The ORTHODONTIC workforce

©robertprzybysz/i Stock/Thinkstock

MARCH 2015

The

ORTHODONTIC

workforce

CONTENTS

www.nature.com/BDJTeam BDJ Team 02

©iStockphoto/Thinkstock

Highlights

04 The twenty-ﬁrst century

orthodontic workforce

Highlights the changes that have

taken place over the past decade and

proles an orthodontic nurse and an

orthodontic therapist.

11 ‘There is a family atmosphere in

our lab’

BDJ Team meets Willette Jean Lati,

a dental technician who works in an

orthodontic laboratory in London.

22 Are you addicted to sugar?

Certied health coach and blogger

Laura omas explains how to control

your sugar cravings - and shares a low

sugar apjack recipe.

Regulars

03 News

28 New products

30 BDJ Team veriﬁable CPD

In this issue

13 Needlestick safety for the whole

dental team

An update on risk management and

the use of sharps.

16 The denture box

How the denture box facilitates

denture hygiene, reduces the chance of

accidental damage, and more.

20 Rules for shared parental leave

Parents of babies due on or aer

5 April 2015 will be able to share

statutory leave.

25 How to dispose of

hazardous waste

Waste segregation and management

in dentistry - with one hour of CPD.

From the Vital archive.

March

2015

CORE

CPD:

ONE HOUR

www.nature.com/bdjteam

NEWS

NEW APP FOR BRITISH DENTAL

CONFERENCE 2015

Delegates at this year’s British Dental

Conference and Exhibition will nd

everything they need at the tip of their ngers

thanks to a new app specially designed for the

event. A rst for 2015, the app is suitable for

both Apple and Android devices and makes

managing your time at the event and getting

around even easier than before. e app is

available to download now via the Apple App

Store or Google Play.

Key features of the new app include:

■

 A personal agenda feature allowing

delegates to browse full programme

information and add sessions they would

like to attend to their own personalised

event diary

■

 Full speaker bios

■

 Venue and exhibition maps

■

 Instant event notications

■

 Access to special show oers

■

 Visitor information from cash machine

locations to car parking

■

 Direct access to Twitter and Facebook

allowing users to interact and share views

with other delegates and organisers

■

 Notes section that allows you to save and

email notes to yourself.

Linda Stranks, Director of Marketing and

Membership at the British Dental Association

(BDA), said: ‘We have designed this app to

make the event experience as simple and

smooth as possible. Many of our delegates

now carry smartphones so it makes sense

to interact with them and provide show

information directly into their hands. We

want to make the event even more interesting

for visitors and more interactive for

exhibitors.’

is year’s event will take place from 7-9

May at the Manchester Central Convention

Complex with many of the sessions of interest

to the whole team. However, in addition,

there are also a number of sessions which

have been designed with particular team

members in mind.

Dental nurses

One session that’s not to be missed is the

Career Pathways presentation in the Training

Essentials theatre (Friday, 12 noon). In this

special session for dental nurses, BADN

President Fiona Ellwood will look at the

opportunities that are out there for dental

nurses. She will help dental nurses reect

on developing as a specialist practitioner

and consider what a new dental contract

might mean for dental nurses’ future career

pathways.

Dental hygienists and therapists

On Friday morning the BSDHT is hosting a

must-attend Conference Pass session at which

Paul Brocklehurst, Senior Clinical Lecturer/

Honorary Consultant, Dental Public Health

and NIHR Clinician Scientist, University

of Manchester will be looking at

the evidence supporting the

use of dental hygienists and

therapists in primary care.

Another highlight for

dental therapists is the

Paediatric Prevention

presentation in the

Training Essentials

theatre (Saturday,

11 am) in which

Amanda Gallie, Dental

Hygienist and erapist,

and DCP Advisor,

Health Education England

(East Midlands) will look

at systems for developing

a child friendly hygiene and

therapy practice. In total the Training

Essentials theatre oers 19 x 30-minute

sessions based on the BDA’s Training

Essentials portfolio. Topics include dealing

with emergencies, radiation doses in dental

radiography, child and adult safeguarding,

infection control and team working.

Practice managers

and administrators

One highlight that’s not to be missed is the

ADAM team leadership presentation in the

Training Essentials theatre (ursday, 4 pm).

In this special session Association Honorary

Vice President Tracy Stuart will walk through

the steps of building a team rather than a

group of people that turn up to the same

place of work each day. She will help you

understand the many hats you need to wear as

a business owner or manager. She will share

the changes in marketing, what is working

and what isn’t and how you can convert

calls into patients and treatment plans into

solutions the patients wants to pay for without

becoming an aggressive sales person.

Further event highlights include a large

exhibition featuring the live Demonstration

theatre, Speakers’ corner and Innovation

zone, free advice sessions with BDA advisors

and an evening social programme including

networking drinks, a Cuban party night. Up

to 15 hours’ CPD will be on oer with all core

CPD subjects covered.

Conference Passes for dental care

professionals oer great value with a one day

Conference Pass priced at £95 and a full three

day Conference Pass just £155. is gives you

access to all the lectures as well as the shorter

sessions in the Exhibition Hall.

Alternatively, you could attend the event

free of charge by registering for your FREE

Exhibition Pass which gives you access to the

shorter Training Essentials theatre sessions

outlined above as well as the other Exhibition

Hall sessions. Don’t miss out!

Further programme information and

booking details for both Conference

and Exhibition Passes is available at

www.bda.org/conference

Delegates can register online at www.bda.

org/conference or by calling 0870 166 6625.

Please note!

e UK general election will take place on

ursday 7 May 2015. If you are planning to

attend the event on this day and wish to vote

in the election you will need to apply for a

postal vote if you cannot attend your local

polling stations.

Do you have a news story that you would

like included in BDJ Team? Send your press

release or a summary of your story to

the Editor at bdjt[email protected].



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03 BDJ Team www.nature.com/BDJTeam

bdjteam201530

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FEATURE

www.nature.com/BDJTeam BDJ Team 04

The twenty-first century

ORTHODONTIC

workforce

Orthodontic workforce planning

Historically, orthodontic workforce planning

has proved dicult. In 1985 Stephens et al.

predicted an oversupply of orthodontists

and yet only 13 years later the Task Group

for Orthodontics identied a shortfall and

recommended a target of 480 general dental

service specialist practitioners for the UK.

is wide ranging and perspicacious report

took into account training mechanisms,

European directives and wider drivers from

the Chief Medical and Dental Ocers. At

that time they were mindful of two other

unknowns in planning the workforce, the

inuence of ‘grandfathering’ onto specialist

lists and the potential impact of ‘orthodontic

auxiliaries’ as they were then known.

e rst complete survey of the

orthodontic workforce in the UK was carried

out during 2003 and 2004.

is survey was

commissioned by the Department of Health

and carried out by the University of Sheeld.

e aim was to assess the existing orthodontic

workforce in relation to current and future

population needs. It was questionnaire-based

and investigated the location of workforce

and the ratio of 12-year-olds per whole time

equivalent orthodontic provider in each

Strategic Health Authority. Type of provider,

case mix and productivity (assessed as

number of cases treated per year) were also

investigated. An orthodontic provider was

considered to be a specialist or non-specialist

who treated more than 30 cases per year.

Of the 1,660 UK orthodontic providers

identied, 919 were General Dental Council

(GDC) registered specialist providers. In the

hospital setting, 243 NHS consultants and

68 university teachers were identied. Fiy-

ve worked in a community setting and 221

were in training. e specialist practitioner

group was the largest group (548) and the

practitioner group (non-specialist providers)

represented 26% of the workforce (432).

At this time, orthodontic therapists did

not exist and attempts were not made to

measure their potential impact on workforce

need. Several scenarios were presented with

the problem of addressing the shortfall in

orthodontists and it was emphasised that the

demand for increased numbers of providers

could be lessened if those patients falling

T. Hodge

and N. Parkin

highlight the

changes that have taken place

in the orthodontic workforce over

the past decade and review the

roles of various members of the

orthodontic team.

Consultant Orthodontist, Leeds

Dental Institute;

Consultant

Orthodontist, Charles Clifford

Dental Hospital, Sheffield

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FEATURE

05 BDJ Team www.nature.com/BDJTeam

into low index of treatment need categories

of treatment were not o ered orthodontic

correction. Following this survey, and

the introduction of contracting, for those

patients with a dental health component

(DHC) score of three and below orthodontic

treatment is no longer available on the

NHS. An exception to this rule is those who

fall in the DHC category three where the

aesthetic component scores six or higher. It

was also highlighted in the report that there

was considerable variation in geographic

distribution of providers, similar in fact to the

variation shown in the study by O’Brien and

colleagues.

In recent years, probably the most

signi cant change to the orthodontic

workforce has been the introduction of

orthodontic therapists.  ere is anecdotal

evidence that this has already impacted on the

employment of some dentists and specialist

orthodontists in the workforce and continues

to impact on the employment of newly

quali ed specialists and clinical assistant

dentists. Future workforce issues will need

to be reassessed by the Centre for Workforce

Intelligence, with input from the British

Orthodontic Society (BOS). Consideration

should be given as to whether potentially

smaller numbers of specialists will be needed

to be trained in the future or whether there

needs to be a reduction in the number of

orthodontic therapist training providers.

In many ways this latter problem should

have been circumvented.  e original pilot

study to establish training of orthodontic

therapists, and conducted in Bristol, made

it very clear that a very small number of

centres should be involved. It was recognised

that it was important to fully evaluate the

appropriateness of the training and skills

acquired from the initial courses over time

before further proliferation of programmes

around the UK. At the end of the Bristol pilot

it was suggested that there should initially

be an establishment of one or two auxiliary

training courses in the UK to ensure the

development of a national standard, and

that further courses would then be seeded

from these

THE CURRENT WORKFORCE

Orthodontic nurses

In 2000, a survey was undertaken to

investigate the delegation of orthodontic tasks

and the training of chairside support sta in

Europe.

At this stage in the UK the role of the

orthodontic therapist had not been developed.

From the nine tasks investigated, the only

one which was permitted to be undertaken

by a dental nurse in the UK was the taking

of radiographs.  is survey highlighted that

UK dental nurses were allowed to work

without quali cations or formal training.

However, currently all dental nurses have to

be registered with the GDC.  ose employed,

but not yet quali ed, need to be enrolled

within two years of commencing employment

or waiting to start on a recognised training

programme leading to GDC registration.

In addition, the clinical duties dental

and orthodontic nurses are permitted to

undertake have increased. Many nurses not

only take radiographs but routinely give oral

hygiene instruction, take impressions and

clinical photographs.  ese roles, as with all

dental registrants in the team, are laid out in

the GDC Scope of practice documentation.

Finally, as well as the Certi cate in Dental

Nursing, the National Examining Board for

Dental Nurses (NEBDN) also run additional

post-quali cation courses leading to

certi cation that many orthodontic nurses

undertake in assisting them perform their

additional clinical roles competently

including the:

■



Certi cate in Orthodontic Nursing

■



Certi cate in Oral Health Education

■



Certi cate in Dental Radiography.

Orthodontic therapists

Orthodontic therapists are a grade of dental

care professional (DCP) introduced in 2007.

 e recommendations for the training and

deployment of orthodontic auxiliaries in

the UK were based on the experiences of

the Bristol pilot study,

which provided a

foundation for the current training models

being used in Bristol and Leeds.  ese were

the  rst two training centres to qualify

orthodontic therapists.

