Newsletter: May 2016

Message from the Chair

The end of 2015 saw several members of the Dental Council (‘the Council’) finishing their terms.  Dr Michael Bain completed six years on the Council and stepped down as Chair.  Leslea Eilenberg, Minnie McGibbon and Dr David Stephens also completed varying lengths of service on the Council. The strength of Councils and Boards is derived from the knowledge and skills of the individuals, but also the diversity that is encapsulated by the people at the table.  The Council was fortunate to have had these practitioners and lay people willing and ready to contribute to the regulatory functions of the oral health professions.  I thank them all for their time and commitment to the Council.

Of course these changes have also brought renewal to the table.  In December 2015, the Hon Jonathan Coleman, Minister of Health appointed four new members for a period of three years. These appointments included: Dr Jocelyn Logan, dentist Auckland; Gillian Tahi, dental therapist Auckland; Charlotte Neame, dental hygienist Wellington; and Karen Ferns, layperson Auckland.  I look forward to their new insights and perspectives.  The Council elects its own Chair and Deputy Chair at the commencement of each calendar year.  In February 2016, I was elected as Chair and Dr Andrew Gray, dentist Wellington, as Deputy Chair.

A clear focus on priorities has been a legacy of the work undertaken by Council over the past couple of years. The five strategic priorities that the Council is focussing on, in the period to 2020 are: professional and practice standards, engagement with the Council, lifelong practitioner competence, an organisation with the capability and capacity to deliver its functions and priorities, and ensuring strong governance.

In August 2015, the Council introduced our Standards Framework.  This can now be readily accessed on the website.  The Council is receiving ongoing support for the clarity and utility of these standards.  We are advised by both of the tertiary educators for oral health professionals (University of Otago and Auckland University of Technology) that they are being embedded in the education content of their programmes.  We have also been advised that their clarity assists groups such as competence review committees, to assess whether practitioners are meeting the expected minimum standards.

Council always anticipated that the Standards Framework required further work to ensure that the practice standards were updated and clarified.  The Transmissible Major Viral Infections Practice Standard was confirmed in August 2015.  Practitioners are now receiving clearer and more timely advice about their health when affected by a transmissible major viral infection, and the expectations of Council.  A consistent and expert advisory panel with medical specialist input forms part of this standard. 

Council openly and widely consults on each of the standards as they are developed or reviewed.  While consultation is a statutory obligation, and we know that at times practitioners feel they hear from us more than they might wish, we do receive support for this open style of development of change.  Feedback through the consultation process is always helpful and it frequently leads to changes.  

We have recently confirmed the Infection Prevention and Control Practice Standard.  Practitioners are aware that this can, at times, be a confusing and complex area. The new practice standard is written in a format that clearly articulates 24 standards that must be met.  The document then provides guidance about how to meet the standards by offering advice about the actions and behaviour that enable practitioners to meet the minimum standards.  In the case of the Infection Prevention and Control Practice Standard I particularly acknowledge the New Zealand Dental Association, who have spent a great deal of time and effort in the process of education and information about this topic over the last few years.  We are grateful to everyone who submitted and contributed to our work on this topic, which is such a key to public safety in oral health care.  

The Council anticipates that the format of a clearly articulated standard with supporting guidance will become the norm for its practice standards.   Work is actively underway on the review of the Sedation Practice Standard, and the Council will be consulting on this document later in 2016.  

The Council is currently engaged in a second round of consultation on the proposal for a scope of practice in Oral Health Therapy.  Significant changes have been made from the first proposals on this topic, particularly in the areas of the provision of restorative dental care for people aged 18 years and over, and in the consultative professional relationship between an oral health therapist and dentist and/or dental specialist. The consultation document is available on the Council website and submissions are due by 27 May 2016. 

The Health Practitioners Competence Assurance Act has now been in place since 2004.  The current Council has the benefit of 12 years’ experience with cases and situations that current and past Councils have been required to consider.   As a governance and regulatory organisation that is committed to continuing to learn and develop, we are currently using time at meetings to review our processes and significant decisions, and the learning that can come from reviewing our own work.  This is very similar to the responsibility we all have to periodically engage in a degree of reflection and discussion with our peers about our own practice.  

The next few years promises to be one of exciting change, not the least for the University of Otago as they develop a new School of Dentistry.  The Council wishes the School well with this very challenging project.  In keeping with the commitment of the tertiary education providers, to deliver graduates able to practise contemporary oral health care, the Council is responsible for ensuring we have a regulatory system for practising oral health professions that is contemporary and appropriate for New Zealand.  I look forward to working with you, with the public, with stakeholders in oral health care and with Council staff and members to deliver that over the next few years.

Naku noa na. 

