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Principal Preparing for Dental Practice
Preparing for Dental PracticeF. J. Trevor Burke, Ruth Freeman
The present work gives current data on all aspects of the medical problem, from aetiology and pathology to financial aspects, medico-legal implications, and current nursing practices. It reviews the knowledge and techniques currently available to the clinician and focuses on evidence-based knowledge for prevention, treatment and assessment of pressure ulcers. Specific patient groups include the Spinal Cord Injured. Current and future techniques are described that will provide information on the susceptibility of subjects to pressure ulcer development and the possibilities of tissue repair using tissue engineering strategies.
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Preparing for dental practice F J Trevor Burke Ruth Freeman OXFORD UNIVERSITY PRESS 01_Pre.qxd 18-06-2004 03:12pm Page i Preparing for dental practice 01_Pre.qxd 18-06-2004 03:12pm Page ii Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. 01_Pre.qxd 18-06-2004 03:12pm Page iii Preparing for dental practice F J Trevor Burke Professor of Primary Dental Care University of Birmingham School of Dentistry Birmingham, UK Ruth Freeman Professor of Dental Public Health Queen's University Belfast School of Dentistry Belfast, Northern Ireland 1 01_Pre.qxd 18-06-2004 03:12pm Page iv 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Sao Paulo Shanghai Taipei Tokyo Toronto Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press, 2004 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2004 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer A catalogue record for this title is available from the British Library ISBN 0198508646 (Pbk) 10 9 8 7 6 5 4 3 2 1 Typeset by Cepha Imaging Pvt. Ltd., Bangalore, India Printed in Hong Kong on acid-free paper by Phoenix Offset Ltd. 01_Pre.qxd 18-06-2004 03:12pm Page v Preface Preparing for dental practice is for senior dental undergraduate students and vocational dental practitioners to prepare them for dental practice. It is also for general dental practitioners to enable them to undertake continuing professional development. The value of this book is its holistic flavour, combining the business of practice with the science of clinical dentistry and the humanity of patient care. Readers will be able to prepare for dental practice in the 21st century by amalgamating these aspects of primary care in order to care for their patients. The majority of undergraduate texts in the UK specialise in oral surgery, preventive dentistry, endodontology, crowns and bridges, and routine conservative treatment. Increasingly, UK (and US) dental schools are providing comprehensive patient care programmes and general practice courses. In these courses, students are encouraged look at the holistic care of the patient and identify their overall treatment needs, rather than thinking purely in a clinical and departmental manner. In order to develop an holistic view of dental care, the first chapter of this book examines issues in relation to career choices, the location of the practice, and the means by which access to dental care may be increased. Chapters 2 and 3 take the reader inside the dental practice to examine relationships within the practice setting. This includes the relationship with the patient as well as the dental team. The fourth chapter describes clinical excellence in primary dental care by examining clinical decision-making, the need for referral, and the place of prevention and restorative philosophies in the treatment of patients. The last chapters examine the business of dental practice and suggest future pathways for the newly qualified dental practitioner. Preparing for dental practice is new and exciting and provides the background for an holistic approach to patient care and treatment. It does this by encouraging senior dental undergraduates, vocational dental practitioners, and general dental practitioners to inquire and investigate their role as primary dental care practitioners. It provides accessible information to enable dentists to enjoy their primary dental practice, and to experience a successful career in primary dental care. 01_Pre.qxd 18-06-2004 03:12pm Page vi This page intentionally left blank 01_Pre.qxd 18-06-2004 03:12pm Page vii Acknowledgements Dr Mike Grace Dr Robin Gray Mr Colin Lee Professor G R Ogden Professor A J M Plasschaert Professor A Richardson Mrs Penelope Vasey Professor N H F Wilson Many thanks are also due to Mrs Lyn Malthouse for her expert secretarial assistance. 01_Pre.qxd 18-06-2004 03:12pm Page viii This page intentionally left blank 01_Pre.qxd 18-06-2004 03:12pm Page ix Contents Contributors xi Chapter 1 The first job 1 1. Career options 3 2. Applying for a position 12 3. Choosing the 'right' practice 17 4. Ease of dental treatment 26 5. Emergencies in the dental surgery 31 6. Infection control 35 Chapter 2 Practice building – relationships around the patient 59 1. The dentist-patient relationship 60 Chapter 3 Practice building – relationships within the practice 93 1. The dental team 94 2. Health and welfare of the dentist and his/her team 114 3. Conclusion 119 Chapter 4 Practice building – the need for excellence in treatment 123 1. Treatment planning 126 2. Promoting oral health in primary dental care 140 3. Use of minimally invasive techniques (MI) 165 4. Caring for patients with special dental needs in primary care 175 5. Treatment of dental emergencies 192 6. Referrals 200 7. Evidence-based dentistry 229 8. Clinical governance 237 Chapter 5 Essential business principles of dental practice 243 1. Essential accounting and insurance 243 2. Marketing the practice 256 Chapter 6 The future 259 Index 263 01_Pre.qxd 18-06-2004 03:12pm Page x This page intentionally left blank 01_Pre.qxd 18-06-2004 03:12pm Page xi Contributors Dr Mike Grace Editor British Dental Journal 64 Wimpole Street London W1M 8AL, UK Dr Robin Gray 62 Manchester Road Altrincham Cheshire WA14 4PJ, UK Professor Graham Ogden Dundee Dental School Park Place Dundee DD1 4HN, UK Professor Alphonse Plasschaert Department of Cariology and Endodontology Katholieke Universiteit Nijmegen PO Box 9101 NL 6500 HB Nijmegen The Netherlands Professor A Richardson 33 Cherryvalley Park Belfast B756PN Northern Ireland Mrs Penelope Vasey 53 St Helens Wood Road Hastings East Sussex TN34 2QR, UK Professor Nairn Wilson Central Office GKT Dental Institute Floor 18, Guy's Tower King's College London Guy's Hospital London SE1 9RT, UK 01_Pre.qxd 18-06-2004 03:12pm Page xii This page intentionally left blank 02_Chap01.qxd 18-06-2004 03:21pm Page 1 1 The first job 1.0 Career options 1.1 General dental practice (primary dental care) • Associateships and Assistantships • Vocational training 1.2 Salaried practice 1.3 Community Dental Service 1.4 Personal Dental Service (PDS) 1.5 Academic dentistry • Teaching • Research • Clinical • Examining • Administration • Writing 1.6 Hospital dentistry 2.0 Applying for a position 2.1 Writing a curriculum vitae (CV) • Personal details • Education and academic achievements • Prizes and distinctions • Positions of responsibility • Interests, hobbies, and activities • Personal statement • Other details • References 2.2 The letter of application 2.3 The first interview 2.4 The first impression • Further reading 3.0 Choosing the 'right' practice 3.1 Practice location • City centre location • Suburban location • Rural location • Working in socially deprived or affluent areas 3.2 The practice philosophy 3.3 The practice staff • Nurses and receptionists 02_Chap01.qxd 18-06-2004 03:21pm Page 2 2 PREPARING FOR DENTAL PRACTICE 3.4 3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.3 5.0 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19 6.20 6.21 6.22 6.23 • Number of dentists The practice décor The practice equipment Whether a dentist lives on the practice premises Emphasis on postgraduate achievements and continuing professional development The practice organisation The patient base Ease of access to dental treatment Physical access Psychological accessibility • Behavioural management techniques to increase psychological accessibility • Pharmacological techniques to increase psychological accessibility Financial access • NHS treatment • Private treatment • Financial access: the dentist's viewpoint (see section on dentist–patient relationship) Emergencies in the dental surgery: equipment and drugs • Prevention of emergencies • Common causes of collapse in the dental surgery Infection control Introduction Routine procedures Patient perception Acceptance of patients Confidentiality The infected dental health care worker Training in infection control Surgery design Ventilation Floor covering Work surfaces Choice of equipment Water supplies Decontamination of instruments and equipment Pre-sterilisation cleaning Sterilisation Decontamination of handpieces Instrument storage Single-use (disposable) items Surface cleaning and disinfection Decontamination of instruments and equipment prior to service or repair Disposal of clinical waste Blood spillages 02_Chap01.qxd 18-06-2004 03:21pm Page 3 THE FIRST JOB 6.24 6.25 6.26 6.27 6.28 6.29 6.30 6.31 6.32 6.33 Biopsy specimens sent through the post Personal protection Immunisation Hand protection Eye protection and face masks Surgery clothing Aerosol and saliva/blood splatter Inoculation injuries Infection control policy Infection control checklist • At start of day/session • Before patient treatment • During patient treatment • After patient treatment • At the end of each session • At the end of the day 1.0 CAREER OPTIONS While it could be considered that a career in dentistry is limited by the fact that the new graduate is trained only as a dentist, there is indeed a wide variety of careers within dentistry itself (Table 1.1). A suggested pathway for these career options is illustrated in fig. 1.1. This is derived from the Faculty of General Dental Practitioners' (UK) career pathway, which provides a route to Fellowship of the Faculty and provides for recognition of general dental practitioner special interests. In this respect, the Faculty of General Dental Practitioners (UK) provides postgraduate education and training for general dental practitioners (GDPs), and produces guidance on issues such as record keeping and prescribing (www.fgdp.com). Table 1.1 Career options within dentistry General dental practice Principal (practice owner) Associate Assistant Vocational dental practitioner Specialist Salaried practice in industry in the armed forces with a corporate body Community dental clinic Personal dental service (PDS) Academia Hospital dentistry 3 02_Chap01.qxd 18-06-2004 03:21pm Page 4 4 PREPARING FOR DENTAL PRACTICE FOUNDATION STAGE MFGDP(UK) or equivalent Ongoing CPD CLINICAL COMPONENT STAGE 2 Accumulates 60 credits MANAGEMENT COMPONENT FELLOWSHIP ASSESSMENT Accumulates 60 credits clinical, 30 credits management and 30 credits other areas FFGDP(UK) Figure 1.1 FGDP(UK) Career Pathway. 1 . 