It was also the

basis for those institutions that subsequently

established programmes (Swansea,

Edinburgh, King’s, Manchester, Preston

and Warwick).

Working under appropriate supervision

and following a prescription, orthodontic

therapists are permitted to undertake

numerous reversible orthodontic procedures.

In reality this includes most orthodontic

procedures, such as bonding brackets,

changing archwires,  tting functional

appliances and retainers and debonding

appliances.

 e exact details of the scope of practice

for orthodontic therapists as laid out by the

GDC

are shown in Table 1 and the speci c

capabilities of orthodontic therapists can

be found in the GDC Preparing for practice:

Dental team learning outcomes for registration

document.

Since the  rst orthodontic therapists

quali ed in 2008, 364 of these personnel are

now registered with the GDC (as of May

2014).  is has signi cantly increased the

orthodontic workforce and in many areas

has led to an increase in access to a specialist

led orthodontic service. It is expected that

therapists will have had a bene cial e ect in

reducing geographical inequality of specialist

©robertprzybysz/i Stock/Thinkstock

INTRODUCTION OF ORTHODONTIC THERAPISTS.’

CHANGE TO THE WORKFORCE HAS BEEN THE

Edinburgh, King’s, Manchester, Preston

and Warwick).

and following a prescription, orthodontic

CHANGE TO THE WORKFORCE HAS BEEN THE

‘IN RECENT YEARS, PROBABLY THE MOST SIGNIFICANT

FEATURE

www.nature.com/BDJTeam BDJ Team 06

care, although this has still to be conrmed

in the latest BOS survey expected to be

published in the near future.

ere have been possible concerns raised

about the quality of supervision of this

grade of dental registrant.

At the outset

many, including a number of educational

providers, were keen that while DCPs could

work independently from a dentist once they

had a treatment plan, due to the nature of

orthodontics where progress and mechanics

were constantly being re-evaluated, an

appropriate reassessment schedule would be

required every visit. erefore an orthodontic

therapist should never be le unsupervised.

Others felt this view was over prescriptive

and perhaps such guidelines would be a

disincentive to employing therapists.

As a

result, a working party from all the groups

of the BOS convened leading to a set of

guidelines being published on the supervision

of qualied orthodontic therapists by both

the BOS and the Orthodontic National

Group (ONG).

Orthodontic technicians

Orthodontic technicians are registered dental

professionals who construct custom-made

orthodontic appliances to a prescription from

a dentist or orthodontist. If they are trained,

competent and indemnied they can:

■

 Review cases that come in to the

laboratory to decide how they

should progress

■

 Work with the dentist/orthodontist on

treatment planning and appliance design

■

 Modify orthodontic appliances according

to a prescription

■

 Give appropriate patient advice and

carry out shade taking. is may be

especially useful mid-treatment when

constructing temporary pontics to replace

missing units.

With additional training, working alongside

an orthodontist, technicians may also

assist in the treatment of patients by taking

impressions, recording facebows and occlusal

registrations, tracing cephalograms and taking

photographs. e skill of an orthodontic

technician in the orthodontic workforce

is probably nowhere more central than in

delivering an orthognathic service where

accuracy, skill and good communication are

crucial for success in treatment outcomes.

Table 1 Scope of practice of the orthodontic therapist

Orthodontic therapists can: Orthodontic therapists cannot:

Clean and prepare tooth surfaces ready for

orthodontic treatment

Remove sub-gingival deposits

Identify, select, use and maintain appropriate

instruments

Give local analgesia

Insert passive removable orthodontic

Appliances

Insert removable appliances activated or

adjusted by a dentist

Re-cement crowns

Remove ﬁxed appliances, orthodontic adhe-

sives and cement

Place temporary dressings

Identify, select, prepare and place auxiliaries

Place active medications

Take impressions

Pour, cast and trim study models

They do not carry out laboratory work other

than previously listed as that is reserved to dental

technicians and clinical technicians

Make a patients’s orthodontic appliance safe

in the absence of a dentist

Diagnose disease, treatment plan or activate

orthodontic wires - only dentists can do this

Fit orthodontic headgear

Fit orthodontic facebows which have been

adjusted by a dentist

Take occlusal records including orthognathic

facebow readings

Take intra and extra-oral photographs

Additional skills which orthodontic therapists

could develop during their career include:

Place brackets and bands prepare, insert,

adjust and remove arch wire previously

prescribed or, where necessary, activated by a

dentist

Applying ﬂuoride varnish to the prescription of a

dentist

Give advice on appliance care and oral health

instruction

Repairing the acrylic component part of

orthodontic appliances

Fit tooth separators Measuring and recording plaque indices and

gingival indices

Fit bonded retainers Removing sutures after the wound has been

checked by a dentist

Carry out Index of Orthodontic Treatment Need

(IOTN) screening either under the direction of a

dentist or direct to patients

Make appropriate referrals to other healthcare

professionals

Keep full, accurate and contemporaneous

patient records

Give appropriate patient advice

Table 2 GDC learning outcomes

for dentists–management of the

developing and developed dentition

1.13.1 Identify normal and abnormal

facial growth, physical, mental and dental

development and explain their signiﬁcance

1.13.2 Undertake orthodontic assessment,

including an indication of treatment need

1.13.3 Identify and explain development or

acquired occlusal abnormalities

1.13.4 Identify and explain the principles

of interceptive treatment, including timely

interception and interceptiv orthodontics, and

refer when and where appropriate

1.13.5 Identify and explain when and how

to refer patients for specialist treatment and

apply practice

1.13.6 Recognise and explain to patients the

range of contemporary orthodontic treatment

options, their impact, outcomes, limitations

and risks

1.13.7 Undertake limited orthodontic

appliance emergency procedures

FEATURE

07 BDJ Team www.nature.com/BDJTeam

General dental practitioners and

dentists with enhanced skills

General dental practitioners (GDPs) perform

a key role in the orthodontic workforce acting

as diagnostic gatekeepers. e GDC Preparing

for practice documentation

it lists the

learning outcomes for dentists to be registered

with the GDC (Table 2).

Although orthodontics is a very specic

area of expertise, and only those registered

on the specialist list with the GDC can call

themselves a specialist orthodontist, any

registered dentist can carry out orthodontics

as long as they are competent to do so.

Historically, a signicant proportion of

orthodontic treatment has been carried out

by GDPs in the UK. e 2005 report revealed

that 17% of orthodontic providers had no

orthodontic qualication. e report also

highlighted that in some regions, Shropshire,

Staordshire, Trent, North and East Yorkshire

and Lincolnshire, the majority of orthodontic

provision was carried out by non-specialists.

Since 2006 the speciality has seen the end of

fee-for-item payments and the introduction

of the new individualised contracts. While the

majority of these contracts have been made

with specialist orthodontic practitioners,

contracting has occurred among a group of

existing NHS primary care general dentists.

Initially known as dentists with a special

interest in orthodontics,

these clinicians are

now known as dentists with enhanced skills

(DES). While not being eligible for specialist

list registration with the GDC these providers

will have gained additional experience

and training in orthodontics and can be

formally recognised by the commissioners

of orthodontic care (known as area teams

since April 2013). A DES is expected to treat

patients within their competence and refer

complex cases to a specialist orthodontist

or local hospital service as part of a local

clinical network. If this clinical network works

eciently and eectively, the likelihood of

population need being met and high quality

of care being maintained will be increased.

Training of DES oen used to take place on

two-year orthodontic clinical assistantship

schemes but now few, if any, of these remain.

Instead, there has been a recent increase in

longitudinal general professional training

(GPT) schemes for foundation dentists with

placements in orthodontic specialist practice

or in hospital departments.

Recently, GDPs have increased their

presence in the orthodontic workforce by

oering short-term orthodontics to adult

patients wanting an improvement in their

anterior smile aesthetics. While this has

caused debate

a move away from anterior

alignment using a handpiece to reshape

teeth together with ceramic restorations has

to be welcomed.

It should, however, be

appreciated by those practitioners oering

short-term orthodontics that it provides

a relatively limited range of outcomes and

frequently a specialist referral for correction

of a patient’s wider malocclusion may be

indicated.

Specialist practitioners

Specialist practitioners work in primary care

and are registered as specialists with the

GDC. At the time of the introduction of the

specialist lists in the late nineties a number

of people gained entry to this group via

‘grandfathering’. However, entry should now

only be on receipt of orthodontic training

in other EU member states or in the UK by

securing an orthodontic speciality training

registrar post. Entry to these salaried posts

by UK/EU applicants is competitive with

essential criteria for application including the

possession of a dental degree, registration

with the GDC and completion of a period

of dental foundation/vocational training

or GPT demonstrating experience in a

range of dental specialties. Interestingly, the

GDC are currently completing research,

including patient and public, stakeholders’

and registrants’ views on regulation of

the specialties and are asking these three

questions to gather evidence on the way

forward:

■

 Does regulation of the specialties bring any

benets (potential and/or actual) in terms

of patient and public protection?

■

 Is regulation of the specialties

proportionate to the risks to patients in

relation to more complex treatments?

■

 Are the specialist lists the appropriate

mechanism for helping patients to make

more informed choices about care not seen

as falling within the remit of the general

dental practitioner?

Many consider that the reason specialist

lists are useful is because specialist training

and dened standards of practice help to

deliver better treatment and improve clinical

outcomes for patients who receive specialist

dental care. In orthodontics the likelihood

that a treatment will benet a patient is

increased if appliance therapy is planned and

carried out by an experienced orthodontist.

Orthodontists also spend less time on

treatment and achieve better quality outcomes

than cases treated by general dentists who

have not undergone a specialisation course in

orthodontics.

e training programme leading to

specialisation in orthodontics in the UK

is three years full-time (or part-time pro

rata)

and involves undertaking a university

postgraduate degree at the Masters

(MSc, MClinDent, MPhil) or Doctorate

(DClinDent, DDS) level and upon successful

completion of the programme, eligibility

to sit the Membership in Orthodontics

examination of the Royal College of Surgeons.

e training programmes are currently

monitored by the Postgraduate Deaneries

and the Specialist Advisory Committee but

with national developments through Health

Education England these arrangements are

likely to change. e workload undertaken by

specialist orthodontic practitioners reects

the comprehensive learning outcomes of

the specialist training programmes which

include being able to diagnose anomalies of

the developing dentition and facial growth,

carrying out a wide range of simple and

complex treatments both interceptive and

comprehensive in nature including multi-

disciplinary management of a variety of

treatments and understanding psychological

aspects relevant to orthodontics.

Community orthodontists

e community orthodontic service is a

long-established part of NHS provision.

In a changing climate of dental provision

over recent years, providing orthodontic

support for Trust-based ‘Personal Dental

Services’ schemes, under the umbrella of the

salaried primary dental care services, has

become increasingly important. Community

orthodontists are specialist-trained providers

who undertake orthodontic treatment for

a range of special care patients who have

limited access to other, appropriate specialist

treatment.

e majority of such patients who are

able to receive orthodontic treatment oen

require close liaison with other health care

professionals for a holistic approach to

management and not infrequently this service

provides a ‘safety net’ in those areas of the

country not well served by specialist practice

or hospital orthodontic providers.

