Newsletter: November 2018

From the Chief Executive

Greetings from the Chief Executive

We suddenly find ourselves at the end of 2018 – a year that has proved to be one of the busiest in my time with the Council.

We reached an important milestone with our new IT system in September as we started using the new system for the dentist and dental specialist APC round. Although we received the APC applications on paper, they were processed by our team using the new IT system. The next milestone will come early next year when we open the practitioner portal for our practitioners to submit their applications, make payments, and update their contact details online.

You can learn more about our IT system changes in the IT system update section of the newsletter - please contact us if you have any queries or concerns.

The Council remains focused on improving our current recertification system. Following some intensive and robust discussions around the Council table and in other forums, a discussion document was released for consultation on 13 August 2018. Consultation ended on 26 October and we are now reviewing over 400 submissions received before preparing a report for Council's consideration.

In mid-July we visited the University of Otago for the 12 postgraduate programmes accreditation review. This year we had a core team review all the generic accreditation standards and discipline specific sub-groups (made up of international academics – mostly from Australia, and a New Zealand practising dental specialist from each discipline) that focused on the individual curriculum and assessment aspects of the programmes under review.

This year is also the first time that the new Dental Council (NZ)/Dental Board of Australia dental specialist competencies was used as benchmark for the dental specialist curriculums and assessment processes. This new approach strengthened the robustness of the accreditation review process.  

The Council also completed the accreditation review of the New Zealand Association of Orthodontists’ orthodontic auxiliary training programme and the Auckland University of Technology’s undergraduate oral health programme.

The accreditation reviews are ongoing, with final accreditation decisions expected in early December.

I’ve visited the University of Otago on a number of occasions this year and have enjoyed watching the transformation of the new dental school from a construction site towards a state of the art facility. The new school in Dunedin and the teaching facility planned for South Auckland will be a valuable resource for our oral health students and graduates, and the public of New Zealand.

Finally on behalf of the Dental Council, I’d like to take this opportunity to extend congratulations to our ex Council Chair, Prof Robert Love, on becoming an Officer of the New Zealand Order of Merit (ONZM) for services to dentistry and research earlier this year. Prof Love is recognised as an international expert in dental accreditation, dental education and regulation, and a multi-award-winning researcher.

This is a wonderful personal achievement for Prof Love, and much deserved recognition of his leadership in the area of endodontics and dental regulation, amongst many other contributions to the dentistry profession.

Marie Warner

IT system update

From Friday 14 September, we started using our new IT system internally including processing applications from dentists and dental specialists for their annual practising cycle. 

We expect that early next year, the practitioner portal will be opened for all practitioners and applicants to complete transactions online. You will receive more information about how to set up your online account to access the practitioner portal at the relevant time.

New graduates applying for registration and an APC should use the form on our website. 

In the meantime, practitioners should be aware of the following changes to the way information is displayed on the public register now that we have started using our new IT system.

Registration numbers replaced by 'Person ID' number

With our new IT system, we have moved to using sequential numeric person ID numbers for each practitioner. Your person ID number will appear on your APC certificate and on your entry in the public register.

The new IT system uses a single unique identifier for each practitioner (the ‘person ID’). Therefore the Council will no longer use profession based registration numbers (e.g. DD1234, DH2345, DT3456, or DN4567) to identify and communicate with practitioners, and will use the person ID instead.

Previously practitioners’ registration numbers were shown and could be searched on the public register. The public register now shows the practitioner’s person ID and HPI numbers.

We have been in contact with the Ministry of Health, ACC, and the pharmacy sector to ascertain how the change may impact their systems. If practitioners are required to make any process changes, we will advise you.   

Qualifications displayed on the register

You will notice that only qualifications that enabled registration in a scope of practice now appear on the public register. We alerted practitioners to this change last year.

The only variation to this information relates to practitioners registered in the oral and maxillofacial surgery (OMFS) specialist scope of practice.

Council has considered that where an individual practising in the OMFS scope has obtained a medical degree before the Dental Council required this qualification for registration as an oral and maxillofacial surgeon in New Zealand, their medical qualification will be displayed for the benefit of the public. The reason for this is the nature of the medical components of an OMFS specialist, the potential for dual registration with the Medical Council, and because a medical degree has been required for registration in this scope of practice since the early 2000s.