Dr. Robin Whyman

Chair

Dental Council congratulates new graduates

Congratulations go to the graduates from the University of Otago and Auckland University of Technology oral health programmes.

The Council welcomes each new graduate to the oral health professions and wishes them further success as they begin their professional practice.

The 2015 graduate numbers are shown below. The numbers show 84 percent of new graduates have, so far, registered with the Council and, of those, 98 percent have been issued with an annual practising certificate, as at 31 March 2016.

Oral health therapy scope of practice follow-up consultation

At the end of 2014, the Council consulted with stakeholders on the proposed oral health therapy scope of practice. A total of 86 submissions were received. A committee was established to consider the submissions in detail. The committee presented its recommendations to the Council in February 2016.

In summary: 

• The Council agreed there is a need for an oral health therapy scope of practice.
• The proposed oral health therapy scope of practice was reconsidered, as it was not aligned with the education provided. The education currently delivered by the New Zealand oral health programmes must underpin the proposed oral health therapy scope of practice.  Amendments to the proposed competencies for an oral health therapist were made to take into consideration the specific concerns raised and to reflect the changes made to the proposed scope of practice.
• The value and need of a signed working agreement was also discussed in detail.
• A registration transition approach is proposed, but on a principle level, oral health graduates who transition into the oral health therapy scope of practice can continue to perform the same activities as they currently can, based on their specific registration and practising status.

The Council is at present consulting on a revised oral health therapy scope of practice, updated draft competency standards for oral health therapists, and related topics.

Submissions close on 27 May 2016. Have your say on this important issue by submitting your views on the proposals. 

Infection prevention and control practice standard consultation outcome

The Council consulted with stakeholders on a draft infection prevention and control practice standard from October 2015 to December 2015.

The Infection Prevention and Control Practice Standard was finalised in March 2016. The consultation outcome letter highlights the main changes in practitioners’ obligations in the area of infection prevention and control from the current requirements.

The updated Infection Prevention and Control Practice Standard came into effect on 1 May 2016.  The exception is the requirement of a data recording device and/or printer for sterilisers, that has an implementation date of 1 May 2018. Details of the provisions for this specific implementation are provided in Standard 15 within the practice standard. 

Medical emergency practice standard – final implementation of training obligations

Resuscitation training requirements

The updated Medical Emergencies in Dental Practice – Practice Standard was introduced in September 2014. The obligations on the new resuscitation training requirements (new training levels and revalidation every two years) are still subject to staggered implementation.

What does this mean for me? 

Note: CORE = Certificate of Resuscitation and Emergency Care.

All practitioners must have a valid resuscitation training certificate at the correct level, to meet the training obligations under this practice standard.

Requirement to hold oxygen and the associated equipment[1]

The requirement to hold oxygen and the associated equipment by those practitioners who have not yet been required to complete their new CORE Level 4 training has been extended until the expiry of their current resuscitation certificate, or by 30 September 2016, whichever is earlier.

Radiation Safety Act 2016 assented by parliament

The Radiation Safety Act 2016 was enacted in March 2016 and comes into effect on 7 March 2017.

The Act introduces several changes relevant to dental practice including:

• a new licensing requirement for owners of radiation sources
• removal of the earlier restriction that user licences for dental purposes could only be issued to dentists or medical practitioners
• a tightening of the rules relating to people acting under the direct supervision or written instructions of a licensee
• a provision that enables users to avoid user licensing if they are authorised under regulations to be made under the Act.

The Council has worked closely with the Office of Radiation Safety during recent months, in the hope that dentists, therapists, hygienists and orthodontic auxiliaries can avoid user licensing requirements under this provision.

The Council has been advised that a public consultation document is imminent that covers the Ministry of Health’s initial proposals regarding the proposed exemption regulations. The Council will make a submission on behalf of its regulated practitioners, but dental associations and individuals can also make submissions once the consultation document has been released on the Ministry of Health’s website. 

Orthodontic working group update

Information about the establishment of the orthodontic working group was published in our December 2015 newsletter. The working group is required to submit a report to Council with its recommendations on a way forward regarding orthodontic treatment provided by general dentists.

The orthodontic working group held its first meeting on 20 February 2016. The members brought a diverse range of perspectives and experience to the group’s discussion and consideration of matters within its terms of reference.

The working group has identified additional stakeholders to be invited to comment on identified issues for the purpose of gathering further information and to inform subsequent discussion.

At this stage, the following stakeholders have been invited to make written submissions by 23 May 2016, and to participate in face-to-face discussions with the working group on 13 June 2016:

• New Zealand Association of Orthodontists
• New Zealand Dentists Orthodontic Society
• New Zealand Dental Association
• New Zealand Dental and Oral Health Therapists Association
• Te Aō Marama
• University of Otago staff involved in orthodontic training
• Accident Compensation Corporation
• Health and Disability Commissioner.