Orthodontic consultants

Consultant orthodontists are those specialists

that have undergone an additional two years

of full-time training (or part-time pro rata),

in many cases sub-specialising for example,

cle lip and palate work, who collectively

can provide any orthodontic service which

the commissioners might require. In

addition eligibility for application to these

posts is subject to satisfactory completion

of the Intercollegiate Speciality Fellowship

FEATURE

www.nature.com/BDJTeam BDJ Team 08

Examination Exam in Orthodontics, FDS

(Orth), although foundation trusts are in a

position to write their own requirements for

appointment to a consultant post. While this

role can be varied, clinical activity is focused

upon the following:

■



Working in conjunction with consultant

oral and maxillofacial surgeons, plastic

surgeons or paediatric surgeons to correct

severe skeletal problems by means of

combined orthodontic and surgical

treatment approaches

■



Liaise with other key specialties to

provide coordinated care for patients

with cle lip and palate, and other

congenital dentofacial anomalies.  ere

is also increasing collaboration with ENT

consultants and respiratory medicine to

manage patients with obstructive sleep

apnoea

■



Provide clinical training for undergraduate

dental students, career junior sta , future

specialists and trainee academics and

participate in continuing professional

programmes for all trained providers of

orthodontic care

■



Undertake personal research, innovation

and service evaluation including audit

■



Working with colleagues in primary

care and dental public health as part

of a professional network to manage

orthodontic services locally.

In summary, the role of the consultant

orthodontist is varied but centres on clinical

consultation, the treatment of severe and

multidisciplinary cases, service coordination,

training and research.

DISCUSSION

 is article highlights the many varied

personnel involved in the delivery of

orthodontic treatment in the UK and

illustrates how the workforce has evolved in

recent years. From the extension of the role

of the orthodontic nurse, the introduction of

the orthodontic therapist into the team, the

mandatory registration of all DCPs and the

increase in uptake of short-term orthodontic

treatments being o ered in general dental

practice, much has changed over the past

decade.

While we may be clearer now as to who

does what in the orthodontic workforce,

perhaps the next workforce issue that will

arise as a result of these changes is how many

of these varied personnel will be needed to

deliver care and their appropriate training.

 e Centre for Workforce Intelligence

published a strategic review in 2013 analysing

the future ‘supply and demand’ of the dental

workforce in England between 2012 and

2040

which revealed that there is likely to

be a surplus supply of dentists by as many

as 4,000 by 2040.  e mechanisms for the

derivation of these  gures is far from clear

and likely to be as hopeless as the information

which led to expansion of undergraduate

numbers in 2006. It is hoped that the report of

the current Workforce Survey Task and Finish

Group of the BOS will form the backbone of

negotiations with the Centre for Workforce

Intelligence, Health Education England

and the Department of Health and will be

instrumental in shaping the future training

of the workforce and delivery of orthodontic

services in England and Wales.

CONCLUSION

 ere has been considerable change in the

composition of the orthodontic workforce

over the last decade. It is hoped that the

extension of roles performed by the various

members of the orthodontic team will lead to

increased accessibility of specialist care.

 e impact of the change in composition

of the orthodontic workforce, in particular

the addition of orthodontic therapists, must

be taken into account when planning future

manpower needs.

1. Stephens C D, Orton H S, Usiskin L A. Future

manpower requirements for orthodontics

undertaken in the General Dental Service. Br J

Orthod 1985; 12: 168–175.

2. Lumsden K W, Brown D V, Edler R J et al. Task

group for orthodontics. Report. Br J Orthod 1998;

23: 222–240.

3. Robinson P G, Willmot D R, Parkin N A, Hall A C.

Report of the orthodontic workforce survey of the

United Kingdom. She eld: University of She eld,

2005. Online information available at: http://www.

bos.org.uk/Resources/British%20Orthodontic%20

Society/Migrated%20Resources/Documents/

Workforce_survey.pdf (accessed December 2014).

4. O’Brien K, Corkill C. Regional Variations in the

provision of orthodontic treatment by the hospital

services in England and Wales. Br J Orthod 1990;

17: 187–195.

5. Stephens C D, Keith O, Witt P et al. Orthodontic

auxiliaries – a pilot project. Br Dent J 1998; 185:

181–187.

6. Seeholzer H, Adamidis J P, Eaton K A, McDonald

J P, Sieminska-Piekarczyk B. A survey of the

delegation of orthodontic tasks and the training of

chairside support sta in 22 European countries. J

Orthod 2000; 27: 279–282.

7. General Dental Council. Scope of practice. 2013.

Online information available at: http://www.

gdc-uk.org/Newsandpublications/Publications/

©robertprzybysz/i Stock/Thinkstock

WHEN PLANNING FUTURE NEEDS.’

OF THE WORKFORCE MUST BE TAKEN INTO ACCOUNT

‘THE IMPACT OF THE CHANGE IN COMPOSITION

FEATURE

09 BDJ Team www.nature.com/BDJTeam

Publications/Scope%20of%20Practice%20

September%202013.pdf (accessed December 2014).

8. National Examining Board for Dental

Nurses. National certi cate examination.

2008. http://www.nebdn.org/documents/

NationalCerti cateProspectus_000.pdf (accessed

December 2014).

9. National Examining Board for Dental Nurses.

Certi cate in oral health education. 2011. http://

www.nebdn.org/documents/OHEProspectus_000.

pdf (accessed December 2014).

10. National Examining Board for Dental Nurses.

Certi cate in dental radiography. 2011. http://www.

nebdn.org/documents/DRPProspectus_001.pdf

(accessed December 2014).

11. Bain S, Lee W, Day C J, Ireland A J, Sandy J R.

Orthodontic therapists – the  rst Bristol cohort. Br

Dent J 2009; 207: 227–230.

12. British Orthodontic Society and Orthodontic

National Group. Guidelines on supervision of

quali ed orthodontic therapists. 2012. Online

information available at: http://www.bos.org.

uk/Resources/British%20Orthodontic%20

Society/Author%20Content/Documents/

PDF/Supervision%20of%20orthodontic%20

therapistsBoard%201212.pdf (accessed December

2014).

13. General Dental Council. Preparing for practice.

2011. Online information available at http://www.

gdc-uk.org/newsandpublications/publications/

publications/gdc%20learning%20outcomes.pdf

(accessed December 2014).

14. Hodge T. Orthodontic therapists: a challenge for

the 21st Century. J Orthod 2010; 37: 297–301.

15. Littlewood S, Hodge T, Knox J et al. Supervision of

orthodontic therapists in the UK. J Orthod 2010;

37: 317–318.

16. Day C, Hodge T. Supervision of orthodontic

therapists:

what is all of the confusion about?

Fac Dent J 2011; 2: 192–195.

17. Hodge T M. Clinical pearl:

in-treatment replacement of

missing incisors. J Orthod 2005;

32: 182–184.

18. Department of Health/Faculty of

General Dental Practice (UK).

Guidance for the appointment of dentists with

special interests (DwSIs) in orthodontics. 2006.

Online information available at: http://www.bos.

org.uk/Resources/BOS/Documents/Careers%20

and%20GDP%20documents/dh_4133859.pdf

(accessed December 2014).

19. Maini A, Chate R A C. Short-term orthodontics. Br

Dent J 2014; 216: 386–389.

20. Kelleher M. Porcelain pornography. Faculty Dent J

2011; 2: 134–141.

21. General Dental Council. Reviewing regulation of

the specialties. 2014. Online information available

at http://www.gdc-uk.org/Aboutus/ ecouncil/

Council%20Meeting%20Documents%20

2014/5%20Reviewing%20Regulation%20of%20

the%20Specialties.pdf (accessed December 2014).

22. O’Brien K D, Shaw W C, Roberts C T.  e use

of occlusal indices in assessing the provision of

orthodontic treatment by the hospital orthodontic

service of England and Wales. Br J Orthod 1993;

20: 25–35.

23. Marques L S, Freitas Junior Nd, Pereira L J, Ramos-

Jorge M L. Quality of orthodontic treatment

performed by orthodontist and general dentists.

Angle Orthod 2012; 82: 102–106.

24. Joint Committee for Postgraduate Training in

Dentistry Specialty Advisory Committee in

Orthodontics. Guidelines for the UK threeyear

training programmes in orthodontics for specialty

registrars. 2012. Online information available

at: http://www.rcseng.ac.uk/fds/jcptd/

higher-specialist-training/documents/

guidelinesfor-the-uk-three-year-training-

programmes-inorthodontics-for-

specialty-registrars-july-2012 (accessed

December 2014).

25. Centre for Workforce Intelligence.

A strategic review of the future dentistry

workforce: informing dental student

intakes. 2013. Online information

available at: http://www.cfwi.org.

uk/publications/a-strategicreview-

of-the-future-dentistry-workforce-

informingdental-student-intakes

(accessed December 2014).

 is article was originally

published in the British

Dental Journal as

‘Who does what’ in the

orthodontic workforce

on 16 February 2015 (218:

191-195).

PROFILE - ORTHODONTIC

NURSE

Ruth Mackenzie, 34, is a dental

nurse at Giﬀ nock Orthodontic

Centre in Glasgow. Ruth worked

at a specialist orthodontic

practice from 2002-2006, at

a private general dental practice from

2006-2010, and has been at her current

workplace since 2010. As well as her dental

nurse qualiﬁ cation, Ruth has a certiﬁ cate

in dental radiography, and enjoys

snowboarding, running and travelling.

What first attracted you

to dentistry?

I have always been interested in how

braces can make people’s teeth move. I

had upper and lower  xed appliances

myself in the past. I was attracted to

working in orthodontics a er noticing

how much more people would smile

a er having braces  tted. My interest

in orthodontics began when I read a

magazine article about clear braces.

I  rst started working in an

orthodontic dental practice in 2002.

 e general practice that I worked in

later on was far quieter.  e sta at the

orthodontic practice were more involved

in the treatment of patients, which I

found very appealing.

We treat a broad mixture of child and

adult patients. It is very satisfying when

patients complete their orthodontic

treatment and are happy with the

outcome - especially with the patients

that were very self-conscious with their

smile before treatment.

Have you undertaken a Certificate

in Orthodontic Nursing?

No but it is something I am interested

in doing and feel I would bene t

from greatly.

Would you recommend working in

an orthodontic practice to other

dental nurses?

Yes, there are many opportunities within

orthodontics and it is very satisfying

to see patients happy with their smile

a er treatment.

Do you have any career plans you

would like to share with us?

I would like to volunteer in a work

placement in a third world country.

©macroart/iStock/Thinkstock

PROFILE - ORTHODONTIC

NURSE

Ruth Mackenzie

nurse at Giﬀ nock Orthodontic

Centre in Glasgow. Ruth worked

at a specialist orthodontic

practice from 2002-2006, at

FEATURE

www.nature.com/BDJTeam BDJ Team 10

PROFILE - ORTHODONTIC THERAPIST

Fiona Carter, 53, is an orthodontic

therapist at Colchester Orthodontic Centre.

Fiona qualiﬁ ed as a dental nurse in

1981 and completed a Certiﬁ cate in Oral

Health Education in 1993, a Certiﬁ cate in

Orthodontic Nursing in 2008, a Diploma in

Orthodontic  erapy in 2009, and was PAR

calibrated in 2014 (Peer Assessment Rating

index). Ruth is a member of the Orthodontic

National Group (ONG) and enjoys running,

cycling, yoga and vintage shopping!