1 G E N E R A L D E N TA L P R A C T I C E ( P R I M A R Y D E N TA L C A R E ) The vast majority of dentists in the UK work in a dental practice or primary dental care environment. There is the opportunity to purchase a practice, which permits the dentist to be his/her 'own boss' as much as is possible within any career. The practice principal chooses the materials to be used, the décor of the waiting room, the equipment in the surgery, and, even, the patients that s/he doesn't want to treat! Alternatively, a dentist may elect to be an associate or assistant, with less involvement in the administration of the practice. Associateships and assistantships The purchase of a practice generally demands that the purchaser intends to be fixed in the practice location for a period of time, in order to build a rapport with the patients and develop the practice. Consequently, until a dentist is certain about the location in which they wish to practice, or until they are in a position to raise the funds with which to purchase a practice, a dentist may wish to become an associate or assistant. The term associate is peculiar mainly to the UK. In broad terms, the associate in a practice contracts to pay the practice owner (practice principal) a proportion of his/her gross fees, usually in the range of 50–60% (depending on location and demand, among other factors), once laboratory expenses 02_Chap01.qxd 18-06-2004 03:21pm Page 5 THE FIRST JOB have been subtracted. In return, the practice principal agrees to supply staff, materials and equipment, and usually patients, and to maintain the practice premises and equipment. The practice principal will often expect the associate to make an agreement that the goodwill of the patients remains with the practice principal. While it is not unusual for associates to remain in the same practice for many years, there is no long-term financial commitment to remain in the same location. An associateship has therefore been the method of employment, for many, before purchasing a practice and making a longterm commitment to a particular practising location. An assistant is often employed on a salaried basis, treating the practice principal's patients. Within the NHS (National Health Service), an assistant will generally work, by prior arrangement, within the contract between the principal and the NHS. Vocational training (Mrs Penelope Vasey) Applying for a VDP position Vocational training, as organised in the UK, is unique in the world of dentistry. In this scheme, new graduates undertake Vocational Training (VT) in selected training practices, where they work four days per week, with one day per week being allotted to postgraduate education. The majority of Vocational Dental Practitioners (VDPs) go straight into vocational training upon graduation. A number of them will have first worked in hospital, but opportunities and salary are equal for everyone undertaking vocational training in practice. The Dental Vocational Training Authority website will direct you to the geographic location of your choice: English Deaneries, Wales, Scotland and Northern Ireland. Trainers are appointed by competitive interview, together with a rigorous inspection of their practices. VDPs can be confident that training practices are of a high standard, and that Trainers have been appointed for their suitability to support and guide you through your introduction to practice: the VT year. It is possible to undertake vocational training part time, if you have domestic or serious sporting commitments. The vast majority of schemes start in August each year, and the trainer lists are published via the Dental Vocational Training Authority towards the end of March or beginning of April. A smaller number of places are available to start in January or February. There are generally sufficient places for every new UK graduate, and feedback from past VDPs advises the new graduate to choose carefully and limit his/her application to a few practices that appeal to the applicant. Having identified a number of suitable practices, the applicant for a VDP position may ask for the opportunity to visit the practice. It should be made clear whether the visit is informal, or for a formal interview. Ideally, the applicant should try 5 02_Chap01.qxd 18-06-2004 03:21pm Page 6 6 PREPARING FOR DENTAL PRACTICE to visit during working hours, to get a feel for the atmosphere and meet the support staff. Some deaneries run 'job shops' when the new graduate can meet a number of Trainers face to face, in one location. Past VDPs say that the best aspects of the VT experience are: • the relationship with the Trainer, in the training practice • support at Study Day sessions with peers and Adviser Thus it is of prime importance to choose a practice that is suitable, rather than jumping at the first available opportunity. There is no greater chance of securing a position by applying to a large number of practices, and this will only serve to put you under extra pressure at a stressful time. DVTA runs a clearing system in July when more places become available through failures at the final BDS examination. Having been offered a position and having decided to accept it, the VDP and the potential Trainer will be required to sign a 'letter of intent'. This is to safeguard both parties. The Trainer agrees not to offer the job to anyone else, and the applicant agrees to stand by his/her acceptance. A contract of employment cannot be signed whilst still a student, but once the dentist has graduated and is on the Dentists Register, the VT contract may be signed. This document sets out the terms and conditions of employment as a VDP, including hours of work: 35 per week in the practice, or 28 hours when time is spent away at a study day. Details of four weeks' holiday entitlement, sick and maternity leave are all covered. The VDP is also required to sign an Educational Agreement with the Postgraduate Dean or Director. This clearly lays out the VDP's responsibilities in attendance and in keeping the Professional Development Portfolio. Full time vocational training lasts for 365 days, and attendance at all the 30 study days is compulsory in order to gain a certificate of completion of vocational training. What will the VDP learn during the VT year that will prepare him/her for practice? The curriculum includes a range of topics which will prepare the VDP well for practice as an assistant or associate, and provide him/her with an appreciation of all the knowledge and skills required as a practice owner. Confidence building in clinical skills is important in the early part of the VT period. Invaluable advice and support will be given by the Trainer in treatment planning and managing patients. The VDP will learn how to work in a team and supervise support staff, and liaise with laboratories, hospitals and general medical practitioners. Some topics may seem to have little relevance at this time, but an introduction to health and safety issues, staff management, financial issues and employment law will prove critical to the future practice owner. Finally, experience in the training practice and discussion at study days will provide an informed idea of what to look for in a 02_Chap01.qxd 18-06-2004 03:21pm Page 7 THE FIRST JOB practice. Having spent a year in an approved training practice, the VDP will probably be less willing to accept any compromise in practice standards in the future. For example, Trainers are required to provide the VDP with a trained dental nurse. Having experienced the benefits of good chairside assistance, this will probably be a high priority when looking at future jobs. Whilst most study days will be at the scheme's postgraduate centre, there are opportunities for visits to national events and organisations. A trip to London may take in the General Dental Council, British Dental Association or one of the Defence organisations. The experience of attending a national conference or study day of the Faculty of General Dental Practitioners is a valuable part of the VT experience. These occasions will vary from year to year, chosen by the VT Advisers for relevance to VDPs. On a daily basis the Trainer offers close support to the trainee. Besides being available in the practice a minimum of three days per week for help on demand, s/he is required to spend time each week on a tutorial. Although the Trainer and trainee will plan the topics to be covered, this is the opportunity to discuss clinical problems that have occurred in the surgery. Schemes consist normally of 12 training pairs, and are run by a Vocational Training Adviser. The Adviser is a source of experienced help, as well as organising the study day sessions and facilitating problem solving sessions within the group of VDPs. Feedback shows this to be considered the single most beneficial aspect of VT. Within each Deanery a Regional Adviser coordinates the schemes, organises training for trainers and is generally responsible for the operation of VT locally. Finally, the Postgraduate Dean or Director carries the ultimate responsibility for the training that is delivered, supports the other VT personnel and signs the certificate of completion of VT. S/He has the power to require VDPs to undertake a further period of training if attendance at either the practice or study day sessions has been inadequate. How will I know if I am making progress? An integral part of VT is the Professional Development Portfolio (PDP). This document belongs to the VDP. Before starting clinical work the VDP will agree with the Trainer and record a tailor-made programme in the PDP. This is a unique opportunity to gain extra experience in clinical areas in which the trainee may lack confidence, or even where the VDP knows that they are weak. By recording week by week the things that have gone well, or not so well, and by building up clinical experience, VDPs can look back and see tangible evidence of progress. Here is a way also of ensuring that the Trainer gives as much time and support as is needed. Of course as the year wears on, needs will change, as will the speed of clinical work and management of patients. 7 02_Chap01.qxd 18-06-2004 03:21pm Page 8 8 PREPARING FOR DENTAL PRACTICE At the end of the VT year, the certificate of completion of vocational training is the passport to automatic granting of a VT number when applying to join a Health Authority list. The successful VDP may then become a principal in the General Dental Services, working on his/her own list number. However, VDPs have been heard to say that to view VT as a means merely to obtaining a VT number is to miss out on a unique opportunity to learn alongside an experienced Trainer and be truly prepared for practice. As with most things in life, the more you put in, the more you will get out. The financial change from VDP to associate For the VDP who becomes an associate, a word of warning. The VDP is a salaried position. As an associate, the dentist must wait for patients to pay their accounts or for the third-party insurers (for example, the National Health Service) to pay the fees that are claimed. This may often take two to three months. During that time, the associate will receive no, or very little, fee payments. This is a situation which must be planned for, for example, by appraising the bank of the situation and negotiating an overdraft. The converse is that fee payments will continue after leaving the associate position. 'High street' specialists Although the majority of general dental practitioners (GDPs) provide all of the treatment which their patients require, there is also, within the practice environment, an opportunity to specialise, or to have an interest in one particular form of treatment. This could lead to referrals from outwith the practice, or from other dentists within the practice. The route to becoming recognised as a specialist requires the dentist to take the MFDS qualification from one of the Royal Colleges, followed by three years' training in a Specialist Registrar post in a hospital environment. A more complete description of specialist training has been provided by Ibbetson (2003). 1.2 SALARIED PRACTICE Dentists may opt to enter salaried practice in a variety of locations. The advantages of such practice could be the predictable salary in comparison to that in general dental practice which is subject to fluctuations depending on busyness, holidays, etc. Salaried practice may also have fixed hours of work. Locations for salaried practice include industry, where large companies provide a dental service for employees (Industrial Dental Service) and the Armed Forces, with the potential for travel to the different world locations where forces are deployed. Corporate bodies may also employ dentists on a salaried basis, although some also employ dentists under associate arrangements. 02_Chap01.qxd 18-06-2004 03:21pm Page 9 THE FIRST JOB 1 . 3 C O M M U N I T Y D E N TA L S E R V I C E The Community Dental Service (CDS), which employs dentists on a salaried basis, provides a varied service to several specific groups of the community. Once thought of as the 'School Dental Service', it provides screening and care (if required) to child patients, the elderly and patients with special needs. The CDS provides a safety net service (Freeman et al. 1997) for those unable to access care in the usual way. There is a clear career structure, from dental officer (specialist) to director of community dental services (management). It has a well-developed programme of postgraduate training, with a high proportion of its dental staff achieving a postgraduate qualification. 1 . 