Dentist and dental specialist APC cycle

Dentists and dental specialists who recently filed their APC or retention applications will have noticed some changes. In particular:

• Annual practising certificates were issued by email.
• Invoices were sent by email as a record for practitioners. Payment was processed as permitted by your completed APC form.
• You will notice that a ‘person ID’ number and not your registration number appears on your APC certificate. As noted above, the person ID number now appears on the public register and we will no longer use registration numbers to reference individual practitioners in our communications.
• If we do not have a current email address for you, you would have received your APC certificate by post.
• If you have received your APC certificate by post, please provide us with an email address (one that is only used by you) as soon as possible to ensure you can create an account and use our new IT system in the future.
• The public register was updated as soon as your application was processed – if your practising status for 2018/19 has been updated on the register and you have not received your APC certificate, please contact us.

Recertification review update

We issued a discussion document in our second phase of consultation with the sector about recertification in August 2018. The consultation period closed on 26 October.

We are now in the process of analysing over 400 submissions received and preparing a report for the Council to consider.

You can view submissions received. The discussion document and other information about phase two of the review, as well as background information, a literature review and key themes from phase one, are also available on our website.  

If you were unable to attend a forum or webinar, or want to rehear the presentation, you can view the video and presentation slides from the Wellington forum online. 

If you have any queries you can email us on recertification@dcnz.org.nz.

Health Practitioners Disciplinary Tribunal

Four decisions from the HPDT relating to oral health practitioners are noted.

Brooke Wiggins, oral health therapist, Hamilton — Decision details

Vicki Anderson, dental technician/clinical dental technician, Kawerau — Decision details

Larisa Beck, dental hygienist, Auckland — Decision details

In all three cases the practitioners were found to have practised without a current practising certificate. The Tribunal reiterated that the requirement of a current APC ensures practitioners are subject to a degree of scrutiny as to their competence and fitness to practise. It is not merely an administrative requirement and needs to be taken seriously by registered health practitioners.

In another Tribunal decision, a charge of professional misconduct was established against Peter Liston, dentist and oral and maxillofacial specialist, New Plymouth. The Tribunal found Dr Liston’s conduct amounted to negligence, malpractice and bringing discredit to the dental profession, and warranted disciplinary sanction — Decision details.

Budget and fees consultation

Consultation on the Dental Council’s 2019/20 draft budget, proposed APC fees and disciplinary levies and other fees for oral health practitioners is now open. Consultation closes 5pm, 14 December 2018.

We have issued a consultation document seeking comments and views from our practitioners and stakeholders. You can send us your submissions by email, post to PO Box 10-448, Wellington 6143, or fax 04 499 1668.

Please contact us if you have any queries about this consultation.

Ministry of Health alerts

Oral health practitioners should be aware of the following alerts issued by the Ministry of Health.

Antimicrobial prescribing guidance

The Ministry has issued an alert on its webpage that has antimicrobial prescribing guidance with links to regional information.

This page will be updated by the Ministry as new information becomes available.

The antimicrobial prescribing guidance webpage was created to help address antimicrobial stewardship activities in the 2017 New Zealand Antimicrobial Resistance Action Plan.

Allergic reactions to fluoride paste

The Ministry has been advised of two cases of allergic reactions after the application of a Casein Phospho Peptide (CPP)-containing fluoride paste by oral health practitioners. 

One of the reactions was severe.  Both patients were known to have an allergy to milk products but in neither case was the patient/parent consulted about the application of the paste, which is not recommended for use in those with a milk allergy.

Oral health practitioners should be familiar with the components of products they are using and of any precautions advised by the manufacturers.  Practitioners have a responsibility to check the patient’s medical history prior to commencing treatment and to confirm that any products or equipment used will not cause life threatening reactions.

Also of note is that the only fluoride varnish product currently approved in New Zealand for the prevention of dental caries is Colgate’s Duraphat Dental Varnish 5% w/v in the 10 mL and 30 mL multidose tubes. 

Please refer to the Medsafe website to identify those medicines approved for use in New Zealand.