Other groups could be invited to comment on further developed positions.

Practitioners’ corner: Informed consent and diagnostic safety-netting

The concepts and processes of consent have changed considerably over the years. With the development of patients’ rights under the Health and Disability Commissioner Act 1994, and the practice standards required by the Dental Council, reaching a decision about patient treatment is a core component of a dental practitioner’s work.

The emphasis is now on sharing decision making with the patient or their carer. It requires an understanding of patient expectations (especially those that are unrealistic) and a requirement for patients to share in the ownership of treatment choices.

Informed consent is an ongoing process and not just a signature on a document. Under the Code of Health and Disability Services Consumers’ Rights, patients are entitled to:

• effective communication
• be fully informed
• make an informed choice and give consent.

Autonomy is the fundamental principal of consent – the right to decide what happens to us in a health-care setting. When we review our own practices and our informed consent processes we should be mindful of any bias or coercion involved. If we have a particular interest, technique or equipment it may affect the way we present options to our patients. If we are unable to carry out a particular treatment we still need to include it in the options presented to our patients.

Clinicians will vary in their diagnoses and treatment decision making. Many practitioners are adopting a Caries Management System, which may include identifying early caries and taking the decision to manage them conservatively. Decisions on when to intervene and restore may differ between practitioners. In these situations, there is a requirement to include patients and carers in the decision making so that second opinions or alternative recommendations will not cause complaints or notifications to the Council. The main question is what alternative views or opinions could be presented to the patient?

Diagnostic safety-netting is a concept that addresses the possibility that dentists have got their diagnoses wrong.

Case example

Recently, the Council received a complaint from a patient regarding the management of their pain. The patient presented to their dentist with pain associated with the teeth on the upper left quadrant. A radiograph revealed a periapical infection associated with tooth 26, and two options were given – root canal treatment or extraction. The patient opted for endodontics because it was the last remaining molar on the top left.

The root canal treatment was completed in one visit but afterwards the pain remained much the same – maybe slightly worse but it continued.

The patient then had a diagnosis of chronic pain with somatisation. The patient now believes the dentist is responsible for the ongoing pain, which has spread across the forehead to the other side of the patient’s face.

The concept of safety-netting involves asking ourselves if we have got our diagnosis right. Is there a possibility of another explanation for the symptoms? In the case study above, root canal treatment and crowning the tooth was probably required, but it is doubtful the tooth was ever the cause of the pain. The presence of this doubt, if communicated to the patient may have prevented what has become a stressful and demanding action against the dentist.

Safety-netting is also a useful tool to use on the completion of treatment. Careful thought on possible outcomes of treatment can be communicated to patients, and in the event of an adverse outcome there is less likelihood of complaint or notification to the Council.

Reference: Almond S, Mant D, Thompson M (2009) Diagnostic safety-netting. British Journal of General Practice 59(568): 872–874. 

Te Aō Marama - New Zealand Māori Dental Association

The Council recognises the unique place Māori hold as a tangata whenua in New Zealand and honour the Treaty of Waitangi principles of partnership, participation and protection in the delivery and promotion of healthcare.

The Council acknowledges the importance of Māori oral health practitioners to inform and contribute to positive outcomes for Māori oral healthcare, and supports initiatives like Te Aō Marama. 

Te Aō Marama, the New Zealand Māori Dental Association, was formed on 26 May 1995 to address concerns over the state of Māori oral health, as highlighted by research. The Association was founded by dental therapist Mrs Inez Kingi, Kaumātua Mr Pihopa Kingi and Patron Professor John Broughton.

Te Aō Marama is now an organisation of around 100 members, who represent the Māori oral health workforce, including clinicians, specialists, health promoters, support staff, researchers, teachers and students. The membership remains committed to its vision of ‘Hei oranga niho mo te iwi Māori’ – Good oral health for Māori, for life.

Te Aō Marama is an important forum for members to support each other while showcasing and sharing information about new initiatives that contribute to positive outcomes for Māori oral health.Te Aō Marama is also a professional body that acknowledges and celebrates members who are driving positive change, optimising leadership potential and working towards reducing inequalities in Māori oral health.

Future work for Te Aō Marama includes supporting the professional development of the Māori oral health workforce and developing rewarding career pathways, building research capability to conduct significant Māori research projects and working closer with iwi and Māori communities to ensure the best access possible to the best services available.

Vision:  Oral health for Māori, for life

Te Aō Marama is keen for practitioners to know about the organisation, and its specific role in the promotion of oral health for Māori. 

For further information about Te Aō Marama:

Visit: www.teaomarama.org.nz

Facebook:  www.facebook.com/teaomaramanz

or email:  nzteaomarama@gmail.com