4 P E R S O N A L D E N TA L S E R V I C E ( P D S ) Prior to 1997, National Health Service (NHS) dental services in the UK could only be delivered by general dental practitioners on the basis of a national contract and a nationally negotiated scale of fees. Personal Dental Services (PDS) were initiated following recommendations in a number of reports, including the report by Sir Kenneth Bloomfield in January 1993 in which the exploration of alternative methods of remunerating general dental practitioners was suggested, partly as a response to growing problems with the availability of NHS dental care. After consultation with the dental profession, it was announced that the local commissioning of general dental services would be explored through pilot schemes, with dentists' entry into these schemes being voluntary. PDS is an alternative method of delivering NHS dental services, based on local contracting arrangements, with the contract for dental services being agreed between the local health authority and one or more providers of dental services. PDS Pilots use the flexibility of locally negotiated contracts to tackle local problems related to dental services and oral health, and it may be considered that local contracting may produce more sensitive and responsive dental care. A central feature of the PDS initiative is the piloting of new ways of funding primary dental care. PDS pilots, in general, have developed two main remuneration models, a salaried model and a capitation system. Another feature of PDS pilots was expected to be their use of Professionals Complementary to Dentistry (PsCD). Some PDS pilots may become a model for new local contracting arrangements if proposals whereby Primary Care Trusts become responsible for arranging contracts with the dentists working on the NHS in their area, are instituted. 1.5 ACADEMIC DENTISTRY An academic career in dentistry is usually associated with a university post in a teaching school. The majority of dental academics will maintain a clinical 9 02_Chap01.qxd 18-06-2004 03:21pm Page 10 10 PREPARING FOR DENTAL PRACTICE Table 1.2 Principal activities of a dental academic Teaching • Undergraduate • Postgraduate Research • Clinical • Laboratory Clinical • Patient treatment • Chairside teaching Examining • Undergraduate • Postgraduate • Research Theses Administration • Organisation of courses • Student care • Committees Writing • Research papers • Review articles • Books • Peer reviewing interest and work with patients both in their own clinical practice and also by way of chairside teaching. However, a smaller number of dental academics choose to work purely in research or in the pre-clinical part of the dental undergraduate course. The principal activities of a dental academic are shown in Table 1.2. Teaching Teaching may form a substantial part of a dental academic's job (Scott 2003). This will take the form of lectures and seminars or problem-based learning, but will generally include the chairside supervision of students providing patient treatment. Most dental academics will also provide teaching at postgraduate level, either in the form of lecture courses or 'taught' higher degree (e.g. Masters) courses. Research Research is an important aspect of the dental academic's work. The dental academic will normally be expected to have achieved an MSc degree by research in the earlier part of their career, followed by a PhD, which would generally be considered essential for promotion to higher academic positions. The type of research undertaken will depend upon the expertise and equipment available in the institution in which the academic is employed, but it is essential that the topic(s) for research are actually of interest to the individual, because it may be considered that the researcher will 02_Chap01.qxd 18-06-2004 03:21pm Page 11 THE FIRST JOB approach his/her work with a good deal more enthusiasm if the subject stimulates the individual. Research may be carried out in a wide number of areas (Scott 2003). These include clinical research (such as clinical trials of materials, preventive programmes or assessment of disease levels) or laboratory-based research (such as dental materials testing, molecular and cellular biology). Clinical Dental academics, other than those involved in the teaching of pre-clinical dental students, will normally hold an honorary hospital appointment and will undertake treatment of patients, often those who are referred from GDPs. Most dental academics develop their own special clinical interest and may carry out clinical research based around their treatment of patients, having obtained ethical approval if necessary. Examining Examinations are central to the dental undergraduate course and postgraduate diplomas, so the dental academic will be involved in these as an examiner but, often, also as the co-ordinator of the examination. S/He will also be called upon to examine research theses. Administration Administration comes with most walks of life, and the dental academic is not exempt from this in relation to courses to be arranged and committee work, notwithstanding the preparation of the often voluminous documentation by which courses and research are assessed. Writing It is essential that research findings are disseminated to the end users – dentists and patients, and, accordingly, the writing of research abstracts (for presentation at research meetings) and papers is central to the role of the dental academic. S/He may also choose to write review articles or books, usually on a subject on which s/he has particular expertise, as this is also a valuable method for dissemination of information. The peer review process, by which articles in peer-reviewed journals are assessed and checked for accuracy prior to publication, is central to the publication of good 'evidence', and as dental academics are often experts in their own fields of interest, they tend to carry the main burden of the peer review process. Some may also become the editor of a dental journal. 11 02_Chap01.qxd 18-06-2004 03:21pm Page 12 12 PREPARING FOR DENTAL PRACTICE 1 . 6 H O S P I TA L D E N T I S T R Y The ultimate aim of a dentist entering the hospital service will generally be to achieve the position of Consultant. Currently, the MFDS diploma awarded by the Royal Colleges in the UK is the entry qualification required for specialist training as a consultant in a dental speciality, of which 13 are recognised by the General Dental Council (GDC) (Table 1.3). Completion of specialist training allows the trainee the choice of achieving a hospital consultant position or entering specialist dental practice in the 'high street'. Both positions lead the specialist to treat a comparatively narrow range of albeit more complex conditions when compared with his/her GDP colleagues and the majority of cases treated by the specialist will be referred from GDPs or medical practitioners. The hospital specialist will be responsible for the teaching of the trainees and for administering the service in his/her department. The hospital consultant and specialist trainees should also undertake research, and due to their extensive patient throughput, this may take the form of assessments of treatment provided. Those dentists who are trained to specialist level may make the choice between hospital or 'high street' by virtue of the salary conditions, namely salaried in the hospital and fee per item in practice. 2 . 0 A P P LY I N G F O R A P O S I T I O N Prior to applying for a position, it is essential that the prospective candidate writes a curriculum vitae. 2 . 1 W R I T I N G A C U R R I C U L U M V I TA E ( C V ) Why write a CV? • A CV is often all that is requested when applying for a post • It shows a degree of organisational and computer skill • It gives the applicant an opportunity to tell others how good s/he is Table 1.3 Specialities for which the GDC maintains a specialist register Oral Medicine Orthodontics Restorative Dentistry Pediatric Dentistry Dental Public Health Oral Microbiology Oral Pathology Oral Surgery Dental and Maxillofacial Radiology Prosthodontics Endodontics Periodontology Surgical Dentistry 02_Chap01.qxd 18-06-2004 03:21pm Page 13 THE FIRST JOB A CV should provide evidence of suitability for the post advertised as well as giving an overview of the applicant's life and interests. CV layouts may vary according to the post being applied for – for a research position, for example, the applicant may highlight that aspect of his/her career. For the purpose of this book, however, it will be assumed that the applicant is applying for his/her first position. Attractive presentation and absence of typographical errors are important. Ideally for a first position, the CV should be no more than 3 pages of A4 in length. Essential information to be included on a CV are: Personal details This section should include given name, surname, date of birth, marital status (number of children) and address. For the dental student, there may be value in stating both home and term-time addresses, with all telephone numbers, and e-mail address if the applicant picks up his/her e-mails regularly. Education and academic achievements This should include secondary schools and university education, listing grades at A-level and examinations passed as an undergraduate. Prizes and distinctions This should list major prizes and distinctions at school and university or as part of general interest (such as Duke of Edinburgh's Award). Positions of responsibility These are often unpaid positions, which indicate the writer's enthusiasm and lack of apathy. Examples of positions which could be included are treasurer of student society, captain in sport, and, editorship of student review. Interests, hobbies, and activities This section may provide the considerate interviewer with a starting question and should be interests in which the candidate plays an active part. Genuine achievements should be included, such as grades at music, membership of drama groups and/or choirs. Personal statement The applicant should give a personal statement giving details of their aspirations and ideals, for example, stating how much s/he is looking forward 13 02_Chap01.qxd 18-06-2004 03:21pm Page 14 14 PREPARING FOR DENTAL PRACTICE to working hard, to working in general dental practice, to achieving high quality, etc. Other details This section could include details of research elective projects completed, previous positions (for the person who has undertaken other work prior to becoming a dental student) or special clinical interests or clinical modules undertaken. Again, this may often provide an easy starting question for the interviewer. References Persons chosen to provide references should have recent knowledge of the applicant and be relevant for the position applied for. In this respect, therefore, for hospital posts, the referee should, ideally, be in a hospital position, while for a dental practice post, the referee could be a part-time lecturer/GDP and a senior member of the academic staff who has supervised the applicant in the clinic. The applicant should always ascertain whether a potential referee is happy to provide a reference before their name is included on the CV. A referee should decline the opportunity to provide a reference if: • they do not know the applicant sufficiently well, or, • if they are unable to write something constructive about the applicant. It is worth asking a potential referee for the best way of making urgent contact, for example at home or by mobile phone, as the competition for some positions may be intense and a quick phone conversation to the referee may provide the person who has advertised the position with the information that s/he needs, rather than waiting for the delivery of letters etc., thereby facilitating the early appointment of the applicant. 2 . 