Turf wars

The debate over scope of practice is becoming more detailed and more heated, with a new study backing the ADA’s position on the topic. But not everyone agrees. By Andy Kollmorgen

Dr Pauline Ford says that any blurring of the roles between OHT’s and dentists may lead to poor treatment outcomes.

Dr Pauline Ford says that any blurring of the roles between OHT’s and dentists may lead to poor treatment outcomes.

Oral health therapists are hardly new, but many will tell you there’s still a big disconnect between the services they provide and the ideas some dentists have about how they should fit in to the workforce. As president of the Australian Dental and Oral Health Therapists’ Association (ADOHTA) and a veteran oral health therapists (OHT), Julie Barker has been pushing for years to bring the perception of the profession into line with the roles that OHTs play.

Due to an underlying issue that’s also in her sights, it’s been an uphill struggle. Barker thinks it’s time to call off the turf war between old-school dentistry and the forward-looking concept of preventative dental therapy. Within the limits of what they’re trained and authorised to do, she would like to see OHTs recognised as independent practitioners in their own right. That wouldn’t mean tapping into the skill set—or the revenue stream—of full-fledged dental school graduates, says Barker. It would mean freeing up dentists to do what they do best. Fortunately for patients, that’s already happening, Barker says. Now she would like to see the fullness of the OHT role officially recognised.

“If we start focusing even more on treatment instead of prevention we’ll really be behind the eight ball. We can’t afford to lose prevention as a focus of the oral health therapy profession.” – Dr Pauline Ford, councillor for ADAQ and convenor of the ADAQ Oral Health Committee

A long-term sticking point for ADOHTA in the current Dental Board scope of practice document is the use of the word ‘supervision’ in describing the therapist/dentist relationship. At the very least, it implies that a proper dentist should be in the room when a therapist is working, presumably to be sure they don’t make mistakes or overstep their roles. In reality, says Barker, many therapists have been working without a dentist looking over their shoulder for years, often performing some of the same tasks dentists are trained to do. At many community health centres in Victoria, for instance, therapists see patients first and refer them to dentists as needed. According to Barker, it’s a model that’s been endorsed by a number of progressive-minded practitioners, including University of Sydney Associate Professor and practice-management trailblazer Hans Zoellner.

Dr Karin Alexander of the ADA says the whole training of Oral Health Therapists is predicated on there being a supervising dentist.

Dr Karin Alexander of the ADA says the whole training of Oral Health Therapists is predicated on there being a supervising dentist.

There’s the reality of how many OHTs actually work; then there’s the idea of how they’re supposed to work under the current scope of practice. Oral health professionals who require supervision can’t be considered independent practitioners, according to the wording in the document. For dentists who haven’t worked a lot with OHTs and are mindful of staying within the guidelines, the supervision clause can be a deterrent to hiring a therapist, Barker says, since the dentist would assume they’d have to be close at hand whenever the therapists worked on a patient. That can look like a time-consuming and costly prospect.

“We have been trying to get the word removed for a long time,” Barker told Bite. “It really has led to a restriction of practice, which we see as counteractive to the larger aims of dentistry. We exercise autonomous decision-making within our scope of practice all the time, but unfortunately there are only a very small number of dentists who understand how therapists work.”

“We exercise autonomous decision-making within our scope of practice all the time, but unfortunately there are only a very small number of dentists who understand how therapists work.” –  Julie Barker, ADOHTA president

Now the Dental Board appears to be coming around to the idea that more autonomous decision-making for OHTs makes good sense. The Board’s current scope of practice registration standard was approved by the Australian Health Workforce Ministerial Council in April 2010, but the council stipulated at the time that the document should be reviewed within a year to 18 months “to assess whether it had any unintended and negative impacts on the scope of practice of dental hygienists, dental therapists and oral health therapists”.

ADOHTA president Julie Barker is concerned that the Dental Board may be making assumptions about the roles and practices of OHTs.

ADOHTA president Julie Barker is concerned that the Dental Board may be making assumptions about the roles and practices of OHTs.

Apparently it did, since the Board went as far as recommending the removal of supervision requirements for OHTs in a consultation document releases in May 2013 (the deadline for submissions was June). It will be a step forward if the recommendation is taken up, Barker says, but ADOHTA would like to see OHTs freed up entirely. Specifically, it wants scope of practice language relating to therapists such as “may only practise within a structured professional relationship with a dentist” and “must not practise as independent practitioner” stricken from the document. That would put the responsibility where it belongs and relieve dentists from any concerns they may have about whether they’re liable for the work a therapist performs.

The ADOHTA submission to the review spelt it out. “All dental practitioners work collaboratively with other dental practitioners and all should be responsible for the treatment they provide.”

For ADOHTA, the Board’s recommendation is encouraging, but there’s one big problem: the Australian Dental Association is dead set against changing the scope of practice to give therapists more leeway—to the extent that it has set up a website (hopeforscope.com.au) dedicated to defeating the Board’s proposal.

For ADA national president Dr Karin Alexander, keeping therapists as part of a team looked after by a fully trained dentist is a matter of patient safety.

“It’s not that OHTs are bad practitioners; it’s not that they’re second-rate practitioners. It’s simply that a three-year degree doesn’t give them the knowledge and training they need to work on their own. Things will be missed, and you won’t know what you’re missing if you don’t know what you’re looking for. That’s where we see the dangers. The whole training of OHTs is based on the fact that there will be a supervising dentist.”

Knowing whether a low-level toothache is likely to develop into an abscess, for instance, takes a trained eye, Dr Alexander argues. So how will an OHT know when to refer the patient to a dentist if they lack the training to detect this and other early warning signs in oral pathology?

