Newsletter: November 2019

From the Chief Executive

Greetings from the Chief Executive

The potential for serious public harm from practitioners who do not follow adequate infection prevention practice is an issue that continues to concern the Council.

Practitioner’s compliance with the infection prevention and control (IPC) practice standard is a core part of practice. Council is aware that IPC knowledge and compliance is poor. I encourage all practitioners to read the article in this newsletter. Take some time to review the relevant practice standard and check to ensure you and everyone in your practice is familiar with the IPC requirements and is in fact complying.

Orthodontic treatment and frenectomies have been the subject of several media stories recently. We remind practitioners that the ethical principles and professional standards set out in the standards framework apply to all areas of your practice—including new or advanced areas. You must only practise within your professional knowledge, skills and competence, and only carry out a task or type of treatment if you have the knowledge and skills to do so competently within your scope of practice.

Another important reminder was highlighted recently in the Council’s decision to remove the 18-year age limit for restorative activities from the oral health therapy (OHT) scope of practice. In reaching its decision, the Council emphasised the importance of an effective consultative professional relationship between each OHT and a dentist/dental specialist. The guidance for working and consultative professional relationships are set out in the relevant practice standards (click “practice standards” on the standards framework interactive wheel).

Our newsletter covers two important consultations that are currently open. To improve public confidence in health regulation through greater transparency, changes made to the Health Practitioner Competence Assurance Act 2003 (the Act) require us to have a “naming policy” in place by 1 April 2020. This policy, as set out in the consultation document, will outline our decision-making process around publicly releasing the names of practitioners including when we will release practitioner names and what we will consider when making that decision.

The other open consultation proposes changes to scopes of practice for all the professions to fix inconsistencies and possible ambiguities dating back to the time they were drafted when the Act was first enacted. The Council is proposing to make drafting changes to some scopes of practice and prescribed qualifications to provide clarity and eliminate any potential uncertainty.

We are looking forward to receiving your feedback and comments to help the Council reach its decisions on both these matters.

Some practitioners have inquired about the Council appointments. As you’ll see in our latest Annual Report although a number of appointments have expired, the current Council members will continue pending an announcement from the Minister of Health.

Medical emergencies - updated practice standard

The Dental Council has reviewed and updated its Medical emergencies in dental practice - practice standard (2016).

The review took place primarily to ensure the document was formatted consistently with other more recent practice standards which clearly set out the standards and provide guidance where appropriate.

The review also looked at the following areas more closely:

• Concerns expressed by dental therapists about the administration of adrenaline for anaphylaxis and whether the concentration described for administration in children is appropriate
• In response to the New Zealand Institute of Dental Technologists’ concerns, the position on oxygen was revisited
• Update the New Zealand Dental Association (NZDA) protocols contained in Appendices A and B of the practice standard and investigate whether these protocols are appropriate for children
• Liaise with resuscitation providers on concerns about training for dental practitioners administering emergency medicines
• Liaise with the New Zealand Resuscitation Council (NZRC) on any key changes to their guidelines that could impact on the practice standard.

In summary, the outcomes of the review are: 

• Council considers that the updated medical emergencies practice standard places no new obligations on oral health practitioners, making consultation unnecessary.
• The title of the practice standard has been simplified to Medical emergencies practice standard.
• The updated practice standard maintains all the information in the 2016 practice standard, and has been formatted consistently with other, more recent, practice standards (standards and guidance)
• A small amount of further guidance has been added to the updated practice standard for standards 1,7, and 8
• References to ‘drugs’ in the 2016 practice standard have been changed to ‘medicines’ in the updated version
• Practitioners’ obligations for the use of oxygen have not changed, including for clinical dental technicians
• Practitioners are encouraged to discuss their training needs with their resuscitation course providers when booking, to enable them to competently administer adrenaline or oxygen, as relevant, in a medical emergency
• Appendices A and B of the practice standard have been updated to reflect current ANZCOR guidelines and NZRC published information.

Practitioners must familiarise themselves with the updated medical emergencies practice standard to ensure they comply. Details of the review and the rationale for the Council’s decisions are in the review outcome document.

New obligations under the sedation practice standard

On 1 October 2019, the last of a staggered series of new requirements for the sedation practice standard came into effect. The new requirements are set out in this article.

Use of capnography for intended level of moderate sedation

Standard 10 requires the use of capnography to monitor the patient when providing an intended level of moderate sedation, except when using only nitrous oxide/oxygen for sedation.