2 T H E L E T T E R O F A P P L I C AT I O N The covering letter, with the CV, will give the person who placed the advertisement a first impression of each applicant. While in the past it could be considered that a neatly handwritten letter was appropriate, a neat, computer-generated letter (and neatly written envelope) is now the norm. The letter should be addressed to the practice owner by name or hospital/university personnel manager. Your name should be printed under your signature. This letter should include the following: • The reason why you have applied for the advertised post • The features in the advertisement which attracted you to that particular post • How the post fits your overall career plan • When you are available for interview 02_Chap01.qxd 18-06-2004 03:21pm Page 15 THE FIRST JOB 2.3 THE FIRST INTERVIEW Dental students entering professional practice will normally have to undertake an interview with their potential employer. This may often take the form of an informal 'tour' of the practice and/or a more formal interview. The interview will normally be conducted by the practice owner, but, on occasions may be delegated to the practice manager, if one is employed. There are two sides to an interview: • first, the interviewer will wish to determine the suitability of the interviewee for the advertised position, and, • second, the interviewee will want to obtain the maximum amount of information about the practice and its modus operandi. Either way, it is incumbent on the interviewee to present his/herself to the best advantage, and to 'sell' (but not oversell) him/herself. The interviewee should be honest, but should strive to tailor his/her answers to give the best impression. However, the interviewee is always potentially in a difficult position, as it is the interviewer who is in control of the proceedings. The interviewer will wish to ascertain the suitability of the candidate for the position, and, for a VDP position, to determine whether the candidate and the practice owner and his/her team will be able to happily work together for a period of a year (or more if all goes well and the VDP is offered an opportunity to continue as an associate). The practice owner will also seek to determine the candidate's communication skills and his/her ability to work with others. The interviewer may also seek to determine the candidate's clinical knowledge by asking for answers to a variety of clinical questions. Answers should be 'to the point' and prior experience at dental school recounted in a positive manner. However, the candidate's success or failure will be largely due to how well they talk and present themselves at interview. Nevertheless, the interviewee should consider him/herself as an equal, although the candidate will be less experienced. For the interviewee, advance preparation is important. The interviewee should ask the practice owner to send the practice's patient information leaflet, which should contain information which is relevant to the interview. There is merit in taking a look at the outside of the practice prior to the interview, to gain information about the practice location, if the candidate does not already know the area. Additionally, this will mean that the interviewee is less likely to get lost when attending for the interview and s/he will know how long the journey to the practice will take. A look at the Dentists Register will reveal the year and place of graduation of the practice owner/interviewer and will thereby give the interviewee an estimate of the interviewer's age. The candidate should write a list of the questions to which s/he wants answers, and bring this to the interview. These could include: • Will the candidate be taking over a full list of patients from the previous dentist, and, if not, how many new patients attend the practice per week? 15 02_Chap01.qxd 18-06-2004 03:21pm Page 16 16 PREPARING FOR DENTAL PRACTICE (There would appear to be little point in taking a position in a practice which has insufficient patients: there can be few experiences less rewarding than sitting in a dental practice with nothing to do but read the newspaper!) • Can I have a look at the present dentists' appointment books? • What are the practice opening hours? • What are the arrangements for treatment of emergencies outside normal working hours, and how often will the candidate, if successful, be on call for these? • What proportion of patients return regularly for recall, what is, in general, the attitude and oral health of the practice's patients? • Is there freedom to choose materials and laboratory? • Who is responsible for bad debts? • What is the general practice policy for acceptance of NHS patients? • Is the practice owner a member of organisations such as the British Dental Association or the Faculty of General Dental Practitioners? • How much CPD does the practice owner undertake and what are his/her special interests? • Is the candidate's surgery fully equipped, with light curing unit, emergency oxygen and emergency kit? For candidates attending for associate or assistant positions, the candidate should additionally enquire about the financial arrangements pertaining to the position. For a VDP position, the candidate should additionally enquire about the number of patients that s/he will be expected to treat each day, what subjects will be covered in the tutorials, and whether the practice has had a trainee previously. Additionally, and importantly, the interviewee should seek to speak with the dentist who is leaving the practice, in an effort to determine his/her reasons for leaving and to ascertain how (un)happy s/he has been while working at the practice. There would also appear to be value in finding out details of staff turnover by speaking to members of the staff: a high rate of staff turnover could be considered to indicate a less-than-ideal working environment. Interviews, from the viewpoint of the interviewer, are discussed in Chapter 3 Section 1.5. page 102. 2.4 THE FIRST IMPRESSION The candidate should be neatly dressed, clean cut and conservatively dressed. Ideally, both men and women should wear a suit. Taking care over appearance not only shows respect, but also will demonstrate to the interviewer that the candidate considers the interview and the position important. If perfume or aftershave is worn, this should not be applied in excess. Fingernails should be 02_Chap01.qxd 18-06-2004 03:21pm Page 17 THE FIRST JOB clean. On meeting the practice owner, the candidate should give a firm handshake, make (and then maintain) eye contact and smile. Further reading The British Dental Association has produced a wide range of Advice Sheets (Table 1.4) and Patient Leaflets. Those entitled, 'Getting a job', and 'Which way now?' and 'A guide to careers in dentistry' are especially valuable to final year dental students applying for their first position. 3.0 CHOOSING THE 'RIGHT' PRACTICE Dentists may often spend as many hours in their dental practice as they may spend with their family or on recreation (fig. 1.2). Time spent on choosing the Table 1.4 The British Dental Association produce a wide variety of Advice Sheets which are free to members. Examples, which may be relevant to dental students or recent graduates, are: Buying and selling a practice Health and safety law for dental practice Marketing in dentistry Associate agreements Employing an assistant in dental practice Corporate dental practice Radiation in dentistry Infection control in dentistry Computers in dental practice Setting up in practice Ethics in dentistry Data protection Prescribing in dental practice Collecting money from patients Introduction to taxation Fee setting in private dental practice Staff recruitment Working abroad Vocational training in dental practice A guide to General Dental Services Regulations Religious and cultural diversity – helping to improve awareness in dentistry CPD, clinical audit and peer review Help with overseas electives 17 02_Chap01.qxd 18-06-2004 03:21pm Page 18 18 PREPARING FOR DENTAL PRACTICE 46 working weeks per year 5 working days per week 8 working hours per day = 1840 working hours per year = 32% of WAKING hours! Figure 1.2 practice best suited to an individual's aspirations, talents and interests is therefore time well spent. It is always tempting to accept the first job offer, but there are strong indications for the new graduate or prospective associate to evaluate the character and philosophy of the practice in which a position is vacant. Questions asked at interview or at an informal 'look' around the practice (see below) may be invaluable in preventing misunderstandings later. For a vocational dental practitioner, associate or assistant, it should be ascertained that the patient base is assured. However, above all, both parties should try to ascertain whether they will be able to co-habit within the same premises for whatever the period of time. There is considerable merit, therefore, during the final undergraduate year, to have visited a number of practices, so that experience is built up in assessing the pros and cons of the practices visited prior to a first job or prior to vocational training. The character of any given practice is a function of a variety of factors, some of which are interdependent. Among these are: • Location • Social class of patients • The practice philosophy • The practice staff • The practice décor • The practice equipment • Whether a dentist lives on the practice premises • Number of dentists • Emphasis on postgraduate achievements and continuing professional development • The practice organisation 3 . 1 P R A C T I C E L O C AT I O N City centre location The patient base of a city centre dental practice is likely to be different from that of a practice in the town or city suburbs or in rural locations. The city centre practice will generally attract patients who work in the city, and is 02_Chap01.qxd 18-06-2004 03:21pm Page 19 THE FIRST JOB therefore unlikely to have a significant proportion of children and adolescents. Many specialist practices are located in the city centre, as they are likely to attract patients from a wider catchment area than the typical general dental practice and will therefore require a central location. There will often be a high concentration of practices in a small area. Referral to a specialist practice, dental school or hospital from a city centre practice is likely to be simpler from a logistical point of view than from a practice in a more remote situation. It is also likely that the city centre practice will be accessible to the dental laboratory, with the advantages that the dentist can readily discuss mounted study casts etc., or refer patients to the laboratory for shade taking should the need arise. Other advantages of the city centre practice may be the close proximity to theatres and places of entertainment, but disadvantages may include problems with parking or its high expense. Furthermore, as rental or purchase costs will be higher in the city centre than in the suburbs, the practice will often not be at ground floor level and will therefore not be likely to attract 'passing' patients. For the practitioner who enjoys treating paediatric patients and whole families, therefore, the city centre practice is unlikely to be suitable. Suburban location The suburban practice is more likely to attract families of patients, with the typical scenario being mother and children attending for routine check-up appointments in a 'block' booking. A dentist who not only enjoys treating children but enjoys carrying out a wide range of treatments for adults and children should therefore investigate practices in a suburban location. Referral for specialist care is also likely to be straightforward from a suburban practice. If the practice is located on a main road or on a bus route, potential patients passing by the practice may be attracted to it – 'passing' patients who could be a source of new patients if the practice is on the ground floor, or otherwise readily visible by those passing. The comments above regarding liaison with the dental laboratory also apply to the suburban practice. Rural location The practice in a rural location is likely to attract patients of all ages and walks of life, given that they are likely to choose the practice based on accessibility rather than other factors. The treatments in such a practice are likely to be more varied than in other types of practice, especially if referral for specialist care is difficult logistically. It may therefore be desirable that the practitioner in a rural practice undertakes additional training in, for example, 19 02_Chap01.qxd 18-06-2004 03:21pm Page 20 20 PREPARING FOR DENTAL PRACTICE removal of impacted third molars, or orthodontics. The latter is possibly of the greatest relevance, given the need for frequent visits, often spread over a period of a year or more. The dentist in a rural practice is likely to become a well-known local figure in the community in which s/he works. This may hold advantages, but, on the other hand, may mean that their every action is scrutinised! Disadvantages may include remoteness from the laboratory, reluctance of patients to accept referral to a remote surgery or hospital and difficulties for the staff in travelling to centres of postgraduate education. Working in socially deprived or affluent areas The 1998 UK Adult Dental Health Survey, as with its predecessors, has illustrated differences in attitudes to dental treatment and attendance between different social groups. Patients from a background where the head of the household is of social class IV or V are less likely to attend a dentist regularly, may be less appreciative of the benefits of maintaining dental health and may be inclined to attend only when in pain than those from households where the head is in social groups I, II or III (higher socio-economic status groups), (Kelly et al. 2000). The practice in an area where the predominant social groups are IV or V (lower socio-economic status groups) may therefore have a higher incidence of patients failing to attend for appointments. Conversely, the satisfaction which the operator may gain when s/he has successfully improved the oral health of a previous non-attender may be great. Higher socio-economic status (SES) group patients may attend on a more regular basis, but may also have higher expectations from treatment, which may be unjustified. Higher SES patients have a greater oral health awareness, but there is no guarantee that their oral health behaviours (toothbrushing) will be better than those from lower SES groups. 