What first attracted you to dentistry?

Nursing was my chosen career but when

I le school I was too young to begin the

SRN (state registered nurse) training. I

saw an advertisement for an orthodontic

dental nurse so applied, not realising what it

entailed, and was successful.  at was way

back in 1978 and by chance I had found a

profession I really enjoyed.

In 1978 there was no recognised

quali cation for orthodontic nursing so my

orthodontist enrolled me on a local NEBDN

course. I gained experience in general dental

nursing by spending half a day a week

working in various local general dental

practices to successfully gain the National

Certi cate.  is con rmed that orthodontics

was the branch of dentistry that I wanted to

continue in.

Fixed appliances were still being made

with stainless steel tape so welding and

soldering attachments was part of the

orthodontic nurse role as was acrylic and

wire repairs to removable appliances,

preforming arch wires and making EOT face

bows which involved learning how to bend

wires, a great skill to have as an orthodontic

therapist (OT).  is was together with all

the other duties of running a busy specialist

orthodontic practice.

Following a short break a er the birth

of my two sons I returned to work on a

part time basis in a multi-disciplinary

dental practice working for an orthodontic

specialist. Gaining my Certi cate in Oral

Health Education in 1993 was a great

advantage having a varied patient base and

the help and guidance of GDPs.

As my children got older and more

independent I had the opportunity to work

with the orthodontist I began my career

with in 1978 within the local Primary

Care Trust, treating a variety of complex

orthodontic cases and also dental nursing

in a special care dental department.  ere

was a speci c managerial element to

this position as it involved setting up an

orthodontic practice within the community

dental department, sta recruitment,

department management and carrying out

audit, producing the department COSHH

manual, Dental Nurse Policy and Protocol,

following Trust guidelines and liaising with

multidisciplinary departments.

When did you decide to become an

orthodontic therapist?

OTs were being discussed as early as

1978 when I started my career. When the

orthodontic therapy course was introduced

in 2007 I knew that this was what I wanted

to do and that this may be my opportunity!

I applied for an orthodontic nurse position

and I was lucky in  nding an orthodontic

specialist who had the con dence in me to

support my application and training and

was prepared to be my training provider.

I studied for the RCS Eng Diploma in

Orthodontic  erapy at South Wales

Orthodontic  erapy course, based at

Cardi Dental School. It was hard work

but also very exciting with excellent

course tutors.

Was it difficult to get a place?

I considered myself fortunate to be selected

for interview and I was so pleased to

be successful at my  rst interview. My

employer/orthodontist also had to be

interviewed as a ‘training provider’.

Was it straightforward finding

employment as an orthodontic

therapist?

Yes because you are trained by the

orthodontic specialist that you work with.

S/he is your ‘trainer’ and a er such a big

investment in time, energy and emotion (not

forgetting  nancial investment), successful

OTs tend to stay with their trainers/training

providers.

 e transition

from orthodontic

nurse to orthodontic

therapist was very

exciting; however,

it was a change for

the whole practice.

Having a very supportive team made

it easier. Patients had to adjust too but

they were all very understanding and

encouraging. I am con dent working within

my clinical capabilities and I am aware of

my limitations. CPD is an essential and

important part of keeping up to date.

I treat a mixture of both adults and

children but a higher percentage of children.

I work within the limits of the OT GDC

scope of practice and following BOS

guidelines.

At Colchester Orthodontic Centre we

are a small but very happy team of ten:

Gareth Davies, the orthodontic specialist

practitioner; two orthodontic therapists;

four orthodontic nurses; a practice manager;

and two administrative sta .

 e most satisfying part of my job is

seeing how delighted the patients are

when treatment is completed and the self-

con dence that this gives them. Not only

because they have a fantastic smile but

because they realise that have they achieved

this through their own hard work. Adult

patients may have missed the opportunity to

undertake orthodontic treatment as a child

and it is rewarding to see the con dence

they gain.

What is the future for OTs?

I think OTs are an asset to an orthodontic

practice and coming from a dental nursing

background OTs are empathetic to the

patient and parents. I think it is an excellent

career path for an orthodontic dental nurse

considering career progression.

bdjteam201531

WHEN TREATMENT IS COMPLETED.’

SEEING HOW DELIGHTED PATIENTS ARE

‘THE MOST SATISFYING PART OF MY JOB IS

Willette Jean Lati is a 26-year-old dental technician

and Clear Aligner Department Assistant Manager

at NimroDental Orthodontic Solutions in London.

FEATURE

Dental destiny

When I was at school, like most people, I was

quite indecisive about what I wanted to do

when I grew up. From a young age till about

secondary school it ranged from wanting to

be a palaeontologist, doctor, vet, chef, scientist

to artist.

I was born in the Philippines but because of

my mum’s work we were relocated to Sydney,

Australia when I was about two-years-old. Aer

ve years, we moved back to the Philippines to

further my education for about six years. We

moved to London in 2002 where I started at

Year 10.

Not doing particularly well during my

A-levels (chemistry, biology, maths and

psychology), I had to look for an alternative

course that catered to my interest in both art

and science. A google search turned me to the

direction of dental technology. So I guess it was

like destiny.

Work experience

To secure a place on a dental technology course

is not very dicult providing you have ve

GCSEs at A*-C (especially in maths, science

and English) and don’t mind getting your hands

dirty. It may be dicult, however, to nd a

dental laboratory to take you on as an apprentice

if you don’t have any prior experience. Work

experience before you start studying is also

recommended as it will give you a better idea of

what sort of business you’re getting yourself into.

I started work experience at NimroDental

in 2007 whilst I was studying my BTEC course

in Dental Technology and have been there

ever since.

I completed a Foundation degree in Dental

Technology in 2009. Both my BTEC and

Foundation Degree courses tried to condense

the principles and practical techniques of all

departments of dental technology (prosthetics,

orthodontics and prosthodontics) in a span of

three years. But I would say that courses focus

more on denture or crown and bridge work.

My class was attended by a majority of girls of

a wide range of dierent ages and backgrounds;

there with only two boys among us. But I

found that other groups or batches were quite

male dominated.

I enjoyed the practical aspect of my

foundation course more than the academic as

I am more of a hands-on sort of learner. It was

interesting to learn and make dierent sorts of

appliances used in dentistry that many would

take for granted. I enjoy being able to build,

recreate, add detail and nish things with my

hands using dierent mediums.

e academic side of my course was a bit

challenging, and also learning to make new

appliances - but practice and persistence does

help to improve and perfect new skills.

In the lab

At NimroDental I make a fair range of

appliances in the lab such as retainers, clear

aligners, removable appliances and Inman

aligners. I have worked my way up from plaster

room technician to assistant manager.

I am currently based on the famous Harley

Street although I wasn’t initially aware of its

reputation until I started working in the lab.

Previously we were located just o Paddington

Street; I used to personally do collections and

drop-os of impressions and appliances in the

Harley Street area and got to meet or see some of

London’s well known dentists and orthodontists.

It was fascinating to learn that a small area has

such a huge reputation of quality of care and

services both from the medical and dental eld.

It was also nice to bump into the odd celebrity

every now and then.

I am currently Assistant Manager of our

Clear Aligner Department headed by Agnieszka

Horton, specialising in the new digital clear

aligner movement system and 3D printed

models. I also attend dental tradeshows to

raise our company’s prole in the dental and

orthodontic industry.

I support my colleague Sophie Cook

11 BDJ Team www.nature.com/BDJTeam

‘ There is a family

atmosphere in our lab’

FEATURE

www.nature.com/BDJTeam BDJ Team 12

(@Nimrodental_SC on Twitter), who is Head

of Marketing, with our social media accounts.

I would like to make special mention of our

mentor Jowita Penkala of Uniqabrand for

teaching us the power of social media marketing

through Twitter and Facebook since November

2014. I have never used Twitter for personal use

but found that it is an amazing tool to connect

to all types of people in the dental industry.

As a lab it is rare for us to be involved with or

to interact with the general public, but we do

try to maintain good relationships with our

clients such as dentists, cosmetic dentists and

orthodontists across the UK and in Europe.

A family atmosphere

Having been at NimroDental for more than

seven years, there is an almost family-like

atmosphere. We are a continuously growing lab

with currently over 30 individuals including the

o ce team.

As a company we enjoy each other’s company

even a er work hours. We organise monthly

work drinks at nearby local pubs or bars.

A few of us have even been travelling around

Europe together.

Regarding my future career ambitions, this

may sound cheesy but they are to be the best at

what I do and to continue to improve and learn

every day, whether it is dental-related or not.

I subscribe to a yearly magazine to regularly

update my CPD hours and try to attend lectures

or  nd free CPD websites online to keep my

skills up to date.

I usually  nish work around 5 pm but stay

a little longer on busier days. To relax or let o

steam a er work I sometimes go to the gym to

swim or train, do a bit of hot yoga or even just

spend a couple of minutes in the sauna.

To be honest, I haven’t got a clue what I

would have done if I hadn’t become a dental

technician! Wherever the wind had taken me I

suppose. I don’t have a set path and just take any

opportunities that come my way.

If you are good with your hands and have

an interest in science, then I would de nitely

recommend a career in dental technology

to others.

TECHNOLOGY. SO I GUESS IT WAS LIKE DESTINY.’

TURNED ME TO THE DIRECTION OF DENTAL

ART AND SCIENCE. A GOOGLE SEARCH

THAT CATERED TO MY INTEREST IN BOTH

‘...I HAD TO LOOK FOR AN ALTERNATIVE COURSE

What three things can Willette not

live without?

1. My iPhone to connect with people

2. The Internet to connect with

the world

3. Sour candies/sweets because

I have a bit of a sweet (sour) tooth

which is a naughty thing in

my profession!

bdjteam201532

FEATURE

Consider the risk

As part of the dental team, needlestick safety

is something you should be acutely aware of in

your day-to-day role. A survey of 1,216 dental

nurses from the UK and Ireland conducted

in conjunction with the British Association

of Dental Nurses (BADN) in 2014 found that

51.2% of respondents had received a needlestick

injury at some point throughout their career,

with 60% of those saying they’d received more

than one. When you then consider the risk

of infection following a needlestick injury is

estimated to be one in three for Hepatitis B virus

(HBV), one in 30 for Hepatitis C virus (HCV)

and one in 300 for HIV (for healthcare workers

worldwide), it is vital that safety procedures are

put in place in all dental surgeries.

The use of sharps

Following the introduction of  e Health &

Safety (Sharps Instruments in Healthcare)

Regulations 2013, all healthcare facilities must

ensure that:

(a)  e use of medical sharps at work is avoided

so far as is reasonably practicable

(b) When medical sharps are used at work,

safer sharps are used so far as is reasonably

practicable

capped a er use at work unless:

i. that act is required to control a risk

identi ed by an assessment undertaken

pursuant to regulation 3 of the

Management of Health and Safety at

Work Regulations 1999 (a)

ii. the risk of injury to employees is

e ectively controlled by the use of

a suitable appliance, tool or other

equipment

(d) In relation to the safe disposal of medical

sharps that are not designed for re-use:

i. there should be written instructions for

employees

ii. clearly marked and secure containers

should be located close to areas where

medical sharps are used at work.