We have received several queries recently about this provision. The sedation practice standard sets out definitions for the minimal and moderate levels of sedation as well as key expectations. These are:

• Minimal sedation is a drug-induced state during which the patient responds normally to verbal commands. Cognitive function and physical co-ordination may be impaired but airway reflexes, cardiovascular and ventilatory functions are unaffected.
• Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation, throughout the period of sedation. The patient has the ability to maintain their airway patency on request, spontaneous ventilation is adequate and cardiovascular function is usually maintained.

The sedation practice standard acknowledges that the transition from complete consciousness through the various levels of sedation to general anaesthesia is a continuum and not a set of discrete, well defined stages.

The use of the word “intended” in standards where the level of sedation is used reflects this principle. This allows room for an unpredictable response to a sedative drug by an individual patient while requiring the practitioner to define the level of sedation intended at the outset.

We remind practitioners that oral sedation should only be used for an intended level of minimal sedation—as this sedative technique can result in a less predictable response than when a sedative drug is administered intravenously or via inhalation. The use of the word ‘intended’ in the standards does not mean that practitioners providing oral sedation can repeatedly sedate patients to a level of moderate sedation, having “intended” to sedate them to a minimal level.

Education and training

The new training provisions in standards 15, 16 and 17 also come into effect on 1 October 2019.

Standard 15 requires formal education and training for:

Dentists and dental specialists wishing to provide sedation who have:

• never provided sedation, or
• have provided sedation in the past but who have not maintained competence.

The formal education and training programme must ensure practitioners meet the competencies defined in Appendix B of the sedation practice standard. As with other areas of practice, practitioners must maintain their competence.

Please note:

• practitioners who have achieved competency in providing sedation before 1 October through a combination of training, experience and continuing education, and have maintained competence, do not need to complete a formal education and training programme to continue providing sedation
• the University of Otago Bachelor of Dental Surgery qualification is considered sufficient education and training to provide and monitor nitrous oxide/oxygen and oral sedation for patients over 6 years of age, subject to the practitioner maintaining competence in these areas.

Standard 16 requires formal education and training for individuals who do not have formal sedation training and are monitoring the patient throughout the sedation and/or recovery periods, regardless of the type of sedative technique used (oral sedation, IV, nitrous oxide/oxygen). The formal education and training programme must ensure individuals meet the competencies defined in Appendix C of the practice standard. These individuals must also maintain their competence. 

Standard 17 requires scenario training relevant to the management of sedation-related complications to be included in the NZRC CORE Advanced training. The  medical emergencies practice standard requires dentists and dental specialists performing any form of sedation, with the exception of relative analgesia, to complete the NZRC CORE Advanced resuscitation training.

Outcome from consultation on the age limit for restorative activities in the oral health therapy scope of practice

The Council recently issued the outcome from its consultation on proposals to remove the 18-year age limit for restorative activities from the oral health therapy scope of practice.

The Council extensively discussed and analysed the feedback both in favour and against the proposal before reaching its final decision to proceed with the proposal and remove the age limit from the restorative activities for oral health therapists (OHTs).

The Council was satisfied that potential clinical risks from allowing OHTs to perform restorative activities for adult patients will be sufficiently minimised by:

• practitioners understanding their clinical capabilities and boundaries
• appropriate education and clinical experience to ensure OHTs practise competently and safely
• OHTs meeting their ethical, professional and legal obligations under the Standards Framework
• established and effective consultative professional relationships between OHTs and dentists/dental specialists.

To implement its decision, the Council will place an exclusion – Restorative treatment on patients 18 years and older – on OHTs scopes of practice effective from 1 November 2019. This exclusion will remain until an OHT completes an accredited adult restorative programme to attain the necessary competencies.

Please contact us if you have any  questions about the placing of exclusions on OHT scopes of practice.

Implementing the new recertification programme

Work is well underway on the detailed design for our new recertification programme and planning for putting it in place.

A series of practitioner focus groups started on 31 October in Auckland, and will be followed by further groups in Wellington and Christchurch through until 12 November 2019. These will be used to test our thinking and confirm that the design for the new recertification programme will be realistic and practical for practitioners.

We have also started a regular tele-conference update for our key stakeholders (associations, specialists’ representative groups, employers, DHBs and education providers) to ensure they hear from us directly about progress and can provide input and ask questions. We will also be holding focus group sessions for these stakeholders in November.

As advised, pending implementation of the new recertification system for all oral health practitioners, the Council has decided to extend the current recertification programmes to 31 December 2020.