3.2 THE PRACTICE PHILOSOPHY Patient expectations of dental treatment have increased over recent decades, and it may be considered that the majority of patients, today, would prefer to retain, rather than lose teeth. It is difficult to understand how a dentist with an extraction, rather than restorative and preventive philosophy, can be successful in practice at the present time. However, while this is an extreme example, the practice philosophy could embrace a reluctance to try new techniques, purchase new equipment or become fully computerised. Good clinical practice demands that dentists and other healthcare professionals stay abreast of current thinking and to question the 'evidence' that is presented in the literature and advertising. The ideal practice philosophy should be forward-looking and therefore encourage learning, audit and research. 02_Chap01.qxd 18-06-2004 03:21pm Page 21 THE FIRST JOB Patients are increasingly discerning and it should be remembered that dentists are, to some extent, in competition with each other. Patients will therefore eventually discover the practice philosophy. The practice providing contemporary restorative and preventive treatments of high quality at a reasonable cost will ultimately become more successful than the practice which does not. The age of the practice owner is not necessarily a factor which influences the practice philosophy, given that the older practitioner can add experience to the 'evidence' for success. For the student or dentist assessing the philosophy of the practice that they are considering joining, a few well-chosen questions may help, for example: Q: Do you fit many resin-retained bridges here? A: No. We tried those some years ago but they don't work, do they? (Indicative of questionable practice philosophy) Q: Do you fit many resin-retained bridges here? A: We fit them when there is a strong clinical indication, but our practice audit has shown that the occlusion is a big factor in the success of these restorations. We give a five-year unconditional guarantee when there is an edge-to-edge occlusion or minimal overbite. We like to provide minimally invasive treatments where possible. (Indicative of good practice philosophy) 3 . 3 T H E P R A C T I C E S TA F F Nurses and receptionists The dentist not only provides treatment but also brings management skills to the practice: s/he will be judged by the painless-ness of injections, by the appearance of restorations and dentures, by the lack of pain or problems post-treatment and by 'chairside manner'. However, it is arguably the remainder of the dental team who give the practice much of its image. (See The Dental Team Chapter 3, Section 1.0, p 94.) All staff should be neatly and tidily dressed, ideally in uniforms. The reception staff should have an air of quiet efficiency. Too much unnecessary conversation shows that they are not as busy as they should be, or answering the telephone as rapidly as they should. All staff should be helpful: their attention should be centred on the patient. Telephones should be answered quickly. In the surgery, the nursing staff should be considerate to patients, the majority of whom are probably not where they want to be when they visit a dental surgery! They should also be efficient and quiet (it is easy to make loud noises which may startle patients when transferring instruments from one site to another!) and know where the various instruments, devices and materials are kept. 21 02_Chap01.qxd 18-06-2004 03:21pm Page 22 22 PREPARING FOR DENTAL PRACTICE Number of dentists A practice with more than one dentist will, by the nature of the situation, have more than one set of ideas about any given topic. In most circumstances, that will be beneficial. The greater number of dentists in the practice, the less frequent will be the on-call emergency times and the less likely that an inexperienced dentist will be left in the practice alone to cope with problems – clinical and administrative – that arise. When visiting a practice the staff morale may be judged by asking the number of years that staff members have been employed at the practice. A high turnover of staff is generally an indication of poor staff morale, poor pay or conditions and a less-than-ideal working environment. It is worth noting that unhappy staff perform less well and more grudgingly than happy, contented and valued staff. Questions for the potential VDP or associate to ask staff in a practice Q; How long have you worked here? A: Three months, and I'll be glad to get away (Indicative of low staff morale) Q; How long have you worked here? A: I've been here for three years and I'm the shortest serving staff member. (Indicative of good staff morale) Another indicator of the practice staff and image: Phone the practice as though you were a new patient: Was the phone answered promptly and courteously? Would you like to be attending that practice yourself, if you were a patient rather than a dentist? 3.4 THE PRACTICE DÉCOR Decorative tastes and styles are personal and it is therefore impossible to please everyone. However, the dental practice is a workplace and as such the décor should be functional. The waiting room should be decorated in a relaxing style, and adequate numbers of up-to-date magazines should be available, as too should tea or coffee. Informative dental literature should also be available, possibly with explanatory videos etc. It should be comfortable, but not overly so because patients will not normally expect to be kept waiting in the waiting area for excessive periods of time. Any patient kept waiting in the waiting area should expect an explanation from the reception staff. An overcrowded waiting area is indicative of either a practice whose number of surgeries has grown without a corresponding increase in the size of the waiting area, or of dentists who are not running to schedule. Neither are to be commended. 02_Chap01.qxd 18-06-2004 03:21pm Page 23 THE FIRST JOB Above all, all areas of the practice should be clean and tidy. Patients will feel that a dirty practice is likely to also be less than fastidious about matters of instrument sterility. Untidiness indicates a lack of organisation, again, not something which enhances patient faith in the procedures of the practice. 3.5 THE PRACTICE EQUIPMENT New surgery equipment is such a high capital expense that it is something which the average dentist, in a practising career of 40 years, will only purchase three or four times. It is therefore unreasonable to expect that surgery equipment should be new. Moreover, it is likely that when a practice owner purchases new equipment it may be for his/her own surgery, with the older equipment being transferred to the assistant's or associate's surgery. However, it is reasonable to expect that the equipment will be in good decorative and working order, that sufficient handpieces are available (likely to be four or five, depending on patient throughput) and that all other surgery equipment, such as the light curing unit, is in the surgery rather than being shared with another surgery in the practice. A not unreasonable question to ask is: Q: I particularly like brand MM bonding agent. Will the practice purchase it for me? A: No we only use XX because it's cheapest. (indicative of a penny pinching attitude) A: Yes. We will be delighted to learn about the new bonding agents that you were taught about at dental school. (indicative of a positive attitude) 3.6 WHETHER A DENTIST LIVES ON THE PRACTICE PREMISES The practice owner living on the premises is not an unusual situation in the UK. It presents advantages and disadvantages to the practice owner. For the owner, advantages include no travel to work and ease of access to home and family during the working day. Disadvantages include the lack of 'windingdown' time between workplace and home and the fact that patients may perceive the dentist as being always available. Depending on how separate the practice is from the house, the new associate VDP or assistant may have particular problems in changing the practice environment. With the wrong personalities, it may seem like entering a family rather than a practice. 23 02_Chap01.qxd 18-06-2004 03:21pm Page 24 24 PREPARING FOR DENTAL PRACTICE 3 . 7 E M P H A S I S O N P O S TG R A D U AT E A C H I E V E M E N T S AND CONTINUING PROFESSIONAL DEVELOPMENT While the failure to achieve postgraduate qualification is not necessarily indicative of a poor practice, or a working environment in which professional development will be difficult, the achievement of one or more postgraduate qualifications by the dentists in a practice is a certain endorsement of the desirability of continuing postgraduate development. Such a practice is likely to encourage their members of staff to take time off for postgraduate courses. Attendance at meetings and courses is an essential aspect of a professional person's life and development, notwithstanding the fact that patients will expect their dentists to be abreast of latest developments. Furthermore, the person who has achieved a dental degree at one time generally requires the mental stimulation that postgraduate study may bring. The practice which actively encourages such study, and which provides a good library of peerreviewed journals is to be sought after. The achievement of additional qualifications should not be confined to the dentally qualified members of the team. It is just as important for the nursing staff, practice manager and hygienists to enrol for continuing education as part of their continuing development. 3 . 8 T H E P R A C T I C E O R G A N I S AT I O N The smooth everyday running of a practice is central to the enjoyment of work by all in the practice. Enjoyment of work by the staff will make for a happy practice and this, in turn, will be noticed by patients. There are many facets to practice organisation and the reader should consult a text on practice management for a full appraisal of the subject. However, organisation is dependent on all staff in the practice being aware of their responsibilities and of the policy of the practice team on matters relating to everyday matters or emergencies. Some of these responsibilities and policies are best placed in written form. Examples of practice policy which could be in written form include matters as varied as: • policy on infection control, • on needlestick injuries, • on late cancellations, • on postgraduate education by all members of the team, • on non- or late-payment of fees, • on the patient who attends late for an appointment, • on whether certain items of treatment are available within the NHS regulations or whether certain patient groups will be treated within the NHS, • whose responsibility it is to check the currency of the emergency drugs, or, 02_Chap01.qxd 18-06-2004 03:21pm Page 25 THE FIRST JOB • the responsibilities of the various members of the team in the event of a patient collapse. Committing such policies and responsibilities to paper makes it simple for joining members of staff to be made aware of the hows and wherefores of the practice organisation. In all matters of practice organisation it is essential that written protocols are available, for three essential functions: • first, writing a protocol forces the writer to gather his/her thoughts together • second, the written protocol can be discussed with other members of the dental team and the agreed protocol amended in the light of new information/techniques • third, the and may be used for training existing and new members of staff Staff – or team – meetings are a valuable forum for interaction between all in the practice and it is at these meetings (see The Dental Team, Chapter 3, Section 1.7, p108) where policies may be discussed and formulated, or changed. Such team meetings should be sacrosanct in the appointment book, and may best be held outwith the practice building so that discussions may be made without the potential for interruption. 