Health and safety law has always placed

general responsibilities on the employer to

provide their sta with a healthy working

environment. However, this legislation now puts

further emphasis on prevention. In reality it

would be di cult, if not impossible, to remove

all sharps from a dental practice, so the next best

thing is to assess the risk correctly, use devices

By Rebecca Allen

©Creatas/Thinkstock

Rebecca is Category Manager at Initial

Medical (http://www.initial.co.uk/

healthcare-waste/). She has worked

in the healthcare sector for the past

13 years and was a Research Chemist

with Bayer Cropscience prior to joining

Rentokil Initial in 2003. She keeps up to

date on all developments within the

clinical waste management industry

and is an active member of the CIWM,

SMDSA and BDIA.

for the whole

dental team

13 BDJ Team www.nature.com/BDJTeam

FEATURE

www.nature.com/BDJTeam BDJ Team 14

which limit the risk of injury and dispose of all

sharps in a safe manner.

Top tips for needlestick safety are shown in

Table 1.

Cradle-to-grave rule

It’s important to remember that when it comes

to hazardous and infectious waste such as

syringes and other sharps at a dental practice,

the cradle-to-grave rule applies.  e producer

of waste will always be held responsible for the

safe and legal disposal of it, even a er it has been

passed onto the waste carrier collecting it.  is is

why it’s important to work with comprehensively

trained sharps waste disposal experts who will

advise on the correct products that comply with

both the UK and EU legislation and safely and

securely dispose of sharps. Health and safety

law is criminal law and healthcare organisations

can be subject to enforcement action if they fail

to comply with the legal requirements.  ere

is also always a threat of civil law action if an

employee is injured due to insu cient practices

and technologies being in place.

Staff wellbeing

Everyone has a role to play in the prevention

of sharps injuries, from trainee sta who are

learning the ropes, to practice owners who will

hold legal overall responsibility for the wellbeing

of their sta .

Another quick and simple way to reduce the

risk of needlestick injuries is to use innovative

solutions such as InSafe syringes – a safety

system providing comprehensive protection

for clinical sta from the beginning of the

procedure through to the disposal of the needle.

InSafe’s syringe and sharps box ensure that the

contaminated needle is never exposed except

during the actual injection. It feels and aspirates

just like a traditional syringe so there will be

no interruptions to the dental practice when

introducing the protective system. When the

injection has been administered, the protective

sleeve locks securely into place over the needle,

protecting clinical sta and patients when not

in use.  e needle can then be safely disposed

of using a sharps container. Specially developed

sharps disposal bins are designed for such waste

and comply with all EU and UK regulations

and directives, and there are companies

available that provide a dependable and safe

collection service.

BDJ Team promotion

Initial Medical Waste Experts

Initial Medical is an expert in

healthcare waste management,

providing a complete collection,

disposal and recycling service for

hazardous and non-hazardous waste,

such as offensive waste produced

by businesses and organisations

within the UK. The safe management

of healthcare waste is vital to ensure

your activities are not a risk to human

health. Initial Medical’s healthcare

waste services ensure that all of

your waste is stringently handled in

compliance with legislation and in

accordance with Safe Management

of Healthcare Waste best practice

guidelines, providing you with the

peace of mind that you are adhering

to current legislation.

For further information visit

www.initialmedical.co.uk or call

0800 731 0802.

bdjteam201533

Always dispose of used sharps

directly into an approved sharps

container

It is essential that your sharps

are segregated and disposed of

correctly based on their medical

contamination. The lid colour and

label on the container relates to how

the waste should be treated and

disposed of.

Where possible, place the sharps

container at the point of use

This avoids the need to walk anywhere

with a needle, which creates higher

risk of an injury occurring.

Do not re-sheath needles

When the Health & Safety (Sharps

Instruments in Healthcare) Regulations

2013 came into place, the recapping

of needles was banned, so it is

now against regulations to do so.

The purpose of this is to prevent

needlestick injuries from occurring

when removing the needle. You should

use a safer sharps device to remove

needles from your syringe.

Do not leave sharps lying around

Although this may seem obvious,

sharps injuries are still known to occur

as a result of sharps being left lying

around, when other people are not

aware that they are there, so it is

extremely important that they are

disposed of immediately after use.

Report all sharps

injuries immediately

If a sharps injury does occur, you need

to ensure you follow the below steps:

■

Encourage bleeding from

the wound

■

Dry the wound and cover it with a

waterproof dressing

■

Seek urgent medical advice

■

Report the injury and ensure

all details are reported in your

practice’s accident reporting book.

Table 1 Top tips for needlestick safety

WELLBEING OF THEIR STAFF.’

LEGAL OVERALL RESPONSIBILITY FOR THE

ROPES, TO PRACTICE OWNERS WHO WILL HOLD

TRAINEE STAFF WHO ARE LEARNING THE

PREVENTION OF SHARPS INJURIES, FROM

‘EVERYONE HAS A ROLE TO PLAY IN THE

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• Vibrant and FREE to attend Exhibition

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M. J. Faigenblum

explains how the denture box facilitates denture

hygiene, reduces the chance of accidental damage and acts as a

means of identification.

UCL Eastman Dental Institute

Patients or their carers need

to maintain as low a level of

denture biofilm as possible. This

article notes that the handling

of dentures is unpleasant to

carers and suggests a method

of reducing this contact to a

minimum yet allowing efficient

cleaning by means of brushing.

It also highlights the potential

damage that can occur due

to mishandling or accident.

The denture box acts as a safe

storage unit and its ‘footprint’

allows accurate recovery in an

institution where dentures can

be inadvertently mingled.

www.nature.com/BDJTeam BDJ Team 16

The

denture

box

Edentulous patients

e programme for the 2013 British Dental

Association’s conference contained some

60 lectures, none of which dealt with the

treatment of edentulous patients. is

reects the subject’s relative absence from the

literature and reinforces the perception that

the need for complete dentures is waning.

Nonetheless, as recently as 2009, 6% of the

combined population of England, Wales and

Northern Ireland were edentate and in need

of prostheses.

Most of them are ‘elderly’, that

is 75+, and in consequence a proportion are

likely to be in care homes or incapacitated to a

greater or lesser degree.

e York consensus

declared that for the

edentulous mandible the minimal standard

of care is the provision of an overdenture

supported by two implants. However, in the

recent update on guidelines for the provision

of such treatment under the NHS,

the

authors note ‘…funding for implants on the

NHS is likely to be a precious resource.’ ey

suggest, ‘the decision to provide implants

needs to be balanced against alternative

modes of restoration, their ease of provision,

longevity and outcome rates’.

An alternative mode of restoration is the

provision of optimal dentures, if necessary,

at the hands of an experienced dentist.

is might preclude the need for surgical

intervention and is especially relevant for

patients who are not amenable to surgery.

added benet is that if correctly designed, the

denture(s) can act as a stent for implants if

they are subsequently required.

A well-made but retentively compromised

complete upper denture can be stabilised

with the judicious use of a dental xative

and severe bone resorption of either jaw too

is not necessarily a barrier to a successful

outcome. e eect of a resorbed, mobile

maxillary ridge can be ameliorated by a

careful impression technique.

Similarly, in

©Small_World/iStockphoto/Thinkstock

FEATURE

Fig. 2 Angular cheilitis associated with the

stomatitis in Figure 1

Fig. 1 Denture induced stomatitis under an

acrylic partial denture

Fig. 3 Using a plaque disclosing liquid and the result of simple cleaning with a brush and

detergent

Fig. 4 Probable cause for a carer’s

reluctance to handle a denture

FEATURE

17 BDJ Team www.nature.com/BDJTeam

the mandible a skilful technique can provide

a stable denture that can be so -lined if

discomfort cannot be eliminated.  e updated

report

makes provision under the NHS for

patients who are intolerant to such treatment

and where the implant retained or supported

overdenture

would then be treatment of

choice.

 e edentate state is most o en the result of

a lack of awareness of the importance of oral

hygiene. It is therefore unlikely that attention

to this will be radically altered when the teeth

are replaced by dentures. Even if this is not

always the case, patients may not be aware of

the potential harm of the denture bio lm.

Denture biofilm

Denture plaque (DP) di ers in its constituents

from the normal dental bio lm.

In the

physically healthy individual it can be

aesthetically objectionable with a build-up

of materials found in the mouth that can

produce an unpleasant odour.

 ey can also

induce mucosal in ammation that is, denture

stomatitis, and a potentially dis guring

angular cheilitis (AC).

9,10

Denture stomatitis (DS) can appear in

di erent forms. Found typically under a

maxillary denture it produces a bright red

imprint of the outline of the denture on

the underlying mucosa (Fig. 1). Due to a

lack of symptoms, its presence is frequently

unnoticed by the patient and by the dental

professional.

Not infrequently, DS is associated with AC

described as a usually bilateral erythematous

 ssuring of the corners of the mouth (Fig.

2).  e poor appearance that this produces

is exacerbated by deep labial folds that

encourage maceration of the corners of the

mouth with saliva.  ese folds are o en

present when the vertical dimension is

signi cantly reduced but is not a cause of the

cheilitis.

AC can sometimes be a result of

vitamin and iron de ciency anaemias.

Removal of denture plaque is therefore

important.  e  lm may not be visible but its

presence can be demonstrated to the patient

by the use of a plaque disclosing agent (Fig.

3).  e two main denture cleaning methods

of brushing with a non-abrasive paste or

soaking in chemicals have been reviewed.

 e authors found that there was a lack of

evidence to suggest that one method was

superior to the other. In the author’s opinion

the demonstration of the removal of disclosed

plaque by brushing is preferred to simply

advising chemical soaking. However, without

assistance brushing becomes a problem when

the patient is unable to use one hand, for

example due to injury or a stroke. A possible

solution is suggested below.

 e healthy individual can be expected to

respond to oral hygiene advice but this may

not be the case with patients who are seriously

in rm and/or residents in care establishments,

and this can pose a serious problem. It is

now recognised that dental and denture

plaque allow the colonisation of respiratory

pathogens.

‘Dentures should be considered

an important reservoir of organisms

which could colonise the pharynx, and the

importance of controlling denture plaque

for the prevention of aspiration pneumonia

cannot be overemphasised.’

Where rigorous

oral hygiene procedures have been instituted

a reduction in the rate of pneumonia and

deaths has resulted.

Oral care assistance

A Swedish study

compared the di erences

in attitude to the maintenance of oral health

PNEUMONIA CANNOT BE OVEREMPHASISED.’

PLAQUE FOR THE PREVENTION OF ASPIRATION

‘THE IMPORTANCE OF CONTROLLING DENTURE

Fig. 6 Denture lightly impressed into the

laboratory putty

Fig. 5 A denture box

Fig. 7 Impression left by the denture

Fig. 9 Resin bonded bridge with

cingulum rests

Fig. 8 The patient is able to steady the box

with his left hand

Fig. 10 Kennedy Class 1 denture with a

cingulum bar major connector

Fig. 11 Kennedy Class 1 denture replaced

into the silicone impression to avoid

accidental damage when cleaning

FEATURE

www.nature.com/BDJTeam BDJ Team 18

in dependant elderly and severely disabled

patients in a group of 398 health workers.

ey were asked regarding a) personal oral

healthcare habits b) experience and attitudes

in assisting oral care and c) willingness to

assist patients/residents with their daily oral

hygiene. is study revealed that oral care

assistance is viewed as more disagreeable than

other nursing activities.