If the dental team approach isn’t broken, why break it up, Dr Alexander wonders. “The dental team has been around for over 30 years. I’ve got a hygienist on my team, and we all work together. It’s a system that works, so why change it?”

Aside from professional bodies like the ADA, the Board’s scope of practice proposal has come under scrutiny from other quarters, in particular Dr Pauline Ford and Associate Professor Camile Farah of the University of Queensland’s School of Dentistry. They co-authored a paper, ‘Oral health therapists: what is their role in Australian health care?’, arguing that OHTs should concentrate more on fulfilling their role as originally conceived rather than be given the green light to operate independently and, presumably, shift further toward clinical services. (The paper was published in February 2013 in the International Journal of Dental Hygiene.)

Lead author Dr Ford, who is also a councillor for the ADA’s Queensland branch (ADAQ) and convenor of the ADAQ Oral Health Committee, believes that any additional blurring of the line between the roles of dentists and OHTs would be a step backward for oral health and disproportionately affect patients who can’t afford to attend a private practice.

“I see it as a lost opportunity for that component of the dental workforce,” Dr Ford says. “If we start focusing more on treatment instead of prevention—which was the founding idea of oral health therapy—we’ll really be behind the eight ball. We can’t afford to lose prevention as a focus of the oral health therapy profession.”

The long-term fallout would be especially detrimental to lower socioeconomic groups, whose oral health is increasingly under threat, Dr Ford says—not least due to the marketing tactics of sugary drink makers and ready access to their products. “We’re seeing more and more inequities in oral health in the community.” If OHTs were to move further away from their original purpose, the financially strapped public sector would be even less likely to deliver on the preventive aspects of dental care.

Dr Ford is quick to point out that she is a big supporter of OHTs in the workforce and understands the pressures they face.

“There is more and more pressure to deliver technical services rather than oral health education and oral health promotion. And some employers may require oral health therapists to stick to a narrower remit, perhaps for productivity reasons. After all, there are very few item numbers that correspond to the kind of oral health guidance and educational support that oral health therapists are intended to provide.

“These are not areas of oral health that generate a lot of remuneration, but having a workforce dedicated to them is crucial if we are to make any real progress toward a preventative model.”

Will removal of the word ‘supervision’ from the scope of practice language—should that happen—mean OHTs will be setting up their own independent practices and referring patients to dentists only if they think there’s a problem that’s beyond their skill set? Dr Alexander doesn’t think so, but she’s worried about the OHT-driven thinking that led to the proposal. “Currently I don’t think that’s the intent of the Board, but it’s a real concern that something that already works may be broken apart for no
apparent gain,” she says.

Julie Barker is more worried about the Board’s thinking, especially since only one OHT sits on it. “They’re probably not as informed as they think they are, and that leads to assumptions.”

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3 Comments

  1. I would like to challenge Dr Alexanders assertion that “the whole training of Oral Health Therapists is predicated on there being a supervising dentist”. I have been involved in designing curriculum and leading oral health therapy education for 18 years in the university sector. The education and training of oral health therapists has been based on autonomous practice and has included diagnosis and treatment planning within scope since the initiation of these programs- supervision by a dentist HAS NOT been part of this model, however collegiality has. This model has always seen OHTs (including therapists and hygienists) as primary care providers who refer patients with needs beyond their skill to a dentist or other health practitioner.
    There is sound evidence to support their ability to do this within their own scope of practice and to reliably refer patients with needs beyond their scope. This model of care has been in place in New Zealand for almost 100 years and in Australia for almost 50 years. This is not new. Every health practitioner has a responsibility to recognise the boundaries of their own scope of practice and work in collaboration with other practitioners where patient needs demand it.
    Dental therapists, dental hygienists and oral health therapists are registered by the same laws as every dentist and all the other health practitioners and have the same requirements for competent, current and ethical practice within the scope of their education and training.

  2. I graduated from Dental Therapy in 1977, part of my training was to know and understand my scope of practice, we were taught to collaborate and discuss our patients needs, we always looked to conservative dentistry and preventative dentistry as gold class
    To breach this understanding was unthinkable!
    We worked in dental clinics independently of a dental officer and would discuss patients needs via a phone call and booking the patient in to see the Dental Officer, we knew the local dentist and introduced ourselves as Professionals in the field of children’s oral health, we worked with school communities and taught all who crossed our paths the benefits of regular check ups and the importance of continuing your dental health throughout your life… To think we would fail in our Profession as to not know when we need to refer, discuss or stop a procedure would be an indictment on the very people who educated us!
    The lack of understanding within the dental profession is sad but one I hope we can continue to improve and find the “dental team” includes these very passionate professional people with all the expertise they have to offer.

  3. Oht’s know what their role is when they take on their course and not every oht is great just as not every dentist is great at their job. What is known is dentists are trained to identify, diagnose an refer oral pathologies.

    Ohts are trained as an auxiliary provider and do not have the knowledge or training in their degree courses to provide primary care to patients or enough knowledge to act as an intermediary in the triage process.

    The reason Ohts can act independently in private practice is their initial diagnosis and treatment planning is provided by a trained and qualified professional. Ohts are not trained to identify the full range of oral pathologies and not trained in specialist disciplines to be able to identify situations they should refer.

    I am in my 4th year of training as a dentist and every week I come across a new problem I have to refer, however without the training I have been receiving I would have no idea whether a problem was pulpal, periodontal, or psychological in nature.

    Ohts like to talk a lot about how good they we at their jobs but they lack the understanding and training to know what true oral diagnosis and triage requires.

    The more you learn the more you realize you know very little, and when you learn more you have a better knowledge of when to refer and when to treat yourself. Thankfully the bureaucrats in charge haven’t buckled to the tune of cost cutting yet.

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