3 . 9 T H E PAT I E N T B A S E It is essential that the new graduate or potential associate seeking a position knows whether there is a patient base already registered with the practice which is sufficient to keep them employed, and in the case of an associate, with the potential to achieve the income which is desired. While the new dentist in a practice will ultimately hope to attract new patients to the practice, s/he needs a list of patients to treat on week one. The person hoping to work in a practice should therefore be given full access to appointment books, to check on practice busyness. Enquiries should be made on the number of new patients attending the practice per month, and a well-organised practice should be able to provide such figures. It should also be noted that an associate will generally treat more patients than a vocational dental practitioner, so a VDP's list will not be as large as that for an associate. At the outset, the new dentist in a practice should be aware whether s/he is taking over a 'list' from a previous dentist or whether s/he will be expected to build up a new list of patients. The latter situation is likely to arise when a dentist starts up a new practice, but should not what a VDP or associate would expect. While the arrangements for a VDP are relatively fixed, for the potential associate there are a number of questions to be asked. Among these are: • Financial arrangements – % of gross paid to the practice owner • Assignment of fees – to practice owner or associate • Who pays bad debts? • Holiday entitlement 25 02_Chap01.qxd 18-06-2004 03:21pm Page 26 26 PREPARING FOR DENTAL PRACTICE Questions to be asked by both VDP and associate are: • Is there a choice of laboratories or is the practice tied to one laboratory? • Is there freedom to order materials that are preferred? 4 . 0 E A S E O F A C C E S S TO D E N TA L T R E AT M E N T Among the factors upon which access to dental treatment depends are: • Physical access • Psychological access • Financial access 4.1 PHYSICAL ACCESS The issues of physical access to dental treatment involve: • the ability of the patient to travel to the practice: this in turn, is dependent on whether the practice is conveniently located to the patient's home or place of work, whether the patient has his/her own transport, or, if not, whether they can justify the cost of a taxi or other public transport • the accessibility of the practice itself: whether ramps are provided for wheelchair users or the infirm, whether a lift is available if the surgery is not on the ground floor, and whether car parking is easily available. In this regard, an information sheet should be available, not only for fit and able patients, but also for those with special needs. Written directions to the practice from a variety of directions, or a map, should be included. 4.2 PSYCHOLOGICAL ACCESSIBILITY In 'Maintaining Standards: Guidance to Dentists on Professional and Personal Conduct' (GDC 1997) the General Dental Council stated that: 'Dentists have a duty to provide and patients have a right to expect adequate and appropriate pain and anxiety control' and that included 'Pharmacological methods of pain and anxiety control, local anaesthesia and conscious sedation techniques' The need to provide oral health care which affords anxious patients the opportunity to access dental treatment in the usual way is recognised as a goal of primary dental care. The requirement for dental practitioners to increase psychological accessibility is associated with the formation and maintenance of the treatment alliance (see Chapter 2, Section 1.3: the dentist–patient relationship). In order for dentists to achieve this accessibility 02_Chap01.qxd 18-06-2004 03:21pm Page 27 THE FIRST JOB and treatment goal there are a number of behavioural management and pharmacological techniques which may be employed. It must be emphasised that the role of behavioural management and pharmacological methods of anxiety control should be directly related to the quality and quantity of the dental anxiety experienced by the patient. The means of assessing dental anxiety and the choice of behavioural management and/or pharmacological technique used is described in greater detail in Chapter 2. Behavioural management techniques to increase psychological accessibility: • Iatrosedation is, simply, dentists providing the environment to allow for effective communication between the patient and themselves. Iatrosedation is the first part of the psychological management of the dentally anxious patient. A non-clinical setting allows the dentist to establish rapport and for the patient to express their fears and worries. • Tell-show-do is a simple means of preparing children and anxious adults for dental care. Tell-show-do reduces anticipatory anxiety by providing patients with details of their treatment. The dentist tells the patient what is to be done, shows the patient what will be done and then does it. Communication is an important aspect of this behavioural technique with the dentist using language the patient can understand. In terms of evidence-based treatment tell-show-do have been shown to reduce anticipatory anxiety in children attending for DGA extractions (Carson and Freeman 1998). • Desensitising hierarchy is a process in which the patient and dentist jointly negotiate a treatment plan based on the patient's least feared item of dental treatment through to their most feared. Treatment starts with the least feared treatment (e.g. prophylaxis) and works through those items of treatment which are slightly feared (e.g. infiltration anaesthetic and filling) to the most feared (e.g. an extraction of a lower molar). During the treatment the patient's confidence increases as their anxiety is reduced. As before communication is central to this form of behavioural management as it allows the dentist and patient to work together towards a common treatment goal. In essence the patient's dental anxiety is contained and reduced prior to progress to the next treatment in the hierarchy. • Hypnosis, biofeedback and relaxation are a family of behavioural techniques which are used to reduce anxiety by inducing muscle relaxation: i. Hypnosis induces an altered state of consciousness which is characterised by muscle relaxation and suggestion. Hypnosis has been used extensively in dentistry to reduce anxiety and induce states of relaxation. Disadvantages however exist as patients who are extremely anxious find it harder to relax and enter the hypnotic state and the technique is time intensive with new patients. 27 02_Chap01.qxd 18-06-2004 03:21pm Page 28 28 PREPARING FOR DENTAL PRACTICE ii. iii. The British Society for Medical and Dental Hypnosis (BSMDH) is a national organisation of doctors, dentists and other health professionals within the NHS. The BSMDH offers recognised and accredited training for those health professionals interested in hypnosis and its use in the treatment of stress/anxiety. For those interested in this therapeutic technique, more information may be sought from the BSMDH website (http://www.bsmdh.org). Relaxation or applied relaxation (Willumsen et al. 2001) is associated with biofeedback and hypnosis. The principle behind relaxation is that physical relaxation inhibits anxiety. The dentally anxious patient will be instructed to tense and then relax muscles throughout the entire body which will lead to relaxation of the body as a whole. Relaxation has been shown to be an excellent means of helping patients reduce their dental anxiety. It is also a useful adjunct to the treatment of patients with severe gagging reflex. Biofeedback involves the training of patients to control their physiological responses (e.g. increased heart rate) to anxiety-provoking situations. The technique is based on the premise that through monitoring the patient can voluntarily control the physiological manifestations of anxiety and by doing so can reduce the emotional dimension of anxiety. Pharmacological techniques to increase psychological accessibility • Oral sedation: Benzodiazepines are the most commonly used group of drugs for pre-medication. The disadvantages of oral sedation with diazepam include the difficulty in monitoring serum levels, the onset of action for oral diazepam is 45–90 minutes with a duration of action of 2–4 hours. Other benzodiazepines include midazolam. The advantages of midazolam are that it has a shorter half-life, rapid onset and duration of action. Beta-blockers have been used with little success in reducing dental anxiety. • Inhalation sedation or relative analgesia (RA) is the combination of nitrous oxide with oxygen. The 'hypnotic effect' of RA is enhanced by the dentist's communication skills. RA is recognised as being the most controllable and safest technique of conscious sedation currently available to the dental profession. The main advantages of RA are well known: these include the ease of administration, titratability, reversibility, rapid induction and rapid recovery. RA has been shown to be effective and successful in reducing anxieties, acceptable to child patients and cost-effective. General dental practitioners regard RA as an acceptable means of treating anxious children but have called for continuing education to increase their clinical competency in the administration of inhalation sedation (Freeman and Carson 2003). • Intravenous sedation: Many agents are used for intravenous sedation but the most common are midazolam and propofol. The intravenous 02_Chap01.qxd 18-06-2004 03:21pm Page 29 THE FIRST JOB sedation can only occur when a separate sedationist is present who can devote his/her attention and time to the level of consciousness of the patient. 4.3 FINANCIAL ACCESS The ability of a patient to pay for their treatment is a fundamental aspect of access to treatment. To some, the cost of treatment may be a barrier to care. Dentists are in the top 5% of wage earners in the community, and it therefore follows that dental treatment may seem expensive to the remaining 95%. In the UK, treatment is funded in a variety of ways. NHS treatment A considerable proportion of the population of the UK opt to receive their dental treatment within the NHS regulations. At the time of writing patients pay up to 90% of their treatment costs up to a maximum amount. Patients may be exempt from these charges if their salary falls below a certain level. Expectant mothers and those who have had a baby within the previous year are also exempt. Arguably it is the group whose salary falls just above the exemption level who will find funding for NHS – or, indeed, any form of dental treatment most difficult. Private treatment This may take one of two forms: (i) the patient pays the fee for each item of treatment (ii) the patient enters a private capitation scheme such as Denplan (Denplan Ltd. Winchester, UK) to whom they pay a fixed amount per month. The scheme, in turn, provides the majority of their treatment at no additional cost. The amount which the patient pays is set following an assessment of their potential treatment needs, which is assessed from their previous incidence of treatment. A considerable proportion of the population of the UK, variously assessed at between 25% and 50%, do not attend for regular dental examinations. Some patients choose to attend only for emergency treatments. Others do not attend because of anxiety about dental treatment. Others do not attend because they feel that treatment is not affordable. Others prefer to spend their disposable income on other things, perceiving dental treatment (or oral health) to be of limited value. In the UK, in 2002, circa 25% of treatment was carried out privately by the ways described above (Laing and Buisson 2003), with the UK public being estimated to have paid, for the first time, more funds for private treatment 29 