Annual report 2017/18

The Dental Council has now published its 2017/18 Annual Report. The report includes the audited financial statements to 31 March 2018 and information on the Council’s operations and statutory functions, including registration and APC numbers, competence and conduct cases, and examinations and accreditation.

The report also includes a comprehensive update on progress made on our strategic priorities.

Prescribing relief

As oral health practitioners, being able to prescribe drugs as part of our clinical practice is a privilege. To preserve this right practitioners must ensure they adhere to the relevant legislative requirements and meet all ethical principles, professional and practice standards that apply.

Council has considered several cases where prescribing has given rise to concern – these cases are a useful reminder about potential issues and provide an opportunity for practitioners to check their own practice in this area.

Lost or repeat prescriptions

The practice of dentistry often requires using medication such as antibiotics, pain relief and sedation for our patients. A prescription is the request from the dentist to the pharmacist to dispense the required drugs, and is often given directly to the patient to take to their preferred pharmacist. However it is not always convenient or possible to give the patient their prescription, so an alternative is required. 

Recently Dental Council received a notification from the Pharmacy Council, relating to concerns about a dental practitioner emailing a prescription to their patient. This notification from the Pharmacy Council arose from a Professional Conduct Committee of the Pharmacy Council investigating 37 pharmacists who dispensed allegedly fraudulent prescriptions to a particular patient of this practitioner over a four month period.

The patient involved presented to the practitioner in pain as an emergency. The cause of the pain was identified and options for treatment given. The patient consented to root canal treatment and in the interim, antibiotics and tramadol were prescribed because the patient said paracetamol was not working.

Ten days later, while the practitioner was away, the patient rang and explained that they had lost the prescription. The practice manager rang and spoke to the practitioner and it was agreed that a prescription would be emailed to the patient. The prescription was not signed. The patient presented copies of a single prescription, for Flagyl and 10X100mg Tramadol slow-release tablets at several pharmacies. 53 of the 60 prescriptions presented were unsigned.

According to the Pharmacy Council this raises concern regarding the practitioner’s professional practice, specifically with respect to therapeutic oversight and the unlawful provision of a prescription to the patient.

When a patient needs to repeat their prescription, or has lost a prescription form, they often prefer to make their request by phone or email rather than pick up the prescription from your practice or arrange a follow up visit.

In these situations, it is preferable for you to contact the patient’s chosen pharmacist and submit the prescription form by email or fax to the pharmacist directly. When this process is followed you must then supply the signed original prescription to the pharmacist within seven days.

Codeine

Concerns have been raised throughout various sectors in New Zealand recently about the availability of codeine and misuse of analgesics containing codeine, particularly as it can be converted into heroin using a process known as “home baking”.

Dental Council received a notification from a pharmacist about the amount of codeine prescribed by a practitioner in the pain management strategy for a specific patient.

According to the practitioner, the patient had stated that paracetamol and ibuprofen were not effective for their pain and insisted that codeine and tramadol were more successful. In this case, an analysis of the records indicated that the prescriptions matched the treatment provided. Once treatment was completed the prescriptions ceased.

The first line of treatment for most dental and dento-alveolar surgery pain is usually paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID). The addition of codeine or an opiate (either alone or in combination with NSAID) appears to offer no benefit.

Exceptions do arise and drugs, such as codeine and tramadol, may be required on occasion. Where patients insist on alternatives, or where it is apparent first choice pain relief is not adequate, consider, or reconsider, the following:

• What is the diagnosis or cause of the pain?
• Are further local measures possible? 
• Could the patient have any drug dependency or other drug related issues?
• Should the patient’s medical practitioner be consulted?
• Would it be wise to share the case with (specialist) colleagues?

Also of note is Medsafe's recent alert following a review on the safety of codeine. The review concluded that codeine poses an unacceptable risk of harm for children and has recommended changes to the age restrictions for its use.
In particular, Medsafe recommends codeine should not be used in:

• Children aged less than 12 years.
• Adolescents aged less than 18 years to control pain following surgery to remove tonsils or adenoids, for symptomatic relief of cough, or in those whose respiratory function might be compromised.
• Women who are breastfeeding.

The changes to the approved use of codeine in New Zealand are in line with changes in other countries, including Australia, the United States, Europe and Canada.
Medsafe is working with sponsors of codeine-containing products to update the data sheets and package labelling to include the revised age restrictions.

