Chapter 4 The orthodontic team Sameer Patel, Orthodontic Specialist, London
The healthcare team has undergone significant changes over the 20th century from a hierarchical model where the Consultant and Senior Matron ruled over junior doctors and nurses with limited roles for those without a medical degree to a healthcare system that recognises the value that each member of the team can provide to patient care. It is often the case that the most junior, fresh pair of eyes can identify areas of practice that may be improved. The General Dental Council have released documentation in relation to teamwork that feeds into the core standard “co-operating with other member of the dental team and other healthcare colleagues in the interests of patients”. However, in order to ensure a well-functioning dental team, it is important that there are clearly defined roles for each member, with knowledge of each person’s training and competency. Much has been discussed in relation to the role of dental hygienists and therapists, particularly because of the recent changes to allow direct access but this article aims to explain and clarify the roles within the orthodontic team, where there may be subtle differences compared to the wider dental team.
Team members The orthodontic nurse is a dental nurse who has undertaken further training in orthodontic nursing. Following successful completion of appropriate dental nurse training, the dental nurse is eligible for enrolment onto appropriate training programmes such as the NEBDN Certificate in Orthodontic Nursing. These courses are often similar to dental nurse training on a ‘day release’ type programme where classroom based learning is augmented by chair side experience. These qualifications may also include impression taking and photography providing increased support to the orthodontist during the examination and record taking phase of treatment. Orthodontic nurses are qualified to provide oral hygiene instruction to patients with orthodontic appliances but, similar to their dental counterparts, are not considered competent to undertake any form of orthodontic treatment independently. Many orthodontic nurses and other dental care professionals who wish to become more involved in orthodontic care choose to pursue a diploma in Orthodontic
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Therapy, a DCP role established in 2007. Course structures can vary but are usually undertaken on a part time basis for one to two years with the support of an orthodontic specialist to support chair side skills. Orthodontic therapists are competent to undertake reversible orthodontic treatment which ultimately covers a significant amount of orthodontic treatment including the changing of archwires, fitting of headgear and fitting retainers under the prescription of the supervising clinician (dentist or specialist orthodontist). There has been some debate regarding the level of supervision required for an orthodontic therapist and a 2015 Working Group between the BOS and Orthodontic National Group have developed guidelines for the level of supervision required. The orthodontic technician, while often not physically present, plays a crucial role within orthodontic treatment ranging from the fabrication of removable orthodontic appliances, retention appliances and shade taking where patients may have missing teeth. The role of the orthodontic technician is particularly important for patients who require orthognathic treatment, where she/he undertakes a mock surgery on the orthodontic models (model surgery) to help the orthodontic team confirm their surgical plan and to construct wafers used during surgery to ensure a predictable outcome. Given that the orthodontic technician is distant from the rest of the healthcare team, robust communication is vital for both written prescriptions and advice via phone and email. Many technicians train in all aspects of dental technology before self-specialising into the field of orthodontics. Dentists with a special interest in orthodontics have historically provided a significant proportion of orthodontic treatment in the UK, particularly in the Midlands. These dentists completed a two-year clinical assistantship scheme to be recognised as a dentist with enhanced skills, though now training is often via longitudinal training supported in a hospital or specialist practice. New NHS commissioning guidelines for all dental specialties recognise the value of general dentists with specifically enhanced skills. Within orthodontics, these Tier 2 practitioners are able to provide orthodontic treatment of limited complexity as long as they start 50 cases per year to prevent degradation of their skills. Orthodontic specialists have undertaken a three-year full time training programme entered into in a competitive process. During this training, they will undertake a higher research degree (at Masters or Doctorate level) and successfully pass the Membership of Orthodontics examination held by the Royal Colleges of Surgeons. These specialist practitioners work within the primary care or community services and are able to treat and diagnose anomalies of dental development and facial growth and undertake a wide range of treatment including those which may require multidisciplinary input. 34
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After completion of specialty training, specialists may choose to undertake further hospital training in order to be eligible to apply for consultant posts within the secondary care service. This training involves the treatment of patients who require multidisciplinary care including orthognathic and hypodontia cases as well as specific training in treating patients with cleft lip and palate and obstructive sleep apnoea. A hospital consultant can also be involved in the teaching and training of specialty trainees and undergraduate students, helping to manage local clinical networks and undertake academic research. Overall, each team member provides a specific and unique role within patient care but a vital member if the team is the general dentist. Without timely and appropriate referral of patients to orthodontic services, the purpose of the team becomes moot. It is therefore important that general dentists have a solid understanding of treatment criteria within the NHS service and how to monitor important aspects of the developing dentition including impacted canines and the effect of poor prognosis first molars on orthodontic treatment planning. These are supported by Royal College Guidelines and the development of managed clinical networks and local professional networks help improve dentists’ confidence with what can sometimes seem like a secret art. The success of the orthodontic team, like many others, depends on a clear understanding of the roles and competencies of each team member and excellent communication between team members including the general dental team.
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