This update is an important reminder of the supervision requirements for orthodontic auxiliaries and dental assistants, and the tasks that only registered health practitioners can perform.
KEY POINTS TO NOTE
To ensure all registered oral health practitioners practise within their scope of practice including defined supervision levels, and comply with the standards framework and other legal and professional obligations, please note the following:
All registered practitioners
- only registered health practitioners may perform Restricted Activities, and then only if permitted to do so by their scope of practice.
Orthodontic auxiliaries –registered under the Health Practitioners Competence Assurance Act 2003 (the Act)
- orthodontic auxiliaries must practise under the direct clinical supervision of a dentist or orthodontist who is present onsite where the work is being carried out and who is responsible for the patient’s overall clinical care outcomes
Dental assistants – not registered under the Act
- dental assistants may provide a range of clinical support to a registered oral health practitioner when treating patients, provided they have suitable training and the registered practitioner provides onsite clinical direction and monitoring.
- dental assistants cannot perform Restricted Activities.
Case background – dental assistant working for an orthodontist
The Council recently considered a case where a dental assistant removed orthodontic braces without a dentist or orthodontist onsite at the dental practice. The orthodontist remotely reviewed photos taken by the dental assistant and made a follow up appointment to see the patient within 48 hours.
The orthodontist believed that because the dental assistant was not a registered oral health practitioner, the supervision requirements that apply to orthodontic auxiliaries (who are registered) did not apply. The Council made it clear in its findings that this interpretation is wrong. Compounding this error was a failure to recognise that a dental assistant is not entitled to undertake a restricted activity.
To address the possibility that other practitioners are similarly mistaken, the Council felt it was important to highlight this case, clarify the supervision requirements for orthodontic auxiliaries and dental assistants, and draw your attention to Restricted Activities.
Who is responsible to supervise orthodontic auxiliaries and dental assistants, and how?
In its finding, the Council made it clear that the responsibility to ensure orthodontic auxiliaries and dental assistants are adequately supervised and work within the boundaries of their respective roles lies with the dentist or specialist in the practice or dental team.
- the dentist or orthodontist must always be onsite to provide direct clinical supervision when an orthodontic auxiliary is undertaking procedures
- the dentist or dental specialist must always be onsite to provide direct clinical direction and monitoring to dental assistants.
Should a situation arise where the dentist or orthodontist cannot meet these supervision requirements, they need to make suitable arrangements for their patients to be seen on a different day or by a different registered clinician.
To protect the public from the risk of serious or permanent harm, the Act allows for specified activities to be restricted to registered health practitioners only. However, by designating specified activities as Restricted Activities, the Act also provides two important protection mechanisms for the professions it regulates.
The first is to reserve professional titles for registered health professionals only. It is an offence for an unregistered person to claim to be a particular kind of health practitioner. Unless you are a registered orthodontic specialist for example, you cannot call yourself and practise as an “orthodontist”.
It follows that dental assistants, who are not a registered profession under the Act, should not give patients the impression that they are registered health practitioners.
The second protection mechanism is to reserve certain designated activities as the exclusive domains of regulated professions. This means that performing a restricted activity is only permitted by a person who is a registered health practitioner permitted by their scope of practice to undertake that activity.
As dental assistants are not registered health practitioners, they accordingly cannot undertake a restricted activity.
Can a dental assistant provide clinical care?
In the case before the Council, the restricted activity in question was:
“Clinical procedures involved in the insertion and maintenance of fixed and removable orthodontic or oral and maxillofacial prosthetic appliances.”
The Council’s Policy Statement on Restricted Activities under the HPCA Act 2003 recognises that de-bonding/de-banding fixed appliances, including brackets fall within the ambit of the restricted activity.
The Council considers the removal of braces to be a restricted activity, braces being a “…fixed orthodontic appliance…” and the removal of braces from the teeth being a “…clinical procedure…”.
While the Council recognises that unregistered dental assistants help dentists, dental specialists, oral health therapists (OHTs), dental hygienists and dental therapists in providing a limited range of clinical support to patients, the Council’s policy makes it clear that the registered practitioner is ultimately responsible and accountable for the patient’s clinical care outcomes.
On this basis, it is only appropriate for dental assistants to undertake clinical activities if:
- they are suitably trained, and
- they are subject to onsite clinical direction and monitoring by a registered practitioner, and
- patients are not given the impression that the dental assistant is a registered health practitioner, and
- they do not undertake a restricted activity.
The registered practitioner has a corresponding duty to ensure the dental assistant is able to provide clinical care.
Orthodontic auxiliaries are a registered profession under the Act.
The Scope of practice for orthodontic auxiliaries and the Working relationship between orthodontic auxiliaries and dentists/dental specialists - Practice standard require orthodontic auxiliaries to practise under the direct clinical supervision of a dentist or orthodontist.
The scope of practice for an orthodontic auxiliary expressly permits:
- removing fixed orthodontic attachments and retainers
- removing adhesives after the removal of fixed attachments using burs in slow speed handpieces where there is minimal potential for the removal of enamel.
Orthodontic auxiliaries are lawfully able to perform the removal of braces provided they do so under direct clinical supervision. The supervision requirement in the orthodontic auxiliary scope of practice states:
- Orthodontic auxiliaries are responsible and accountable for their own clinical practice within their scope of practice, but the dentist is responsible and accountable for the direct clinical supervision.
- Orthodontic auxiliaries practise under the direct clinical supervision of a dentist who is present on the premises at which the work is being carried out.
In practice, this means a supervising dentist or orthodontist must be present on the premises where and when an orthodontic auxiliary carries out their work.
With on-site direct clinical supervision and working within their scope of practice, orthodontic auxiliaries provide valuable support to the orthodontic team, and a range of clinical services to orthodontic patients.
Suitably trained dental assistants may also undertake a range of tasks in a dental practice but only if a dentist, dental specialist, OHT, dental hygienist or dental therapist is onsite to provide clinical direction and monitoring.
However, it is important to note that dental assistants must never undertake Restricted Activities, nor give patients the impression they are a registered health practitioner.