Prescribing for legitimate purposes

A pharmacist notified Council of concerns about the prescribing pattern of a practitioner.

A practitioner, with repetitive strain injury was prescribed codeine by his medical practitioner. Based on the long term and chronic nature of the pain, the practitioner requested further prescriptions for codeine from a family member (a medical practitioner) and a number of colleagues. The practitioner then presented prescriptions for codeine to various pharmacies to ensure “a supply to provide to patients when required for pain management”.

It was not possible to reconcile the amount of codeine prescribed by Medical Practitioners Supply Order (MPSO) with the clinical records. In this case it was also not possible to reconcile the amount of nitrous oxide purchased with the number of cases receiving inhalation sedation at the practice.

Prescribing drugs should be for legitimate patients only. It is not appropriate to prescribe for colleagues, friends or family members unless they are your legitimate patients. In this case the practitioner had developed a drug dependence.

Controlled drugs register and storing drugs

If you do hold or dispense controlled drugs, you are required to keep a controlled drugs register in accordance with the requirements of regulation 37 and as laid out in Schedule 1 of the Misuse of Drugs Regulations 1977, regulation 40. It is good medical practice to keep a drugs register even if you do not prescribe or dispense controlled drugs – particularly where the drug cabinet is jointly accessed by members of a group practice.

Controlled drug prescription pads and forms must also be kept secure. Where a controlled drug prescription is posted, you must ensure that it is done in a secure manner, and you must maintain a record of all controlled drug prescriptions you send by post.

Council received a notification from a pharmacist regarding the amount of Midazolam required by a group practice.

During the inquiry process Council identified a number of concerns about compliance with requirements for practitioners treating patients under sedation, and securely storing drugs with limited access available for appropriate staff.

Some important requirements to remember

A register must be kept and should include details of:

• Drugs purchased and placed in storage
• Any drugs used, allocated to a particular clinician
• Patient details with respect to the drugs used – in addition to requirements in the patient records 
• A note of a regular audit of the register
• Amount of nitrous oxide purchases and details of patients provided with inhalation sedation and an estimate of length of time of administration.

If you have any questions or comments about this article, please contact us.

What is the role of a clinical dental technician when providing immediate dentures?

The delivery of immediate dentures is a team effort and often involves dentists, dental technicians and clinical dental technicians - it also requires good planning and communication.

Key points

• Clinical dental technicians can construct an immediate denture under prescription from a dentist, in the same way that dental technicians do.
• In any situation where a patient requests an immediate denture directly from a clinical dental technician, the clinical dental technician must refer the patient to a dentist or specialist prior to commencing the case, so a diagnosis and treatment plan can be developed.
• A dentist can only refer or return an immediate denture patient (post extraction) to a clinical dental technician once the healing of the tissue is confirmed.
• Everyone involved in managing an immediate denture patient must stay within the boundaries of their scope of practice.
• Informed consent and treatment planning is required so that the patient understands the role and responsibility of each practitioner for every aspect of the immediate denture treatment, including aftercare.
• Communication between the dentist, clinical dental technician and patient is especially important when a clinical dental technician provides clinical services to the patient, so that the patient receives timely and accurate information about the options and costs involved in their treatment.

Background

Patients can access immediate dentures in different ways. Typically a dentist will confirm the treatment plan and send impressions, bites, and other relevant information to the dental technician who constructs the immediate denture. Once the dentures are ready, the dentist extracts teeth as required and then places the denture. A healing and adaption period follows for the patient after the denture is in place.

Usually, the dentist makes the necessary adjustments to relieve sore spots and assess the condition of the extraction sites within 24 to 48 hours after surgery. Further adjustments are made as required, and a temporary reline will likely be needed to compensate for the bone resorbing over the next few months. A permanent reline or a replacement denture is made typically around six months after extraction.

What are the limits on clinical dental technicians providing immediate dentures?

As with other dental appliances, a clinical dental technician can undertake the technical work required to construct an immediate denture requested by a dentist under prescription.

When an immediate denture is prescribed by a dentist, the dentist engages the clinical dental technician in the same way as they would engage a dental technician, and responsibility for the satisfactory outcome of the immediate denture remains with the dentist.