02_Chap01.qxd 18-06-2004 03:21pm Page 30 30 PREPARING FOR DENTAL PRACTICE (£1.9 billion) than for NHS treatment (£1.8 billion). It may be considered that this figure is increasing annually. NHS fees are negotiated on a national basis between representatives of the dental profession and government, and, accordingly, in areas of the UK in which dental practice premises, staff wages and running expenses are high, many dentists have ceased to provide dental treatment under the NHS. In these areas, those who are low wage earners may find difficulty in obtaining dental treatment which they feel is affordable. A number of initiatives have been commenced by the government to improve access to NHS dentistry. Among these are the Personal Dental Services pilots (see Section 1.4). Financial access: The dentist's viewpoint (see section on dentist–patient relationship) From the dentist's viewpoint, fees per item of treatment are generally calculated on the basis of the time required to complete the treatment at a given hourly rate, that rate being decided by the dentist. Within the NHS, the hourly rate is fixed following negotiations between the profession and government. For private treatment, the hourly rate comprises (see also section on finance): • The dentist's time charge for the treatment, plus • The overheads in running the practice on a daily basis. The highest proportion of the overhead costs is generally the staff wage cost, followed by charges associated with the premises (bank loan for purchase of premises and equipment, or, capital cost or rental, local charges, electricity, materials, stationery etc.), dentist and staff pensions. The situation may therefore arise in which the dentist feels that the fees awarded by the NHS do not cover his/her hourly rate. In such a situation, for the practice to remain viable financially, there are only two courses of action: • Cease treatments under the NHS • Carry out the treatment in a shorter time. In the latter situation, it does not always follow that treatment carried out faster is less good than treatment carried out slowly. Some dentists are capable of working faster than others. However, it is generally when a dentist feels that s/he is not carrying out the treatment to his/her best ability because of insufficient time that can be awarded because the dentist's hourly rate is greater than that awarded by the NHS, or because laboratory fees are limited, or that s/he is not able to offer the most appropriate treatment, that the dentist opts to no longer treat patients under the NHS conditions. It will be apparent to readers that this situation is most likely to be reached by dentists practising in the most expensive areas of the UK where practice running costs are likely 02_Chap01.qxd 18-06-2004 03:21pm Page 31 THE FIRST JOB to be highest. Hence, a proportion of practices in the UK, perhaps a quarter (Laing and Buisson 2003) have 'converted' wholly to private treatment or partly NHS and partly private. This 'conversion' may be a difficult decision for the dentist, who may be giving up the financial security of working for the NHS, to enter the different demands that providing private treatment brings and the uncertainty of how many patients will 'convert' from NHS to private. However, the dentist should never judge a patient's ability to pay for treatment. Patients from lower SES groups may value their dental care sufficiently to pay private fees for it; conversely, higher SES group patients may have the attitude that they deserve NHS treatment because they pay substantial monies in taxes. Additionally they may be unable to afford private care because they have children at private school, a high mortgage and the 'need to keep up with the Jones'. Alternatively, they simply may not value their oral health. 5 . 0 E M E R G E N C I E S I N T H E D E N TA L S U R G E R Y: EQUIPMENT AND DRUGS Prevention of emergencies Medical emergencies are best prevented. All members of the dental team should be trained to be watchful for signs of patient collapse (for example, sweating and skin pallor) in all areas of the practice, including non-clinical areas. Additionally, emergencies may be prevented by careful assessment of the patient prior to and during treatment. All members of the team should know how to clear and maintain the airway and be competent in carrying out cardiopulmonary resuscitation (CPR). Records of initial training and update courses (annual or more frequent refresher courses are appropriate) should be kept. Additionally, dentists should be able to perform venepuncture. Medically compromised patients should be identified by ascertaining their medical history. New patients should complete a comprehensive written medical history and this should be verified verbally, with the medical history updated at each subsequent course of treatment. All dental practices should have clear protocols for the treatment of medical emergencies which may arise, for use in staff training. Common causes of collapse in the dental surgery Fainting Fainting may be caused by anxiety/fear, pain, fatigue, fasting and high temperature and humidity. The patient will feel weak or nauseated, skin pallor will be evident and the skin will be cold and moist. The pulse will be slow initially, then fast and full, and the patient may lose consciousness. 31 02_Chap01.qxd 18-06-2004 03:21pm Page 32 32 PREPARING FOR DENTAL PRACTICE Treatment is by lowering the head and loosening tight clothing. Recovery is normally rapid; if not, other causes of collapse should be considered. A glucose drink or tablet may be given if the patient has not eaten, and oxygen administered to medically compromised patients. Angina Angina is caused by a reduction in oxygen to the heart through narrowing of the coronary arteries, or high blood pressure which leads to increased oxygen demand and may increase the size of the heart. The patient will experience a severe 'crushing' pain which may radiate down the left arm: it will be brought on by exertion, anxiety or during digestion of a large meal and will be relieved by rest. Treatment is by stopping activity or treatment, administering glyceryl trinitrite tablets or spray sublingually, and providing oxygen. If the symptoms do not subside in 10–15 minutes, the patient diagnosis should be revised to coronary thrombosis. Coronary thrombosis/myocardial infarct A myocardial infarct occurs when a branch of the coronary artery is blocked by a clot causing death of the muscles supplied by that artery. The patient will experience pain in the chest, radiating down the left arm, with the pain of much longer duration than angina. There will be signs of shock, such as cold clammy skin and low blood pressure. These symptoms may occur in a patient with no previous cardiac history. Management is first by calling for help from the emergency services (with a view to obtaining admission to hospital), placing the patient in a comfortable position, administering oxygen at 2–4 litres per minute. In cases of cardiac arrest, CPR should be commenced. Epilepsy This is a convulsive disorder, with the attack being characterised by an aura, a tonic phase in which the patient loses consciousness, may stop breathing and become rigid. This is followed by a clonic phase in which convulsions occur. The patient may traumatise their tongue in either phase. Management is by stopping treatment, attempting to prevent the patient from harming him/ herself, and placing the patient in the recovery position after the clonic phase. Fits generally stop spontaneously. After the fit, the patient may feel drowsy and should be accompanied home. Prevention is by ensuring that patients take their medication as usual prior to treatment. Collapse of patient taking steroids Steroids are prescribed for a wide range of medical conditions and adrenal function may be depressed in patients taking steroids for one month or more. Symptoms include weakness, nausea and pallor, weak and rapid pulse and loss of consciousness. Management is by placing the patient flat, 02_Chap01.qxd 18-06-2004 03:21pm Page 33 THE FIRST JOB administering oxygen, summoning assistance and giving 100 mg Hydrocortisone sodium succinate IV and obtaining urgent transport to hospital. Prevention is typically by pre-operatively doubling the dosage of medication for patients taking less than 7.5 mg prednisolone per day who require surgery or extended treatment. It is advisable to liaise with the prescribing physician. Anaphylaxis This is a severe allergic reaction characterised by a sudden and catastrophic release of histamine. In the dental surgery, most common causes are penicillin or latex allergy. Symptoms include facial oedema, bronchospasm and difficulty in breathing/wheezing, severe shock, nausea and vomiting and progressive loss of consciousness. Management is by laying the patient flat, summoning urgent assistance, giving 0.5–1 ml 1:1000 adrenaline IM (smaller doses for younger patients), repeating this dose every 15 minutes, Hydrocortisone 100-200 mg IM slowly, 10–20 mg chlorpheniramine maleate (Piriton) 10 mg/1 ml slowly IV, administering oxygen and obtaining urgent transport to hospital. Asthma An acute asthmatic attack may be triggered by the stress of a visit to a dental surgery, infection or allergens. Symptoms include breathlessness, expiratory wheezing and a rapid pulse. Treatment is by reassurance and the administration of the anti-asthma drugs normally taken by the patient, such as a salbutamol nebulizer, which the patient should be asked to bring when attending the dental surgery. If the attack is severe, assistance should be requested and 200 mg hydrocortisone IV administered. Hypoglycaemia The insulin-dependent diabetic may develop hypoglycaemia by missing a meal while taking their normal dose of insulin. Emotional stress may also compound the problem. Symptoms include drowsiness, excitability and aggression, sweating and trembling and a full and rapid pulse. Management is by laying the patient flat, giving sugar orally if the patient is conscious and 1 mg Glucagon in 1 ml sterile water IM if the patient is unconscious. The unconscious patient should be transferred to hospital. Hyperventilation Hyperventilation may occur in cases of anxious or hysterical overbreathing. Symptoms include lightheadedness, agitation and paraesthesia. Management is by reassurance, and breathing into a bag. If the hyperventilation is severe and the patient does not respond to the measures outlined above, then it may be necessary to give 10 mg diazepam IV. 33 02_Chap01.qxd 18-06-2004 03:21pm Page 34 34 PREPARING FOR DENTAL PRACTICE Cerebral vascular accident (Stroke) This may occur with a cerebral thrombosis, haemorrhage or embolus. Symptoms include loss of consciousness, headache, deep and noisy breathing, incontinence and paralysis of one side of the body. Management in the dental surgery is by maintenance of the airway, administration of oxygen and transfer to hospital at the earliest opportunity. Inhaled or swallowed object Foreign bodies, such as teeth, crowns or root canal instruments, may be swallowed or inhaled. A patient may exhale the foreign body without stimulating the cough reflex. If it is suspected that a foreign body has been swallowed or inhaled, the patient should be transferred to hospital for a chest or abdominal X-ray. Further management depends upon whether the object is in the lungs or gut, and whether it is sharp or blunt. The Heimlich Manoeuvre may be performed if the patient is choking and unable to cough out the foreign body. From the above, it can be seen that a typical dental practice emergency drug cabinet may contain a wide variety of drugs (Table 1.6). A system Table 1.6 Typical emergency drugs which may be stored in a dental practice Drug Presentation Route of Indication administration Oxygen Cylinder, valve, tubing and mask 0.4 mg per dose spray 1 mg in 1 ml (1:1000) 100 mg in 2 ml sterile water Inhalation Glyceryl trinitrate Adrenaline Hydrocortisone sodium succinate Chlorpheniramine 10 mg in 1 ml maleate solution Glucagon 1 mg powder + 1 ml sterile water Glucose Drinks or tablets Salbutamol 0.1 mg per dose inhaler Sublingual IM IM IM IM (epipen) Oral Inhalation All emergencies except hyperventilation Angina Anaphylaxis Anaphylaxis advenal crisis Asthma Anaphylaxis Diabetic hypoglycaemia (patient unconscious) Diabetic hypoglycaemia Asthma (after Thornley A: course work submitted for MSc at University of Birmingham and British Dental Association Practice Quality System) 02_Chap01.qxd 18-06-2004 03:21pm Page 35 THE FIRST JOB should be in place which gives a staff member responsibility for checking that the drugs which are stored are within their use-by-date. 6.0 INFECTION CONTROL The application of a risk-free infection control regimen is central to the safe treatment of patients in dental practice. All dentists have a duty of care to their patients to ensure that adequate infection control procedures are followed. Members of the dental team have a duty to ensure that infection control procedures are followed routinely. The mouth carries a large number of potentially infective micro-organisms; saliva and blood are known vectors of infection. Most carriers of latent infection are unaware of their condition and it is important, therefore, that the same infection control routine is adopted for all patients. The British Dental Association produces a wide variety of Advice Sheets for dental practitioners, including one on practice infection control. The most recent version of this was published in 2003 and is reproduced in Sections 6.1 to 6.33 of this chapter, by kind permission of the British Dental Association. 