Practical Prosthodontics for the Dental Team

RESEARCH

Practical prosthodontics for the dental team

By R.Dubal,1 S.Buth2

Introduction of fixed, removable and implant-retained Teamwork is an essential aspect of good prostheses. Fixed prostheses include clinical practice, clinical governance and for restorations such as crowns, bridges, inlays ensuring optimal patient care. An effective and onlays. Removable prostheses include patient pathway involves interaction with a acrylic and cobalt chromium dentures. Implant number of different members of the dental retained prostheses can be fixed or removable team, all aimed at providing the best possible including crowns, bridges and dentures. outcome for the patient. Each member of Twenty-first century prosthodontics the team has an influential role to play in has moved a long way from conventional making the care pathway as efficient and as treatments and treatment planning. smooth as possible, not only for the patient The emphasis is now very much on the but also for the dental team. Poor teamwork preservation of natural tooth tissue and the can lead to breakdown in communication use of enamel and dentine bonding wherever and deterioration in working relationships, possible. The modern prosthodontist is more ultimately leading to sub-standard patient care aware of the implications of failure cycling and and a loss of patient trust and confidence. is keener to buy biological time. The General Dental Council (GDC) have The Adult Dental Health Survey (2009) stated in their guidance document ‘Principles revealed that in England, Wales and Northern with less associated biological damage at the of dental team working’1 that a good team Ireland, 94% of the combined population were time of failure. includes the following components: dentate, meaning that they had one or more There has been a move towards the whole 1. Good leadership1 natural teeth.3 With the current population of dental team being involved in patient care. For 2. Clear, shared aims, and work together to the previously mentioned countries estimated most patients, the care pathway begins from achieve them1 to be 57.9 million people, this leaves just under the moment they enter the practice reception 3. Different roles and responsibilities, and 3.5 million people with no teeth at all. Further area, before they even see a dentist. understand those roles and responsibilities.1 to this, 13% of adults in England had natural The receptionist, oral health educator, teeth with dentures.3 The survey also revealed hygiene and therapy team, dental nurse, dentist The most recent figures from the GDC that in England 8% of dentate adults had and technician, are all responsible in ensuring report that 40,721 dentists are currently one or more carious or unrestorable teeth.3 that the patient is cared for optimally. This registered to practise in the United The statistics, when considered in real terms, is facilitated by good communication and Kingdom.2 As the workforce increases in provide us with the sombre conclusion that organisation within the team. The roles of size, care teams increase in number and the need for care, by means of prevention, each team member are distinct and valuable, diversify in function. This is reflected in the restoration and maintenance, is as important and all contribute to the patient’s summative emergence of dental therapists, orthodontic now as it has ever been. experience. In this article we will consider the therapists, clinical dental technicians and The recent revolution in our understanding various roles of each member. oral and maxillofacial clinical scientists. With and provision of conservative and more increasingly more diverse skills available and adhesive clinical prosthodontic treatment The role of the clinician a multitude of roles to be fulfilled, the pillars has also led to the evolution of roles within Prosthodontic treatment requires a healthy of effective communication, teamwork and the dental team. There has been a change in and stable periodontal foundation. A patient-centred outcomes become even more the way in which we manage dental disease successful approach and response to oral important. Prosthodontic procedures involve and rehabilitate patients with missing teeth. health promotion requires engagement and a wide array of individuals with a variety Each member of the team has an increasingly involvement between the patient and the of skills, who come together to ensure high more valuable part to play with an emphasis dental team. Whilst dentists lead, guide and quality rehabilitation for patients. on communication, prevention and the patient coordinate clinical pathways, input from all being at the centre of the care process. This Prosthodontics is reflective of the quality of life and ‘patient- 1 Prosthodontic procedures are the commonest centred’ approach which we should all be Raj Dubal is a specialty trainee in 2 treatment modality undertaken by dental embracing today. With a co-operative and restorative dentistry; Shabana Buth is a dental core trainee year 3 surgeons. Prosthodontic care includes focused patient, it is more likely that our direct decision-making, planning and the provision and indirect restorations will perform better www.nature.com/BDJTeam BDJ Team 08 © 2015 British Dental Association. All rights reserved RESEARCH