Current consultations

The Council is currently seeking feedback on two proposals – a naming policy and changes to scopes of practice and prescribed qualifications.

Council invites all practitioners and other individuals or organisations with an interest in these proposals to comment. Your feedback will inform the Council’s final decision.

You can read more about these proposals on our website.

Naming policy

Changes made to the Health Practitioner Competence Assurance Act 2003 require the Council to develop a naming policy that outlines what its decision-making process will be around publicly releasing the names of practitioners; when it will do so; and what it will take into account when making that decision. Submissions close on 6 December 2019.

Scopes of practice and prescribed qualifications

The Council is proposing to make drafting changes to scopes of practice to provide clarity and eliminate any potential uncertainty. Some changes to the prescribed qualifications for the general dental and oral surgery specialist scopes of practice are also proposed. Details can be found in the consultation document. Submissions close on 12 December 2019.

The changes proposed in this consultation will NOT change, limit or impact the tasks practitioners registered in the affected scopes and related professions are currently able to perform in their day-to-day practice. Similarly, the professional relationships, established working relationships and agreements or supervision levels under which practitioners practise will not change as a result of these proposals.

Remote DIY dentistry – understand your professional obligations

The Dental Council has received several queries from health practitioners concerned about an emerging area of DIY dentistry – remote orthodontic treatment – that is now available in New Zealand.

Global commercial enterprises such as WonderSmile and SmileDirectClub have entered the New Zealand market, offering remote or direct-to-consumer customised teeth aligners.

What is the Dental Council position?

Our key responsibility under the Health Practitioners Competence Assurance Act 2003 (the Act) is to regulate practitioners registered with us to practise in the oral health professions in New Zealand, in the interests of protecting the health and safety of the New Zealand public.

We recognise the oral health industry is constantly evolving with the opportunities provided by technology. And we agree that new technology enabling oral health treatment with little or no direct contact between a registered practitioner and their patient increases the potential for risk of harm.

However, the Act does not give us any jurisdiction over non-registered practitioners, nor commercial enterprises offering dental equipment or services. 

…but isn’t providing orthodontic treatment restricted to registered practitioners only?

To protect public safety, the Act allows for specified activities to be restricted, meaning they can only be provided by registered health practitioners. In this new and emerging area of remote services, a question arises whether taking an oral scan with the intent of providing orthodontic treatment would fall under the practice of dentistry as a restricted activity.

In our view from the available information about the processes advertised by these direct-to-consumer companies, there does not appear to be “…insertion…” of a removable orthodontic device as it is the customer or patient who does that.

Further, arguing that the use of the scanner is a “clinical procedure involved in the insertion … of a removable orthodontic appliance” might be too remote from the obvious intent of the definition of a restricted activity to apply.

However, there is potential to argue otherwise—and there is growing disquiet among the dental profession about the safety of the remote service being offered.

If restricted activities are being performed in New Zealand by non-registered persons then that would become a matter for the Ministry of Health, not the Dental Council to investigate and prosecute. Anyone found guilty of illegally performing a restricted activity faces a fine of up to $30,000.

What is the Dental Council doing about it?

The Council has drawn this matter to the attention of the Director-General of Health to highlight a potential public safety issue.

The Ministry of Health could declare an activity, such as providing remote DIY orthodontic services, to be “restricted” to registered practitioners only. The Ministry would be required to consult widely on any proposal should a change to the list of restricted activities be proposed.

We have also added information for patients on our website about orthodontic treatment.

What are the legal and professional responsibilities of practitioners?

As with any area of innovation, registered practitioners must ensure that ethical and regulatory standards are maintained—irrespective of how the services are delivered.

This means that any registered practitioner practising dentistry remotely would be held to the same standard of care as the practitioner providing in-practice patient care. The absence of personal patient contact does not eliminate a practitioner’s responsibility to comply with the mandatory standards set out in the Dental Council Standards framework for oral health practitioners.

Your patients may ask you for your opinion on the merits of seeking treatment remotely. While patients have the right to make their own decisions about their oral health, as an oral health practitioner, you have an obligation to ensure your patients are fully informed of their oral condition.

It is an opportunity to explain the advantages of seeking care from a practitioner registered in New Zealand and the assurance of competence this brings. The Dental Council professional standards require New Zealand practitioners to take an all-inclusive holistic approach to care. This requires you to consider the patient’s overall health, their psychological and social situation, their oral health needs (immediate and long term) and their desired outcomes. A physical clinical examination gives an opportunity to evaluate a patient in areas not possible at a distance. TMJ, muscles of mastication, occlusal function and adequate radiography are best assessed clinically.

