David Bridges BSc(Hons) RDT RDH
Shaun Howe BSc(Hons) RDT RDH

An article in BDJ in Practice Journal from the BDA was published this month with the title “Can a Hygienist work without a Nurse” (Len d’Cruz, Reena Wadia, 2019). Within hours, due to the speed of today’s internet, it is safe to say the item went ‘viral’.

The article purports to be a practical guide for use by dental hygienists [DHs] and their employers and principals within general dental practice. It describes how to manage the DH’s working day without the benefits of chairside assistance in the form of a qualified dental nurse [DN]. To say this article was poorly received by the DH community is an understatement. In a space of an evening, reaction to the content was being discussed across social media platforms. It was not well received. Far from being a helpful guide, it is in reality a document that will be presented to any DH who has the temerity to request nursing support. Within a few short days following publication, anecdotal evidence of at least one practice citing this article and reviewing its provision of DNs for DHs has come to light. This is a most worrying, unwelcome outcome.

The purpose of this article to challenge some of the published content and present the case for DHs in practice needing a DN colleague to assist during the average working day.

The whole premise appeared to be based around DHs working within the widely condemned and underfunded NHS dentistry contract:

“Employing a full time nurse to assist the hygienist is an ideal that a primary care practice might work towards but it is not the norm in the UK and even less likely where a hygienist is providing periodontal care on the NHS under a Band 2 fee…

We are not sure exactly what proportion of DHs actually work within an NHS contract. Many (most?) NHS practices offer hygiene services as a private alternative. DHs and indeed dental therapists [DTs] are effectively excluded from wider adoption within NHS practices due to underfunding and the inability to open NHS courses of treatment for continuing care without a dentist having first performed an exam. This is a subject for perhaps another article.

Clearly there are financial constraints within NHS general dentistry but we would contend chairside assistance for DTs is a given and SHOULD be provided for DHs and practices should view this as inescapable.

In private practice, the economic argument is completely flawed as patients pay fees as determined by the practices’ business model. The fees merely need to reflect the costs plus the desired profit. There is no financial reason for the non provision of chairside assistance for DHs under these business models.

There are many DHs who do enjoy satisfactory chairside assistance however the consensus among the DH community is that the lone working DH is a common reality with the cost of employing support used as a barrier.

The article starts by examining GDC Standards for the Dental Team Guidance. The authors state there is “no legal or regulatory imperative” to have nursing support. This is in direct contradiction of the paragraph they quote:

“You should work with another appropriately trained member of the dental team at all times when treating patients in a dental setting”

This directly taken from paragraph 6.2.2 of GDC Standards (GDC 2103); furthermore, they state this is a “should” not “must” as highlighted by the GDC at the start of the Standard document. However, the authors were selective in which part of the standard they used. The concluding part of the paragraph is clear this is not up for negotiation:

The only circumstances in which this does not apply are when:
• treating patients in an out of hours emergency;
• providing treatment as part of a public health programme; or
• there are exceptional circumstances.
‘Exceptional circumstances’ are unavoidable circumstances which are not routine and could not have been foreseen. Absences due to leave or training are not exceptional circumstances.

It is obvious to many there seems a clear “regulatory imperative” to have support chairside and not merely administrative support.

There is also the assertion no support is needed as DHs historically have worked alone safely, and there has been no change in this situation:

“For many years hygienists had been treating patients without a nurse entirely safely and with minimal risks before this guidance was issued. Logically, nothing has changed to make the delivery of hygienist care unsafe and therefore what is required is a risk assessment.”

This assertion ignores much. Hitherto, DHs were enrolled and worked without a legal requirement for indemnity. Legislation and regulation was less onerous, overseen by a much more benign regulator. DHs were also operating under a much more prescriptive and restrictive ‘Permitted list of Duties’.

There has been huge fundamental change and advances in practise. We now operate in a hugely aggressive, over-regulated environment. We have discrete registration that comes with increased responsibilities to patients and regulators. We are required have our own indemnity. We operate with a much wider scope of practice in a modern dental service with more technique sensitive, complicated and expensive procedures rather than just the use of hand scalers. There is a need to have exhaustively and comprehensively documented everything discussed, offered and (not) performed. We can also deliver that extensive scope of practice, including examination, diagnosis and treatment planning, under Direct Access without the need for a dentist’s involvement at all.

Even in the absence of Direct Access, a DH working under prescription/referral is individually accountable for their own acts or omissions when treating any patient as fitness to practise cases have demonstrated.

It is suggested all this can happen without assistance. Few (if any) dentists would work within the DH scope under those conditions. Len d’Cruz, as an experienced dentist, practice owner and dento-legal advisor should be aware of this. We appreciate Reena Wadia as a more recently qualified dentist and periodontal specialist may not be aware of the evolution of DHs in the UK.

These authors may well have read the Scope of Practice document but do not appear to have read supporting guidelines. The statement “administering inhalation sedation may well warrant the support of a nurse” is erroneous. The intercollegiate guidelines published in 2015 on sedation in dentistry are explicit that any registrant providing inhalation sedation must have a second appropriately trained person present (RCSEng 2015).