members of the multidisciplinary team is crucial. Clinicians have the responsibility of ensuring clear management plans and effective utilisation of the multidisciplinary approach to optimise patient outcomes. The team (dentist, therapist, oral health advisor, dental hygienist and dental nurse) must all share a common philosophy towards optimising patient care. Patients with gingival inflammation are rarely good candidates for prosthodontic treatment. Gingival inflammation can give rise to problems with impression taking, the cementation of adhesive restorations such as veneers and the use of composite resin restorations. Many patients believe that the easiest way to solve this problem is to ask for scaling from a hygienist or therapist on a regular basis rather than take responsibility for their own ongoing care. This would be by means of more aggressive daily home- cleaning, ensuring that the bristles of their toothbrush and interdental brushes remove debris from the gingival margin and pass sub- gingivally where inflammation or pocketing may be present. This may mean both pain and Oral health educators, reception or removable prosthodontic restorations. gingival bleeding for the patient in the first few staff and practice managers It is important that all team members are weeks of using a more aggressive approach. The patient journey begins when an encouraged to bring their own genuine opinion The whole team must be united with a appointment is first booked by the when giving such advice. In general, two views common message that patients must take receptionist. It is the responsibility of the are better than one, and a more inclusive responsibility for their own periodontal health dentist to assess the patient’s suitability for dimension to patient care is delivered. and clean themselves, despite discomfort and treatment and to gain informed consent. Following successful completion of the bleeding, in order to establish and maintain Once a diagnosis is made, a treatment plan procedure, dental nurses are fundamental in periodontal health. Although the dentist has can be formulated and treatment options ensuring that the patient is well, and can provide the role of leading and coordinating care, they discussed and agreed. It can be very helpful any post-operative advice, as well as reassurance must also help build confidence and empower for the oral health educator to contribute to that may be necessary. They can then direct the and encourage all members of the team to these discussions, particularly when they patient towards the reception area. promote excellent communication and care fully understand the treatment modalities The dental nurse’s role also includes when interacting with patients. They will also concerned. Sometimes patients are more adherence to infection control policies, whilst need to reassure and support team members reluctant to discuss their queries with the the surgery is cleared, cleaned and disinfected, when patients question key beliefs of the dentist, and more comfortable with another ready for the next patient. Impressions and any practice, particularly if they are new to them. member of the team; it is not unusual for a other laboratory work should be disinfected, Utilising the full skillset of all members of the patient to have queries and a discussion with and packaged according to recommended team will promote confidence, reflect team the receptionist first as a result of confusion guidelines prior to dispatch. The nurse is cohesiveness and allow more freedom and or misunderstanding. Information leaflets responsible for ensuring the completion of autonomy as well as provide a better model of allow the patient to gather information and care for patients. develop an understanding in their own time All clinical dental team members should and at their own pace. This can help to provide be mindful of monitoring and advising on clarity, raise questions and reinforce consent. ‘The involvement the causes of dental diseases, which include Where oral hygiene is inadequate, it may an increasing frequency of consumption be appropriate to refer the patient to an oral and opinion of sugars, oral hygiene advice, a reduction health advisor, dental therapist or hygienist in alcohol consumption and encouraging for periodontal treatment and oral hygiene of the dental smoking cessation activities. Where instructions. Ultimately, good oral hygiene and preventative measures fail, ongoing patient periodontal health is essential for satisfactory nurse can maintenance and support should be provided. prosthodontic care and long term success. This ensures that both successes and failures are shared, with the needs of the patient always Dental nurses help validate put first. Such principles can be taught and The involvement and opinion of the dental encouraged through group training, practice nurse can help validate subjective decisions subjective meetings to include team-building sessions such as choice of tooth shade, or offering and access to relevant CPD. an opinion on overall appearance of fixed decisions...’