However, in the end, patient autonomy and the patient’s right to make their own oral health care choices, is the overarching principle. 

If you do choose to become involved in emerging areas of remote DIY dentistry, remember the following

• The ethical principles and professional standards of the Standards framework apply to ALL areas of your practice. Carefully consider the following professional standards:
• You must ensure the health needs and safe care of patients are your primary concerns (PS 1)
• You must practise within your professional knowledge, skills and competence; and only carry out a task or type of treatment if you have the knowledge and skills to do so competently within your scope of practice (PS 8)
• You must take a holistic approach to care appropriate to the individual patient (PS 19)
• You must also provide care that is clinically justified and based on the best available evidence (PS 20)
• Recognise the relevance of particular practice standards when undertaking ‘new’ areas of dental services, in particular the practice standards related to informed consent, advertising, and patient records and privacy of health information. 
• Be aware of your obligations under the Code of Health and Disability Services Consumers’ Rights, especially relating to the patient’s right to be fully informed, their right to make an informed choice and give informed consent, and their right to receive services of an appropriate standard.

IT system update

Dentists have completed their APC applications online for the first time. 

By 1 October 2019, the first day of the new practising cycle, 96% of the expected applications had been received, paid for and processed. In this round, 73% of APC applications were processed and approved on the same day they were submitted.

Practice standards audit questionnaires will be issued by our online system in November. If you are one of the 10% of practitioners randomly chosen, you will receive an email and a link to the online questionnaire you’ll need to complete.

Remember you can use our online services at any time if you require any of the following services:

• change your name or update contact details
• change practising intentions during a practising cycle
• download and print a practising certificate or retention letter
• download and print an invoice and evidence of payment for the APC cycle
• apply for registration in other scopes
• apply for a certificate of good standing.

 If you have any feedback or questions about our online services, please email us.

Do you have infection control under control? It's more than a tick-box exercise

The risk to the public that results from a practitioner’s non-compliance with the Infection prevention and control (IPC) practice standard is likely to be viewed by the Council as gross negligence amounting to malpractice, rather than a competence issue, and referred to a professional conduct committee for investigation.

The responsibility for complying with the IPC practice standard rests with the registered oral health practitioner.

Each time you apply for an annual practising certificate, you are asked to declare that you comply with the Council’s ethical principles, professional and practice standards. The questions we ask include:

“Do you understand and comply with the following practice standards as required by Dental Council” and specifically, “Infection Prevention and Control - Yes or No”.

Most practitioners tick the “yes” box indicating they believe they are complying with this standard. However, this is not always accurate.

Case commentary

Despite ticking “yes” to compliance questions in APC application forms, a practitioner has been found to be well-short of compliance.

The practitioner was referred to a professional conduct committee (PCC) for investigation following a significant breach of the IPC practice standard. The practitioner’s autoclave had not been validated for three years and the practitioner had failed to perform any daily testing or logging of cycles, as required by the IPC standard.

Fortunately for the practitioner’s numerous patients, the autoclave subsequently passed all testing and was validated, but this could easily have not been the case. This was a significant ‘near-miss’ situation – placing the health of numerous patients at risk.

The PCC view was that the practitioner appeared to be unaware of their obligations regarding infection control, rather than being knowingly non-compliant. The practitioner’s response was immediate and appropriate once they became aware of the IPC requirements.

The PCC expressed a view that the lack of frequent formal or informal peer contact were likely to have been a factor in the practitioner’s not knowing about the standards. Nevertheless, this was a serious matter and a significant professional failing by the practitioner concerned.

Practitioners are individually responsible to know and comply with their professional obligations.

What the studies show

Earlier this year, the New Zealand Dental Journal (March 2019, Vol. 115) published a study on New Zealand oral health practitioners’ cross infection control practices. The purpose of the study was to update information on New Zealand dentists’ and allied dental practitioners’ adherence to protocols current at the time of the study (data were collected between March and July 2016).

The key points to note from the findings are:

• 889 oral health practitioners were randomly selected for the national study, and the response rate was 39.7%
• fewer than half of the practitioners (45.2%) had read the Dental Council’s cross infection control-related documents current at the time of the study
• the study concluded that most New Zealand practitioners are following cross infection control protocols, but a number are still not doing so, putting patients and the dental team at risk.