Another study

found that nursing sta

considered oral care the most distasteful

aspect of their work (Fig. 4). ey said they

would ‘rather clean up aer bowel movements

or attend to urinary incontinence accidents

than brush a resident’s teeth’.

e denture biolm attached to removable

partial dentures (Fig. 12) will place teeth

at risk, in particular the abutment teeth.

Acrylic resin partial dentures, as with

complete dentures, are prone to fracture if

dropped onto a hard surface whereas metal-

based dentures are more resistant to this

danger, but nonetheless can distort aer being

dropped or by mishandling during cleaning.

is is most likely to occur with a mandibular

denture

with a lingual or cingulum bar

major connector.

As with complete dentures,

cleaning partial dentures may be le to a carer

with the possibility of neglect or damage.

As has been stated, for most individuals the

simplest way to remove the denture biolm

is by mechanical cleaning with a toothbrush

and a non-abrasive paste, at least once a day.

As an adjunct to this, the denture can be

soaked twice a week in 0.1% hypochlorite

solution or chlorhexidine solution for 15-30

minutes.

Long-term nocturnal use should be

discouraged.

According to Manfredi et al.

leaving dentures to soak overnight is counter

to ‘hygienic logic’ because organisms that

inhabit the biolm do not survive prolonged

drying out. ere is no evidence to support

the view that leaving them to dry overnight

will cause warpage of the acrylic.

To summarise, both complete and partial

dentures require careful removal of the

denture biolm. However, this may not be

carried out because:

■

 e patient is unaware of the need to

do this

■

 e patient is unable to physically carry

out the cleaning

■

 e carer nds the process unpleasant and

may do this perfunctorily or even avoid it

■

 In the process of cleaning, the denture

may be prone to fracture or distortion

if mishandled.

The denture box

is is a simple device to hold the denture in

place during cleaning (Fig. 5). It reduces the

risk of fracture and distortion of a prosthesis.

It will also allow a carer minimal handling of

the denture and allow its storage with reduced

risk of ‘getting lost’. In an institution its

‘footprint’ will make positive discovery of the

owner certain.

One half of an orthodontic retainer or

denture box (or a soap box) is lled with

activated laboratory putty (Fig. 6). e

occlusal surface of the denture is pressed

into the putty suciently deeply to produce

rm retention. e denture can be replaced

in the negative impression and the surface

rigorously cleaned with a brush. Where the

patient has the loss of the use of a hand, the

box can be steadied while brushing or it can

be secured on its base with a suction pad or a

fabric fastener.

e occlusal surface of the denture can be

similarly displayed, following an imprint of

the intaglio surface in the lid of the box if it

has sucient depth (Fig. 7).

Fig. 12 The disposition of plaque on the denture is shown with a disclosing solution

Fig. 13 The occlusal surface of the denture is placed in the base of the denture box. The fitting

surface is impressed in the lid

FEATURE

19 BDJ Team www.nature.com/BDJTeam

Case history 1

An 80+ male patient in indierent health had

suered a recent stroke that prevented the

normal use of his le hand. He was provided

with an acrylic partial overlay denture,

primarily to replace his upper front teeth. e

denture was embedded in the silicone putty

and he was able to steady the box with the le

hand allowing the right hand to brush (Fig. 8).

Case history 2

e patient has been provided with a resin-

bonded bridge to replace the lower incisor

teeth with wings on the canines (Fig. 9).

Cingulum rests have been added to the canine

wings to receive the cingulum bar major

connector of the Kennedy Class 1 denture

(Figs 10 and 11).

Case history 3

e cingulum bar connector does not impinge

on the gingival margins but the abutment

teeth, in the presence of plaque, are still prone

to damage (Figs 12 and 13).

Storage

e denture box provides a secure method

of storage particularly in an institutional

environment where it is not unusual for

dentures to be wrapped in tissue and

inadvertently discarded. In addition, where

the denture is not marked for identication,

it is possible for the ownership of a denture to

be confused with others. e imprint of the

denture being unique to the individual can

be used to reclaim it to its owner. e imprint

can be kept clean by washing under a tap and,

if required, a small amount of chlorhexidine

gluconate can be le in situ when stored.

1. NHS Information Centre. Adult dental health

survey – rst release. 2009, amended 2010. Online

information available at http://www.hscic.gov.uk/

pubs/dentalsurveyrstrelease09 (accessed November

2014).

2. omason J M J, Feine J, Exley C et al. Mandibular

two implant-supported overdentures as the rst

choice standard of care for edentulous patients – the

York Consensus Statement. Br Dent J 2009; 207:

185–186.

3. Alani A, Bishop K, Renton T, Djemal S. Update

on guidelines for selecting appropriate patients to

receive treatment with dental implants: priorities

for the NHS – the position aer 15 years. Br Dent J

2014; 217: 189–190.

4. Ellis J S, Levine A, Bedos C, Mojon P, Rosberger

Z, omason J M. Refusal of implant supported

mandibular overdentures by elderly patient.

Gerodontology 2011; 28: 62–68.

5. Felton D, Cooper L, Duqum I et al. Evidence-based

guidelines for the care and maintenance of complete

dentures: a publication of the American College of

Prosthodontists. J Prosthodont 2011; 20 (Suppl 1):

S1–S12 .

6. Watt D M, MacGregor A R. Designing complete

dentures. 2nd ed. Bristol: Wright, 1986.

7. Coulthwaite L, Verran J. Potential pathogenic aspects

of denture plaque. Br J Biomed Sci 2007; 64: 180–

189.

8. Verran J. Malodour in denture wearers: an ill-dened

problem. Oral Dis 2005; 11 (Suppl 1): 24–28.

9. Scully C, EI-Kabir M, Samaranayake LP. Candida

and oral candidosis: a review. Crit Rev Oral Biol Med

1994; 5: 125–157.

10. Gendreau L, Loewy Z G Epidemiology and etiology

of denture stomatitis. J Prosthodont 2011; 20: 251–

260.

11. Chernosky M E. Collagen implant in management

of perléche (angular cheilosis). J Am Acad Dermatol

1985; 12: 493–496.

12. Basker R M, Davenport J C. Prosthetic treatment of

the edentulous patient. 4th ed. Oxford: Munksgaard,

2002.

13. de Souza R F, de Freitas O, Paranhos H, Lovato da

Silva C H, Abu-Naba’a L, Gurgan C A. Interventions

for cleaning dentures in adults. Cochrane Database

Syst Rev 2009; 4: CD007395.

14. Azarpazhooh A, Leake J L. Systematic review of the

association between respiratory diseases and oral

health. J Periodontol 2006; 77: 1465–1482.

15. Sumi Y, Kagami H, Ohtsuka Y, Kakinoki Y,

Haruguchi Y, Miyamoto H. High correlation

between the bacterial species in denture plaque and

pharyngeal microora. Gerodontology 2003; 20:

84–87.

16. El-Solh A A. Association between pneumonia and

oral care in nursing home residents. Lung 2011; 189:

173–180.

17. Wårdh I, Andersson L, Sörensen S. Sta attitudes to

oral health care. A comparative study of registered

nurses, nursing assistants and home care aides

Gerodontology 1997; 14: 28–32.

18. Dharamsi S, Jivani K, Dean C, Wyatt C. Oral care

for frail elders: knowledge attitudes, and practices of

long term care sta. J Dent Educ 2009; 73: 581–588.

19. do Amaral B A, Barreto A O, Gomes Seabra E,

Roncalli AG, da Fonte Porto Carreiro A, de Almeida

E O. A clinical follow-up study of the periodontal

conditions of RPD abutment and non-abutment

teeth. J Oral Rehabil 2010; 37: 545–552.

20. Pienkos T E, Morris W J, Gronet P M, Cameron

S M, Looney S W. e strength of multiple major

connector designs under simulated functional

loading. J Prosthet Dent 2007; 97: 299–304.

21. Meeuwissen R, Keltjens H M, Battistuzzi P G.

Cingulum bar as a major connector for mandibular

removable partial dentures. J Prosthet Dent 1991; 66:

221–223.

22. Manfredi M, Polonelli L, Aguirre-Urizar J M,

Carrozzo M, McCullough M J. Urban legends series:

oral candidosis. Oral Dis 2013; 19: 245–261.

23. Compagnoni M A, Souza R F, Marra J, Pero A C,

Barbosa D B. Relationship between Candida and

nocturnal denture wear: quantitative study. J Oral

Rehabil 2007; 34: 600–660.

bdjteam201534

FEATURE

www.nature.com/BDJTeam BDJ Team 20

Rules

for shared parental leave

By Alan Pitcaithley, practice management consultant

arents will soon be legally

entitled to share statutory

leave following the birth

or adoption of a child. is

‘shared parental leave’ will

apply to eligible parents of

babies due, or children placed for adoption,

on or aer 5 April 2015. It allows employees

to break their absence from work into

separate blocks and to share some of the

leave with their spouse or partner. Potentially,

eligible parents, in the rst year of a child’s

birth or adoption, will be able to dip in and

out of their job, taking time o to provide care

for the child.

Greater flexibility

e idea is to allow greater exibility for new

parents in setting their work-life balances in

their child’s rst year. is will have an impact

on employers and there are, therefore, precise

procedures to be followed.

e mother would normally be able to

take up to 52 weeks’ maternity leave. Shared

parental leave allows a mother to turn her

maternity leave into shared parental leave.

e actual amount of shared parental leave

available depends on how much maternity

leave is taken.

Since a mother must take at least two

weeks’ compulsory maternity leave following

the birth of their child, there could be up to

50 weeks of shared parental leave available.

Any week or weeks of maternity leave taken

by the mother before the birth of the child or

aer the two weeks of compulsory maternity

leave reduces the shared parental leave

available by a corresponding amount. e

remaining amount of shared parental

leave can be used by either the mother

or her spouse or partner to take time

o work to look aer the child.

It is the mother’s initial

choice whether

or not to opt

for shared

parental

leave, but

once that

choice

has been

made the

couple must

agree when

they should

take leave.

ey may

choose

to take

time o at

the same time,

consecutively or

alternately. Whatever their

decision, shared parental leave must be

taken by the child’s rst birthday – any

unused leave at that date would be lost.

Written notice

To use these rights, eligible parents (Table

1) must give their employer proper written

notice; in fact, three dierent notices.

First, the mother must give notice to end

her maternity leave and change over to shared

parental leave. Second, both parents must give

their employers a notice of entitlement letter

that sets out their basic eligibility (Table 2).

Finally, each must provide a notice of leave

letter that species the actual dates that the

employee wishes to take as shared parental

leave. It should include the start date, end

date and overall amount of leave to be taken,

which must be in full weeks. Each notication

fulls a specic purpose but the employee

could combine them all into one letter.

Time limits are important. Eight weeks’

notice must be given, both by the

mother to switch over from

maternity leave and by either

parent before the start of a period

of shared parental leave.

A mother must:

■

 Be an employee entitled to

maternity leave or self-employed

and entitled to maternity allowance

■

 Have given notice to end her

maternity leave and take shared

parental leave.