There is no discussion on how the GDC disciplinary Committees may criticise a registrant who faces allegations of working without support in the light of GDC Standards; The interpretation of GDC Standards in this single article does not make statute or set precedent.

The second part of the article, subtitled “The clinical side” presents a bizarre series of suggestions aimed at how a DH could make their day without support easier! It is highly patronising that two dentists, one relatively new to the periodontal specialty could seek to advise DHs on this despite never having experienced DH practice. The suggestions include:

Prepare for their day by arriving early
Do full mouth pocket charts whilst working alone, recording 4mm and above pockets only, by voice recording and transcribing later.
Carry out effective aspiration whilst working alone
Spend valuable treatment time explaining to patients why they do not get 30 minutes in the chair
How best to use a shared nurse

If we dissect each of these suggestions then we reach the following conclusions.

Who will pay for this extra time? The DH cannot be expected to work for free!
Recording =>4mm pockets does not save any time: all sites have to be probed in order to determine whether the site bleeds or the depth needs recording. There is a very insignificant difference in the extra time needed to record a significant bleeding site or pocket depth.
This is an oxymoron: unassisted effective aspiration
More explanation reduces treatment time even further or, more likely, increases late running. Frustrating for patients and clinicians alike with the extra time provided by the clinician for free…. again.
Our experience of shared nurses was poor. An initial 6 week trial with a shared nurse quickly gave rise to the conclusion from operators and management alike that individual assistance was the only effective way of working. A nurse each was subsequently provided.

It is suggested a DH’s professional value would be enhanced and they would be considered an asset to the practice if they could find ways to work in this wholly unsatisfactory manner. So valued yet they don’t apparently warrant the investment in proper support. Does that mean those of us who do have assistance are thought to be of a lower professional value or less of an asset? Of course not.

Even if one accepted the economic premise for denying chairside support, the article conveniently ignores the possibility that advice such as this could be viewed with some concern by a regulator charged with supervising patient safety. This article flies in the face of the spirit of GDC Team working Standards if not the strict letter of the law.

Mandatory chairside assistance is not required nor desired but every clinician who deems it necessary should be able to have assistance to the level their professional judgement requires. Should mandatory assistance ever be instigated , it would have unintended consequences. Whilst it might appear an attractive proposition and indeed a simple answer to the issues of working unassisted, it is a crude and blunt instrument.

If assistance was mandatory it would affect all clinicians. It would mean if staffing is short, a clinician would be unable to work. In a busy dental practice, it would leave a business totally at the behest of its support employees despite the availability of clinicians and whether they felt they could provide some level of safe service on their own – that professional judgement would be eroded.

For DHs it is easy to foresee who would lose their nurse and go home without pay – it is unlikely to be a dentist. It is for the individual clinician, using their training, experience and professional judgement to decide what is safe practice and thus maintain a continuous, safe service for patients, who are the most important people in this whole matter.. There are some tasks that do not require chairside assistance but much that does in terms of safety, efficacy, efficiency and other more qualitative aspects for both patient and operator. The profession would be wise to recognise this and implement DN support in such a way as works for all rather than having something less desirable imposed by legislation.

The authors would like to thank BDJ in Practice for publishing the article as the one probable benefit is that it has brought a long festering sore of an issue to the fore whilst galvanising a DH and DT workforce, united from their two representative bodies – the British Association of Dental Therapists and the British Society of Dental Hygiene and Therapy – downwards in an unprecedented manner. Even more than during the campaign for Direct Access.

The published article also raises a surrogate question about mentoring a professional group of individuals; there is no cohesive structure in place to help evolve a DH skill set. There may be a preconceived misconception that a DH should be mentored by a periodontologist. We are not sure why this is the case and we, as a profession, should look to our nursing and midwifery colleagues and ask our representative bodies to do so too. A general nurse is not mentored by a specialist, but a more experienced colleague working in the same field (Royal College of Nursing 2019); why should a DH be any different?

The lines have been drawn. It is now time for DHs and DTs to roundly reject this concept and push for the sensible adoption of adequate chairside assistance to the level the individual clinician desires without recourse to clumsy legislation. We think an apology for the patronising nature of the article and the upset caused should be forthcoming along with the retraction of the article.

Len d’Cruz, Reena Wadia, 2019. Can a Hygienist work without a Nurse? BDJ In Practice, 32(2), pp.14–15.
General Dental Council. Standards for the Dental Team. accessed online 17 February 2019 available here: https://www.gdc-uk.org/api/files/NEW%20Standards%20for%20the%20Dental%20Team.pdf
Royal College of Surgeons (England):Standards for Conscious Sedation in the Provision of Dental Care. Accessed online 17 February 2019 available here: https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/dental-sedation-report.pdf
Royal College of Nursing: Mentorship: accessed online 17 Feb 2019 available here: https://www.rcn.org.uk/library/subject-guides/mentorship