appropriate patient identifying labels and trained to undertake a detailed dental history Quality Commission aspirations to set disinfection of the laboratory work including and relevant medical history5 and perform and ensure well outlined standards for the the clinician’s laboratory instructions. They any technical and clinical procedures related profession, there is a shared and implicit are also instrumental in ensuring that to providing removable dental appliances.5 duty on the part of all members of the the correct return dates are noted on the They are also able to prescribe, provide and fit team to ensure that these are met and that correct laboratory prescription form. There removable prostheses to patients directly. relevant policies and best practice guidelines is an intricately efficient inter-play between The number of qualified CDTs emerging are adhered to. Now is an exciting time for clinician, nurse, patient, technician and is increasing and some may argue that they evolution of the dental team, and never has receptionist, and this can be reflective of are now a separate entity to clinicians when there been greater access to opportunities teamwork at its best. It is clear that when we it comes to prescribing, fabricating and for professional growth and development. work together everyone benefits. fitting certain types of removable prostheses. Continuing training and education for all However, it is also important to note that members of the team and regular audit will The role of dental technicians although CDTs may be able to set up their help to ensure that we are all doing what we Dental technicians are registered dental own independent practice, they must are supposed to be doing, and this will equip professionals4,5 who construct devices to a have adequate protocols in place to enable us to improve our services further. prescription from a dentist or clinical dental appropriate patient referrals when faced with In the twenty-first century, with a greater technician.4,5 a patient whose needs are out of their scope of number of more complex prosthodontics They are very important members of the practice.4,5 This is critical in order to ensure an treatments available, it is increasingly prosthodontic team. Depending on their efficient and successful patient care pathway, important that treatment planning, training and registration they either construct which is also robust and comprehensive. explanations of treatment options and the restorations (dental technician) or additionally Many technicians have valuable insight provision of successful prosthodontic care are provide the clinical stages involved in the and experience regarding recording tooth provided by a high quality dental team. As a provision of removable prostheses (clinical shade for a prosthesis, and the management of result, we must work together with a common dental technician). Dental technicians are challenging cases. In some cases it is valuable goal and ideologies, which place our patients involved in the construction of dentures, to call the lab or even visit them so that the at the centre of our focus. As they say, there is crowns, bridges and orthodontic appliances case can be discussed and a combined plan of no I in team… aimed at improving the patient’s appearance, action be established. Careful planning and the speech and masticatory function. Dental combination of skill sets can ensure optimal 1. General Dental Council. Principles of dental technicians are divided into four key groups: treatment outcomes. team working. Available from: http://www. prosthodontic, conservation, orthodontic and Overall, a sound working relationship and gdc-uk.org/dentalprofessionals/standards/ maxillofacial technicians, depending on the type clear communication between the prescribing documents/principlesofdentalteamworking_ of devices they are trained to fabricate. High clinician and the dental or clinical dental br0591_1.pdf (accessed 1 November 2015). standards of care must be shared by all members technician is of paramount importance to 2. General Dental Council. Facts and Figures : of the team. Technicians must feel able to inform ensure both accurate and efficient patient Registrant Reports. Available from: https:// dentists if they are unhappy with clinical quality treatment with successful outcomes. This is an www.gdc-uk.org/Newsandpublications/ issues (eg tooth preparation, denture design, integral part of the patient care pathway. factsandfigures/Documents/Facts%20and%20 impression quality) and vice versa. Figures%20from%20the%20GDC%20 A good relationship between the clinician Summary register%20October%202015.pdf (accessed 1 and dental technician is fundamental in There has been a paradigm shift towards a November 2015). order to achieve prosthodontic success and patient-centred approach to delivering high 3. Health and Social Care Information Centre. contributes to optimal treatment outcomes. quality prosthodontic care. As a function Executive Summary: Adult Dental Health Poor communication can lead to inadequately of this, the patient-care pathway should be Survey 2009. Available from: http://www. constructed or ill-fitting prostheses as well supportive, engaging and informed at all hscic.gov.uk/catalogue/PUB01086/adul-dent- as laboratory work not arriving in time for points of the journey. The calming effect of a heal-surv-summ-them-the1-2009-rep3.pdf a patient’s appointment. Thus it is highly considerate receptionist is often the first and last (accessed 1 November 2015). important, for clinicians to develop a good point of contact for patients, and the psycho- 4. General Dental Council. Scope of practice. working relationship with their dental social and emotional dimension of the care Available from: https://www.gdc-uk. technician colleagues, so that they can freely experience is what patients often judge us on. org/Newsandpublications/Publications/ and clearly communicate the type of appliance As the roles and responsibilities of team Publications/Scope%20of%20Practice%20 desired, material of choice as well as any members continue to evolve, the overlap of September%202013.pdf. (accessed 1 November additional information such as marginal each team member’s duties become wider, 2015). position, type of marginal finish and any and this should allow us to create a more 5. NHS Education for Scotland. A career in specific features pertinent to the case. comprehensive care network. Irrespective clinical dental technology. Available from: of individual roles, there should be a focus http://www.nes.scot.nhs.uk/media/2534970/ Clinical dental technicians on empathetic and effective communication nesd0155_clinicaldentaltech.pdf (accessed 1 Clinical dental technicians (CDTs) are with the patient, which should be honest, November 2015). registered dental professionals who provide comprehensive and comprehendible. All team complete dentures directly to patients and members should be knowledgeable and be other dental devices on prescription from able to answer or redirect common questions a dentist.5 They are also qualified as dental asked by patients. technicians. The key difference is that they are In consideration of the GDC and Care bdjteam201629 www.nature.com/BDJTeam BDJ Team 10 © 2015 British Dental Association. All rights reserved