A partner must:

■

 Be the mother’s spouse, civil

partner or partner (who is a person

in a long-term relationship with the

mother and living with the mother

and child), or the child’s biological

father (even if they are not in a

stable relationship with the mother)

■

 Share the primary parental

responsibility for the child with the

mother at the time of the birth

■

 Be an employee, who is entitled to

paternity leave.

Table 1 Who can share the leave?

©AnaBGD/iStockphoto/Thinkstock

FEATURE

21 BDJ Team www.nature.com/BDJTeam

Continuity

A major change introduced by shared parental

leave is the facility to divide leave into

separate blocks, where a parent can return to

work between blocks and go back on leave

later on. Each block must, however, be made

up of full weeks.  is could cause diﬃ culties

for an employer, so how a practice responds

to a notice of leave letter will depend on if the

employee is asking for a continuous period of

leave or a series of separate blocks.

If a continuous period of shared parental

leave is requested, this request must be agreed.

But if the employee asks for two or more

separate blocks of leave – which would be

interspersed by periods back in work – this is

subject to the approval of the employer.

If you have an objective business or

operational reason to refuse a request for

leave to be taken in blocks you can. But you

must respond in writing, setting out your

reason within two weeks. In this situation, the

employee’s overall amount of requested leave

defaults to a single period of leave to begin

on the original start date for their intended

 rst block of leave. You should ensure that

your employee understands these default

provisions because they can change the start

date by amending their notice of leave or

could withdraw their request altogether.

Being able to refuse a request for shared

parental leave to be taken in separate blocks

would seem to negate the employee’s new

right but an employee can submit three

separate notice of leave letters within the year.

If each one asks for a continuous block of

leave then, as currently understood, each of

these three blocks of leave would have to be

agreed. But this provision has given rise to the

misconception that shared parental leave can

only be taken in three distinct blocks. While

this is the default situation where an employee

gives you three separate notice of leave letters,

they could in any of these requests ask for

their leave to be split into many more parts.

It is therefore theoretically possible that an

employee could take 25 blocks of shared

parental leave, working one week on and one

week o up to the child’s  rst birthday.  is

pattern of shared parental leave would require

an employer’s agreement but in some job roles

could occur under the new arrangements.

Shared parental pay

Most mothers taking maternity leave will be

entitled to Statutory Maternity Pay (SMP),

which is available for up to 39 weeks. If an

employee opts into shared parental leave

then the Statutory Maternity Pay remaining

becomes available as Shared Parental Pay

(ShPP).  is can be claimed by either partner

while on shared parental leave.  e eligibility

for each partner is based on the same earnings

criteria for Statutory Maternity Pay and

Statutory Paternity Pay.

If both parents qualify for ShPP, they must

decide who will receive it or how it will be

divided. Each must inform their respective

employers of how much ShPP each parent

intends to take and when they expect to take

ShPP.  ey must also include a declaration

from the employee’s partner con rming their

agreement to the employee claiming their

amount of ShPP. It is expected that this notice

would be given at the same time as a notice of

leave letter.

Another way to SPLIT it

 e concept of Keeping-in-Touch (KIT)

days that apply to maternity leave has been

extended to shared parental leave.  is allows

an employee to attend work during a period

of leave for training purposes or just to stay

up to date with what is happening in their

workplace.

Under shared parental leave these are

known as Shared-Parental-Leave-In-Touch

(SPLIT) days; up to 20 SPLIT days are

available overall to be shared by the parents.

 e employees should contact their employers

to discuss the date or dates of SPLIT days

that they wish to work, though there is

no obligation on either party to agree to a

speci c date.

Sharing adoption leave

 e right to opt into shared parental leave also

applies to employees who are on adoption

leave. From the end of a compulsory period

of adoption leave, that is two weeks a er the

placement of the child, the adopter can opt

into shared parental leave and share some

of this with their partner or co-adopter.  e

same rules and procedures apply to giving

notice, taking leave and claiming ShPP.

More details

Shared parental leave is a new system and

exactly how it will work for businesses,

employers and employees remains to be seen.

If your principal is a BDA member, the BDA

Advice Employees maternity and parental leave

and pay (see www.bda.org/advice) provides

further information.

bdjteam201535

A notice of entitlement letter must

include the following:

■



The date that the child is expected

or their actual date of birth

■



The spouse’s or partner’s name

■



The spouse’s or partner’s address

and National Insurance number

■



Confirmation that the spouse

or partner shares childcare

responsibility

■



The amount of shared parental

leave available overall for both

parents

■



The dates of any maternity leave

that will be, or has been, taken

■



The amount of shared parental

leave that the employee intends to

take

■



The amount of shared parental

leave their spouse or partner

intends to take

■



A personal declaration that the

employee meets the eligibility

criteria for shared parental leave

and that all the information

provided is accurate

■



A signed declaration from the

employee’s spouse or partner that

they meet the eligibility criteria for

shared parental leave.

Table 2 Notice of entitlement letter

HAVE AN IMPACT ON EMPLOYERS AND THERE ARE,

employee’s spouse or partner that

they meet the eligibility criteria for

shared parental leave.

THEREFORE, PRECISE PROCEDURES TO BE FOLLOWED.’

criteria for shared parental leave

and that all the information

provided is accurate

■

A signed declaration from the

HAVE AN IMPACT ON EMPLOYERS AND THERE ARE,

LIFE BALANCES IN THEIR CHILD’S FIRST YEAR. THIS WILL

NEW PARENTS IN SETTING THEIR WORK-

‘THE IDEA IS TO ALLOW GREATER FLEXIBILITY FOR

FEATURE

www.nature.com/BDJTeam BDJ Team 22

As a dental professional you often advise patients to cut down

their sugar intake, but are your own sugar cravings under

control? asks Laura Thomas

Practising what you preach

You know that your patients’ sugar habits end

up costing them greatly in terms of dental

treatment and you’re regularly dealing out low

sugar lifestyle advice to help them. However,

sometimes you  nd yourself craving sugar

and succumbing to a few more chocolates

than you’d like. Keen to live by your messages,

what can you do to get more control over your

own sugar cravings and protect your own

health from the white stuﬀ ?

Other impacts of sugar

In addition to attacking teeth and enamel,

an excess of sugar has all sorts of other

detrimental impacts on your body.

Re ned sugar, whether in its raw form or

in a processed food like a tomato sauce, is

made up of 50% glucose and 50% fructose.

You need to know that fructose is metabolised

very diﬀ erently to glucose - it’s processed

exclusively by the liver. Consuming an excess

of fructose (sugar) puts serious strain on

this vital organ which can lead to a number

of ailments including non-alcoholic fatty

liver disease and elevated levels of uric

acid (contributing to gout). It’s also worth

noting that excess fructose consumption

over a sustained and long period of time

can increase the risk of the serious chronic

diseases (eg diabetes) that are plaguing the

Western world today.

Sugar also plays havoc on your blood sugar

management, impacting on your sleep quality,

concentration and energy levels. It weakens

your immune system and speeds up the

ageing process.

Finally, sugar is addictive. Over time, a

gradual increase in consumption can start

to negatively aﬀ ect your behaviour.  is can

result in you needing more sweet food to

satisfy your sweet tooth.

Reminding yourself of these reasons can

help motivate you to take consistent actions to

reduce the sugar in your diet.

So what can you do to shi your taste buds

away from sweet?

Stop drinking sugar

It’s likely that because you know about the

detrimental impacts of sugary so drinks

on teeth and

enamel, you

aren’t chucking back half a dozen  zzy drinks

during the day. However, it’s worth being

aware of the more covert sources which may

be exposing your palate frequently to the

sweet taste that drives cravings.

 e sweetener in your tea, the smoothie

drink on the go or that tonic water in your

gin tipple are all still sweet drink sources that

you may not realise have become somewhat

habitual in your routine or lifestyle. Seek to

identify those last few places where you are

drinking sugar and work to eliminate sugar

in all liquid forms. Adapt to unsweetened tea

or coﬀ ee; use fresh lemon or lime to  avour

water [editor’s note - but use a straw to protect

your tooth enamel!] and opt for the whole

 bre rich fruit instead of a sugar condensed

smoothie.

Lower sugar substitutes of your

favourite foods

Quite o en there can be a big diﬀ erence in

sugar content between brands of the same

food. Spending a little time researching and

 nding the ones that don’t have as much

added sugar shaves oﬀ a few grams that

can make a diﬀ erence if you’re eating these

products daily. Muesli, sauces and dressings

are all good items to do this with. By doing

this you’re also becoming aware of the great

lower sugar products that you can easily

recommend to your patients.

Laura Thomas is a certified health coach

and the founder of Happy Sugar Habits,

an organisation working to educate

and support individuals to reduce their

sugar consumption, and feel a sense of

control over their sweet cravings. Laura

runs a successful Mentor Me Off Sugar

detox programme and speaks nationally

about sugar, emotional eating and the

practicalities of a low sugar lifestyle.

Laura was the former the presenter of

The Sugar Diaries radio show for

UK Health Radio, has written for The

Telegraph and the Daily Mail and has

recently been featured in Elle and Grazia

magazines. Find out more at www.

happysugarhabits.com.

Are you addicted to

sugar?

FEATURE

23 BDJ Team www.nature.com/BDJTeam

Being

mindful of

total sugar

(especially fructose)

As mentioned earlier,

fructose is the more

dangerous part of sugar.

Although fruits and natural sources of sugar

have nutritional benet and are healthy in

many respects, they are still sweet and you’re

likely to still experience powerful cravings if

you’re consuming them excessively.

To keep cravings at bay, be mindful of

the total amount of sweet food in your

diet (including fruit), the quantities you’re

consuming and how oen you’re eating it. Be

particularly wary of dried fruit products and

fruit purees that tend to be very concentrated

sources of sugar. If something says ‘rened

sugar free’ always check that it’s not just been

jam packed full of ‘natural’ dried fruit sugar.

Avoid hidden sugar

It goes without saying: avoid sugar that you

don’t know you’re eating. Double check

sauces, dressings, cereals, soups etc. Look to

make your own where you can and cut back

on processed foods as much as possible.

Consider your use of sugar

It’s very common for people to use sugar as

a stress coping mechanism. It’s accessible,

cheap, quick and easy. Take note if you’re

consuming sugar in response to emotional

hunger. Seek to build in other coping

mechanisms that don’t involve sweet food eg

some yoga or a run, something relaxing like a

walk or a simple breathing exercise.

Embrace the savoury foods you love

To avoid the doom and gloom feeling of

eating less sugar, embrace your favourite

savoury foods in all their forms. Try new

combinations of them, be more experimental

with foods and try to enjoy the process of

nding savoury alternatives that you really

get excited about.

Work through social challenges

Oen it’s the social side of sugar that can be

particularly challenging:

the birthdays, weddings

and numerous annual

occasions that are

closely associated

with excessively

sugary food. Seek to

understand if you’re

eating sugar because

bdjteam201536

Have you had a go at this recipe? Let

us know how your flapjacks turned

out and send a photo of the results to

bdjteam@nature.com or upload it on

the BDJ Team Facebook page www.

facebook.com/bdjteam.

