosis, and treatment planning is not within their scope of practice. However, in the delivery of certain treatment modalities, OTs offer significant opportunities in the delivery of care. An aligner type treatment such as Invisalign™ is an example of a treatment where task delegation is exceedingly beneficial. These treatments are generally designed to move teeth using incremental, clear, custom-fitted aligners, which are changed periodically (1–2 weeks on average) as an alternative to fixed appliances. Aligner treatment often differs from fixed appliance treatment, where the treatment plan is constantly reassessed, and new mechanics prescribed and altered throughout treatment. According to one of the authors (DRH), he has shown from his own practice that 75% of Invisalign™ treatment can be managed by the OT, saving the orthodontist, on average, more than 4 hours of clinical time per case through the delegation of patient education roles, initial record collection, aligner delivery, attachment placement, some mid-treatment review and refinement preparation and record gathering.
Nevertheless, the introduction of OTs has had negative implications for some members of the orthodontic workforce. In certain geographical locations, there is now less need for the employment of orthodontic specialists as either assistants or associates, and dentists with a specialist interest in orthodontics. An audit was carried out of the trainers of students of the first four intakes of the Yorkshire Orthodontic Therapy Course, where it was found that 50% in specialist practice had not employed new specialist orthodontists since the introduction of orthodontic therapists, and a further 20% had replaced some orthodontist hours with therapist hours. It may be then that, in the future, there needs to be a reassessment of the UK's orthodontic workforce, although at the present time there are still areas with a shortage of specialist providers. There is also some anecdotal evidence that some GDPs who worked as clinical assistants alongside specialist orthodontists have also reduced in number, which perhaps can largely be attributed to financial reasons, as the cost to employ an OT is significantly less than employing a dentist.7
Since OTs have been introduced concerns have surfaced regarding isolated cases of problems with their supervision and, consequently, the British Orthodontic Society has produced guidelines for the supervision of qualified OTs8 (Figure 2). It is important that both the supervising dentist and the OT understand each other's roles and competencies to ensure safe supervision. The guidelines advise that, wherever practicable, the patient should be seen with the supervising dentist but, where this is not possible, the patient should be seen by the supervising dentist at least at every other visit (Figure 3). The supervising clinician needs to be a specialist orthodontist, or a dentist who is competent in orthodontics (this differs from training where the supervisor needs to be on the specialist list). In addition, an OT can only see a patient when there is a clear, comprehensive prescription from the supervising dentist written in the patient notes and it should not be changed. This therefore means that, when the orthodontist is absent, patient care can continue with the OT under the prescription of the orthodontist. If there is any uncertainty as to what treatment is required, then no treatment should be undertaken and an appointment should be booked for the patient to see the supervising dentist. In circumstances where a patient presents as an orthodontic emergency, the OT can provide limited treatment to make a patient's orthodontic appliance safe; however, the patient should subsequently be booked an appointment with the supervising dentist to ensure that treatment continues to progress safely. These guidelines have recently been updated and can be found on the British Orthodontic Society website.
One of the main concerns when OTs were introduced was whether the quality of the treatment delivered would be affected. A recent cross-sectional, retrospective observational study was conducted at two specialist orthodontic practices in Yorkshire.9 The aim was to compare patients treated by an orthodontist alone, with patients treated by therapists under the supervision of an orthodontist. Factors measured were the length of treatment, the number of appointments and the Peer Assessment Rating (PAR) index change.
The PAR index was developed as a way of objectively measuring the outcomes of orthodontic treatment. It compares pre-treatment and post-treatment study models to assess the change in malocclusion with orthodontic treatment. The higher the malocclusion score, the more severe the malocclusion. The greater the percentage reduction post-treatment, the greater the change in malocclusion and the more successful the orthodontic treatment.
In this study, measurements were taken before the introduction of OTs and afterwards, with the results showing that there was no change in orthodontic treatment outcomes once therapists had been introduced. It is important to note, however, that, while the British Orthodontic Society guidelines state that an orthodontist should supervise orthodontic therapists at every other visit, in this study, the OTs were supervised at every visit. The results also reflect the expertise of the individual clinicians who made and revised the treatment plans; it is possible that not every clinician will be able to achieve these results with or without an OT.9
While this study is encouraging for the use of OTs, it is important also to recognize that, apart from the PAR index, there are other measurements to assess orthodontic activity and the quality of patient care, such as patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). PROMs intend to capture patients' perceptions of their health status, functional status and their health-related quality of life, whilst PREMs capture patients' perceptions about their experiences in the healthcare setting. There are currently no agreed PROMs and PREMs for orthodontic care, but when they become available it is hoped that future prospective research could also look at PREMs and PROMs and the effect OTs may have on them.
Given that OTs have significantly changed the provision of orthodontic treatment and now constitute a large part of a growing orthodontic workforce, it is important that future orthodontists are educated on working with, and supervising, therapists. It is hoped that future orthodontic specialist trainees will be trained to understand the role of orthodontic therapists, understand ethical and safe supervision and gain practical experience of supervision during their training. Orthodontic postgraduate students now need to understand and develop supervision skills during their training and be aware of supervisory guidelines to ensure the effective and safe use of these invaluable DCPs in the workforce.
In conclusion, the introduction of OTs offers the potential for a more cost-effective, cost-efficient, accessible service in both primary and secondary care without impacting on the quality of the treatment provided. Further research is required in this area, but the incorporation of OTs within the dental team has the potential to provide a better service for patients.