However, where a patient requests an immediate denture directly from a clinical dental technician, limitations apply.

In this situation, the clinical dental technician must refer the patient to a dentist or specialist before starting the case for the dentist to develop a diagnosis and treatment plan. This applies even if the patient was initially referred to the clinical dental technician by a dentist, or the clinical dental technician has already taken the initial impressions and bite record from the patient.

It is not within a clinical dental technician’s scope of practice to diagnose dental decay, periodontal health or similar issues.  Accordingly, a clinical dental technician cannot advise the patient directly about immediate dentures as a treatment option. They should instead refer the patient to a dentist, and limit themselves to providing guidance about the process involved.

When can a clinical dental technician become involved?

The roles of the dentist or dental specialist and the clinical dental technician converge when the dentist extracts one or more teeth and fits the denture. At this point the dentist needs to ensure the denture fits properly and check the health and subsequent healing of tissues.

Once the soft tissues are healed, the dentist can refer a patient to a clinical dental technician to provide a soft liner or a permanent reline. As always, good communication between the dentist, clinical dental technician and patient about responsibility for ongoing treatment and costs remains important.

Problems can arise when the patient is sent to the clinical dental technician after the initial 24 to 48 hour post insertion check for ongoing care. The important information to remember at this point is that clinical dental technicians are not able to treat patients before the extraction sites are completely healed.

The scope of practice for clinical dental technicians clearly states that they are only permitted to undertake clinical procedures when there is no diseased or unhealed hard or soft tissue[1].

A clinical dental technician can help clinically post insertion with immediate dentures once the dentist has confirmed the extraction sites are healthy and healed.

During the first two weeks following surgery the tissue that surrounds the extraction sites requires a significant amount of further healing. Typically, it is considered that enough tissue healing has taken place two to three weeks after extraction but this must be confirmed by the dentist, not assumed.

The amount of healing that has taken place in the first few weeks will depend on the initial size of the wound. Sockets of smaller diameter, such as single-rooted teeth may appear mostly healed over after two weeks. Wider and deeper wounds left by comparatively larger teeth (canines, premolars) or multi-rooted molars, or wounds resulting from surgical extractions, will require a greater amount of time to heal.

Why is it important a dentist confirms the tissues are healthy and healed?

The patient may experience denture associated soreness and could develop infection in the socket post extraction. Dry socket is a painful tooth extraction complication that can occur within two to four days and manifests as a deep-seated throbbing pain, bad breath and a continuous unpleasant taste in the mouth.

Secondary infections can also occur several days after tooth extraction. The patient may have fever, abnormal swelling, pain or a salty or prolonged bad taste with or without discharge from the site. Bony sequestra can form at the extracted tooth sites and may cause soreness and interfere with the healing.

Sometimes the tissues heal without intervention. In other cases smoothing of the underlying bone will need to occur for full healing. Post extraction granuloma can happen four to five days after tooth extraction–frequently because a foreign body in the tooth socket starts an infection. This could result from amalgam remnants, bone chips, small tooth pieces, or calculus for example. The foreign bodies aggravate the area and can delay post extraction healing.  

These conditions are outside the scope of practice of a clinical dental technician and require a dentist to manage until the tissues are healed.

Who is responsible for the immediate denture?

Responsibility for the outcome of the immediate denture is initially with the dentist or dental specialist that delivered the immediate denture. It is typically the responsibility of the person who delivers the immediate denture to check the technical work is fit for purpose prior to fitting. However, this is far from predicable in the case of an immediate denture and patients should be well informed of possible issues that can occur during fitting.

The issue of responsibility becomes blurred where, for example, a clinical dental technician has a more prominent role in the initial stages. They may have been the first point of contact for the patient and done much of the pre extraction clinical and technical work, while the dentist carried out the extractions and insertion of the denture. Ultimately each practitioner needs to be responsible for their input into the case.

Issues can also arise when the immediate denture has inherent issues that a reline cannot resolve, such as aesthetic or lip support issues. This is when communication between the patient, dentist and the clinical dental technician is crucial. It is also extremely important that the dentist and clinical dental technician clearly outline their own treatment plan for the patient and obtain informed consent for their involvement from the patient prior to treatment.