6.1 INTRODUCTION Infection control in health care continues to be the subject of intensive research and debate. This advice sheet condenses current knowledge and recommendations in a practical form for the dental practitioner. Implementing safe and realistic infection control procedures requires the full compliance of the whole dental team. These procedures should be regularly monitored during clinical sessions and discussed at practice meetings. The individual practitioner must ensure that all members of the dental team understand and practise these procedures routinely. Every practice must have a written infection control policy, which is tailored to the routines of the individual practice and regularly updated. The policy should be kept readily available so that staff can refer to it when necessary. 6.2 ROUTINE PROCEDURES A thorough medical history should be obtained from all patients at the first visit and updated regularly. Medical history questionnaires alongside direct questioning and discussion between the dentist and the patient are recommended. Discussions should be conducted in an environment that permits 35 02_Chap01.qxd 18-06-2004 03:21pm Page 36 36 PREPARING FOR DENTAL PRACTICE the disclosure of sensitive personal information. The medical history information should be retained as part of the patient's dental records. The medical history and examination may not identify asymptomatic carriers of infectious disease and universal precautions must be adopted. This means that the same infection control procedures must be used for all patients. 6 . 3 PAT I E N T P E R C E P T I O N As a result of frequent media coverage, the public is now aware of the need for dentists to practise good infection control. Displaying an infection control statement may be appropriate in your practice to help allay patient anxiety and gain them confidence. It may encourage them to ask questions, so never be too busy to give an answer. Ensure that all the members of your practice staff are confident and competent to answer patients' queries or know whom to refer to when necessary. 6 . 4 A C C E P TA N C E O F PAT I E N T S Whilst a health professional has the right to accept or refuse to treat a patient, it is important that the dental profession accepts the responsibility of providing dental treatment to all members of the community. Dental clinicians have a general obligation to provide care to those in need and this should extend to infected patients who should be offered the same high standard of care available to any other patient. Those with Human Immuno-deficiency Viruses (HIV), who are otherwise well, and carriers of the hepatitis viruses may be treated routinely in a primary care setting (general dental practice, community dental service, for example). The evidence indicates that, in the absence of an inoculation injury, the risk of infection to a dental health care worker during the dental treatment of HIV-infected individuals is negligible. HIV-infected individuals need a high standard of dental care when they are asymptomatic to minimise dental problems. If they subsequently develop Acquired Immune Deficiency Syndrome (AIDS) it may be appropriate for them to be referred for specialist advice and care. It is unethical to refuse dental care to those patients with a potentially infectious disease on the grounds that it could expose the dental clinician to personal risk. It is also illogical as many undiagnosed carriers of infectious diseases pass undetected through practices and clinics every day. If patients are refused treatment because they are known carriers of an infectious disease, they may not report their conditions honestly or abandon seeking 02_Chap01.qxd 18-06-2004 03:21pm Page 37 THE FIRST JOB treatment; both results are unacceptable. Those who reveal that they are infected are providing privileged information. 6.5 CONFIDENTIALITY All information disclosed by a patient in the course of medical history taking, consultation and treatment is confidential. No part of the information obtained should ever be disclosed to any third party, including relatives, without the patient's permission. Dentists are responsible for the security of information given by patients, whether it is written on record cards or held on computer. All members of the dental team should be aware of the duty of strict confidentiality and seek to ensure it at all times. It is strongly recommended that practices have a confidentiality policy in place and that contracts of employment for dental staff include a statement on the need to maintain confidentiality. 6 . 6 T H E I N F E C T E D D E N TA L H E A LT H C A R E W O R K E R All health care workers have an overriding ethical and legal duty to protect the health and safety of their patients, and those who carry out exposureprone procedures should be immune to or non-infectious for hepatitis B (page 11). A dental clinician who believes he or she may be infected with a blood-borne virus or other infection has an ethical responsibility to obtain medical advice, including any necessary testing. If a clinician is found to be infected, further medical advice and counselling must be sought. Changes to clinical practice may be required and may include ceasing or restricting practice, the exclusion of exposure-prone procedures or other modifications. An infected clinician must not rely on his/her own assessment of the possible risks to their patients. Failure to obtain appropriate advice or act upon the advice given could lead to a charge of serious professional misconduct. Exposure-prone procedures are those invasive procedures where there is a risk that injury to the worker may result in exposure of the patient's open tissues to the blood of the worker. These include procedures where the worker's gloved hands may be in contact with sharp instruments, needle tips and sharp tissues (spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. A dentist who employs a dental nurse who is subsequently found to be infected with a blood-borne virus must undertake a risk assessment to determine whether there is a risk to patients and whether the dental nurse should be redeployed within the practice. The risk assessment must take into account 37 02_Chap01.qxd 18-06-2004 03:21pm Page 38 38 PREPARING FOR DENTAL PRACTICE the duties performed by the dental nurse and the likelihood that the infection could be transmitted to a patient or another member of staff. An infected dental nurse must not undertake exposure-prone procedures in order to remove, as far as is possible, the risk of transmitting infection. There may be employment issues that need to be considered and advice should be sought from the employment advisers at the BDA. The following recommendations for infection control procedures in routine dental practice are made in light of current knowledge and may be subject to revision, as further information becomes available. 6.7 TRAINING IN INFECTION CONTROL All dental staff must be aware of the procedures required to prevent the transmission of infection and should understand why these procedures are necessary. Regular monitoring of the procedures is essential and the infection control policy for the practice should be reviewed regularly and updated when necessary. All new staff must be appropriately trained in infection control procedures prior to working in the practice. Training should equip staff to understand • how infections are transmitted • the practice policy on decontamination and infection control • what personal protection is required and when to use it • what to do in the event of accidents or personal injury. 6.8 SURGERY DESIGN The layout of the surgery, which should be simple and uncluttered, is an important aspect of infection control. There should be two distinct areas: one for the operator and one for the dental nurse, each with a washbasin, which should have elbow- or foot-operated taps, and liquid soap dispensers. The operator's area would have access to the turbines, three-in-one syringe, slow handpiece, bracket table and operating light. The dental nurse's area would contain the suction lines, perhaps the three-in-one syringe, curing light, all the cabinetry containing dental materials and a designated area for clinical waste disposal and the decontamination of instruments. Clean and dirty areas within the surgery should be clearly defined. Where possible, instruments should be decontaminated away from the surgery in a room containing the autoclave(s), ultrasonic bath(s), instrument washer(s) and sinks and a separate hand wash basin. If instruments are cleaned manually before sterilisation, the sink must be of sufficient depth to enable instruments to be fully covered with water during cleaning to minimise the risk of splashing. 02_Chap01.qxd 18-06-2004 03:21pm Page 39 THE FIRST JOB 6 . 9 V E N T I L AT I O N • The surgery should be well ventilated; usually an open window will suffice but, in some cases, it might be appropriate to install an extraction fan or air conditioning • ventilation systems should exhaust to the outside of the building without risk to the public or re-circulation into any public building • the recommended fresh air supply rate of ventilation systems should not fall below 5–8 litres per second per occupant and should not create uncomfortable draughts • mechanical ventilation systems must be regularly cleaned, tested and maintained according to the manufacturer's recommendations to ensure they are free from anything that may contaminate the air • recycling air conditioning systems are not recommended. 6 . 10 F L O O R C O V E R I N G • The floor covering should be impervious and non-slip. Carpeting must be avoided • the floor covering should be seam-free; where seams are present, they should be sealed • the junctions between the floor and wall and the floor and cabinetry should cove or be sealed to prevent inaccessible areas where cleaning might be difficult. 6 . 11 WORK SURFACES • Work surfaces should be impervious and easy to clean and disinfect – check with manufacturers on suitable products for decontamination • work surface joins should be sealed to prevent the accumulation of contaminated matter and aid cleaning • all work surface junctions should be rounded or coved to aid cleaning. 6.12 CHOICE OF EQUIPMENT When selecting new equipment, you should think about – • what you want the equipment to do – will the equipment selected be fit for this purpose? Is there any evidence? Is it compatible with other equipment in the surgery? • how easy it will be to use and maintain – is it CE marked (to demonstrate compliance with Medical Devices Regulations)? 39 02_Chap01.qxd 18-06-2004 03:21pm Page 40 40 PREPARING FOR DENTAL PRACTICE • how easy it is to decontaminate - what are the manufacturer's recommendations? When selecting new hand instruments avoid difficult to clean serrated handles and check that hinges are easy to clean • can the material covering the dental chair and worksurfaces be cleaned and disinfected regularly without deterioration? Check with the manufacturer • selecting foot-controlled equipment whenever possible • training – is it required? Will the manufacturer provide it? 6 . 1 3 WAT E R S U P P L I E S All water lines and air lines should be fitted with anti-retraction valves to help prevent contamination of the li