A recent desktop audit of some Combined Dental Agreement holders indicated that only 33% of those surveyed had correct validation records of reprocessing equipment.

Council’s concerns

The Council is concerned about compliance with the IPC practice standard and the public risk if infection control measures are not adequate.

This concern is based on the practitioner cases considered by the Council and its review of Council practice audit results – these show practitioners are consistently falling short of our compliance requirements in some areas including:

• the current requirements and guidelines for hand hygiene are not always well understood
• the classification of instruments as semi-critical or critical could be based on the use of the instrument rather than the instrument itself
• the prevention of airborne infections and managing aerosols requires materials and instruments within the primary clinical area to be protected from contamination – including cotton rolls and pellets, bur stands and orthodontic pliers
• personal protective equipment during reprocessing instruments is necessary – some audits have revealed that even though the equipment is available on site, it is not always used by busy staff in the sterilising room
• when asked, some practitioners find it difficult to confirm the safety of the water supply to equipment
• most practitioners indicate that they comply with the documentation requirements of the infection prevention and control practice standard, but when asked, are uncertain about the exact documents referred to.

The documentation required to comply with the IPC practice standard include (see page 46 of the standard):

• infection prevention and control practice manual – this must be available and reviewed every two years
• infection prevention and control records – the following records must be kept for a minimum of 10 years:
• monitoring records for sterilisation cycles, instrument washers, ultrasonic cleaners, instrument washers
• maintenance records – from a qualified contractor
• validation records at IQ, OQ, PQ and annual re-qualification (undertaking regular servicing of autoclaves, and conducting and appropriately recording the required daily tests is essential)
• education and training – staff at orientation, and refresher staff training
• incident records
• critical item tracking – the cycle number needs to be transferred to the patient records for critical items.

Back to some basics

Gloves are now worn universally in dental practice but there is some confusion over the appropriate type. For general dental procedures, non-sterile examination gloves that comply with AS/NZS 4011 are adequate. When sterile field is required – for example, oral surgery, surgical extractions, periodontal surgery, implant treatment – it is essential that instruments are laid out on a sterile surface and sterile gloves that comply with AS/NZS 4179 are used.

At present, there are concerns about measles in the community. Oral health practitioners must ensure they have the basic transmission-based precautions in place at all times to supplement the standard precautions, such as providing alcohol-based hand rub, tissues and face masks in reception areas, and ensuring surfaces touched by patients are cleaned appropriately.

Practitioners must ensure that not only their own clinical practise meets the IPC practice standard but that these standards are fully met in the practice in which they work. The “practice” is defined as all settings where a registered oral health practitioner performs activities associated with their scope of practice, so vigilance is required when practitioners work in more than one practice setting, such as rest homes or care facilities.

Another serious breach of Council’s IPC practice standard

Another case recently referred to the Council involved a group practice with multiple clinicians.

At the end of a morning session a dental assistant (DA) prepared the tray of instruments, bagged them, and placed them in the autoclave expecting that another DA would be soon finished and would need to reprocess their instruments too.

After lunch, another DA thought the autoclave had completed its cycle. They picked up the unsterilised instruments, took them to another surgery and used them on the first patient of the afternoon.

Although inadvertent, this was a serious breach of protocols and could pose a significant risk of harm to patients. It may be possible for a colour change to occur when pouches are placed in an autoclave chamber that has not completely cooled. The appearance of pouches changes after a cycle but a label on the autoclave indicating status (dirty or clean) would reduce the risk of such a breach of protocol.

Checklists and systems are important in practices to avoid this sort of breach, especially when there is no dedicated staff member responsible for reprocessing.

You can self-audit your compliance at any time

Practice standards compliance self-audit questionnaires are available on the Council’s website. You can download the questionnaire for your profession at any time and check your compliance.

At the time you apply for your APC, as well as regularly during the year, the self-audit questionnaire is a useful tool to reflect on your compliance. It works best when the standards are read carefully, and the questions answered with specific reference to those standards.

It is also worthwhile using the audit as an opportunity to include all staff in the practice with a view to identifying any changes that may improve performance and patient safety. To undertake the process with a colleague from another practice has some merit too, as it is an opportunity to see things through a fresh set of eyes.

Practitioner’s responsibility

The Council reminds all practitioners they must be knowledgeable on infection prevention and control measures set out in the IPC practice standard. You should refresh your knowledge at least annually.

Remember, the responsibility for infection prevention and control and complying with each requirement of the IPC practice standard rests with the registered oral health practitioner.