These have all the satisfaction of a flapjack but with a savoury twist and no sugar

in sight. Great as a quick breakfast bar or as a substantial snack. The pumpkin and

chia seed topping is optional to simply boost the nutritional count and make them

look pretty!

RECIPE: Savoury olive & almond flapjacks

Makes 8 large bars or 16 smaller bites

Ingredients

200g rolled oats (2 cups)

300ml milk (1½ cups)

75g almonds (½ cup)

20g parmesan cheese (⅓ cup, grated)

60g black pitted olives (½ cup)

½ tsp salt

2 tbsp dried oregano

2 tbsp ground flaxseed

1 tsp cumin seeds

1 tsp chilli flakes

1 tbsp chia seeds (optional)

1 tbsp pumpkin seeds (optional)

Method

■

 Preheat the oven to 180C and line

an 8-inch square tin with parchment

paper

■

 In a medium bowl, mix the oats, salt,

herbs and spices together with the

ground flaxseed

■

 Add the milk and leave it to soak for

10 minutes whilst you prepare the rest

■

 Roughly chop the olives, almonds and

grate the parmesan cheese

■

 Add these ingredients to the mixture,

stir well

■

 Pour the mixture into the tin and

spread evenly

■

 Sprinkle over the chia seeds and

pumpkin seeds

■

 Bake for 45 minutes, remove and

let cool

■

 Slice into bars or squares

■

 Keep refrigerated in an airtight

container for up to 3 days

everyone else is, or if it’s closely tied to the

joy you feel at these events and celebrations.

Building awareness of your sugar habits

in social situations is the rst best step to

adjusting them.

For more tips, recipes and a free low

sugar snack guide to get control over sugar

cravings visit and sign up for updates at www.

happysugarhabits.com.

Training

Essentials

BDA special events oer

*This oer cannot be booked online and cannot be applied to events already booked or two day courses. For full terms and conditions please visit our website.

DCPs book one course for £135 Get one course FREE

Check the website www.bda.org/training for event details.

To book call:

020 7563 4590

@BDAEvents

Courses available cover CORE CPD,

GDC recommended, and business and

personal development topics:

Setting yourself up in practice

Management of medical emergencies

Safeguarding children and vulnerable adults

Growing your practice

Leading the dental team

Performance appraisals

An IRMER course in dental radiography

and radiation protection

Oral cancer

Online marketing and social networking

Handling complaints

Infection control

Getting better results with business planning

Book any Training Essentials

course* and get one Training

Essentials course FREE to

help top up your CPD hours

in 2015.

25 BDJ Team www.nature.com/BDJTeam

he aim of this article is to

give a practical approach

to the subject of waste

management and segregation

in general practice. It is my

intention that this could

be used as a tool in practice to develop the

waste management and segregation protocol

and policy. It can equally be used for an

individual’s development as veriable CPD in

the core subject of infection control.

Waste produced as a result of any

healthcare activity, like dentistry, is

classied as clinical waste. Health Technical

Memorandum 01-05 (HTM 01-05) states that:

‘e Registered Manager is solely

responsible for ensuring that waste is:

■

Correctly segregated

■

Stored safely and securely away from areas

of public access within the premises

■

Packaged appropriately for transport

■

Described accurately and fully on the

accompanying documentation when removed

■

Transferred to an Authorised Person for

transport to an authorised waste site

■

Appropriately registered, with necessary

records and returns at premises.

e Registered Manager should also

ensure that all sta are trained and aware

of the waste procedures.’

Most of the requirements can be found

in HTM 07-01 (Safe management of healthcare

waste) which is followed for England, Wales

and Scotland but not Northern Ireland.

Clinical waste

Clinical waste is any waste which consists

wholly or partly of human or animal tissue,

blood or other bodily uids, excretions,

drugs or other pharmaceutical products,

swabs or dressings, syringes, needles

or other sharp instruments, being waste

which unless rendered safe may prove

hazardous to any person coming into contact

with it.

Also, any other waste arising from medical,

nursing, dental, veterinary, pharmaceutical

or similar practice, investigation, treatment,

care, teaching or research, or the collection of

blood for transfusion, being waste which may

cause infection to any person coming into

contact with it.

It is vital that ONLY sta members

FEATURE

WASTE

How to dispose of hazardous

CORE

CPD:

ONE HOUR

Do you know what constitutes hazardous waste and how to dispose of it

correctly? Mhari Coxon RDH discusses waste segregation and management

in dentistry.

©iStockphoto

FEATURE

www.nature.com/BDJTeam BDJ Team 26

who have a certied Hep B immunisation

should be handling clinical waste. Cleaners

should NOT touch it unless they have been

immunised and are aware of the protocols and

polices and have had adequate training.

Correct segregation

Is the waste a healthcare waste? Table 1 shows

us how we can dene and categorise our waste

in practice.

Hazardous waste must be disposed of

without endangering human health or the

environment and be capable of being traced

from the point of production to the point of

disposal (Table 2).

Colour description for bagging day

to day waste

Orange bags – infectious or anatomical

waste which requires incineration.

Yellow bags with black stripes – continence

pads and other waste produced from human

hygiene (urine, faeces, sputum, tears, nasal

secretions, vomit). Disposed equipment that

does not pose a risk of infection (inhalers,

gowns, gloves, and plaster casts).

Purple cytotoxic and cytostatic waste (waste

which requires treatment to be ‘rendered safe’.

Unlikely to nd this in a dental environment

but you should recognise the danger of these

waste bags or buckets).

Black Domestic waste for landll – also most

authorities have recycling bags you can buy as

a business which vary in colour.

White Amalgam waste for recovery (includes

extracted teeth with amalgam present and

cages from suction if amalgam was removed).

Red Healthcare waste for special recovery eg

X-ray processing chemicals.

Lead foil

Lead foil is now classied as non-hazardous

waste and there is no longer any need for it to

be collected by licensed contractors.

Sharps waste

Sharps are items that could cause cuts or

puncture wounds – including needles,

syringes with needles attached, broken

glass ampoules, scalpels and other blades or

infusion sets.

Orange lidded sharps bins are for hazardous

sharps not contaminated by prescribed

medicines. is bin would include extracted

teeth with no amalgam in them and scalpels.

Yellow lidded bins are suitable for local

anaesthetic cartridges and botox ampules

as they are for sharps, including infectious

sharps, for incineration only. Marked with

‘Medicinal Sharps’. For use with sharps

waste including those contaminated with

medicines other than those which are

cytotoxic/cytostatic.

Again, not likely to be in general practice,

purple lids are for those medicines and

sharps which are cytotoxic/cytostatic.

Waste handling

NEVER:

■

row bags

■

Carry close to body

■

Empty one bin into another

■

Attempt to retrieve items from waste

■

Leave waste areas unsecured

■

Overll bags or containers

■

Allow waste to build up – contact

Environmental Manager if additional

collection is required.

ALWAYS:

■

Apply Standard Infection

Control Precautions

■

Wear Personal Protective Equipment (PPE)

■

Carry out hand hygiene

■

Provide patients with a

waste receptacle

■

Dispose of waste immediately at point

of use

■

Label and secure correctly

■

Give information to patients/carers on

appropriate waste disposal.

Storage of waste

Within the clinical area:

■

Solid sided, foot operated bin

■

Bags not more than three-quarters full

■

Segregation of waste streams

Table 1 Defining and categorising waste in the practice

Hazardous waste Non-hazardous waste

Infectious waste (eg sharps, anatomical

waste, implanted medical devices). Any

waste which poses a known or potential

risk of infection.

Offensive/hygiene waste (eg human

incontinence and other human hygiene,

sanitary waste, nappies, stoma bags).

Waste which may cause offence to those

coming into contact with it.

Cytotoxic and cytostatic medicines

Non-cytotoxic and cytostatic medicines

(expired, unused, spilt and contaminated

pharmaceuticals, bottles and boxes with

residue, masks, connecting tubing, syringes,

drug vials, vaccines, medicinal patches

and sera).

Health care chemicals and hazardous

properties

Domestic waste (uncontaminated

paper towels, flowers, materials which are

unsuitable for recycling).

Batteries (single-cell or Ni-cad batteries) Packaging waste

X-ray photo chemicals

Recyclable materials (cardboard, non-

confidential paper, drinks cans, bottles,

plastic, toner/ink cartridges, cooking oil).

Mercury (from dental amalgam,

spillage from thermometer/

sphygmomanometer, from electrical

switch/battery or fluorescent discharge

lamps).

Confidential paper waste

Other chemicals eg paint, solvents,

some cleaning materials, laboratory

chemicals

Grounds waste

Radioactive waste Food waste

Contaminated furniture or equipment

Uncontaminated, unwanted or broken

furniture or equipment

Asbestos and some construction/

demolition waste

Construction/demolition waste following

risk assessment

FEATURE

27 BDJ Team www.nature.com/BDJTeam

Table 2 Instructions for disposal of waste

Type of waste Instructions for disposal

Anatomical waste

Must be placed in appropriate UN approved container, labelled

and sealed for incineration. Container must not be placed inside

a bag.

Equipment and

furniture

If contaminated, contact waste contractor. If decontaminated

must have a certificate before disposal.

Radioactive waste

Contact Radiation Protection Supervisor or Environmental

Manager for advice.

Dental waste

Teeth are non-anatomical infectious waste – orange stream

Teeth with amalgam must be segregated into white rigid

container with mercury suppressant

Dental practices must have an amalgam separator

Mercury

Areas where mercury is in use must have a spillage kit. Staff

within the area must know how to use the kit. Instructions should

be looked at at intervals as a team.

Medicinal waste

Expired prescription drugs should be handed in to a local

pharmacy for disposal

Chemical waste

Any chemicals in use within healthcare must have a COSHH risk

assessment.

Staff in areas where chemicals are used/disposed must know

how to handle and dispose of them appropriately.

Surgical

instruments

Must be transported in designated, correctly labelled rigid,

locked container to/from decontamination area.

■

Not le in corridors or public spaces

■

Disposed of as soon as possible

■

Tied securely

■

Bins kept clean inside and out.

Aer removal from clinical area:

■

Securely away from public access

■

Safe from pests and animals

■

In locked wheeled bins (available from

your contractor)

■

Away from other items

■

In an area where hand hygiene facilities

are close by (could be wall mounted

hand disinfectant).

Sealing and tagging

Bags must be:

■

No more than three-quarters full

■

Release air to avoid bursting bag

■

Secure the bag using tags or double

tie method

■

Label with department/surgery in which

the waste was generated (for audit

purposes) and with correct European

Waste Code.

European Waste Catalogue (EWC) codes

are mandatory for all waste documentation

– ie it is necessary for the documentation

which accompanies the consignment of

waste containers to state what the waste

is, including its classication per the EWC

(Table 3). Contaminated sharps could t into

any one of approximately ten EWC codes

dependent on particular circumstances. If

the container label includes the EWC code,

then there is a likelihood either that the code

will be wrong or that a substantially greater

number of containers will be required. is is

why it must be written on by the clinician and

initialled again for audit purposes.

Personal Protective Equipment

ALL sta handling waste must have access to

appropriate PPE. In most instances disposable

gloves and an apron will suce. Heavy duty

gloves must be available for use if required.

If uniform/clothing becomes contaminated

they must be changed immediately.

Training

It is essential that every team member

handling clinical waste be aware of how to

segregate, label and dispose of waste safely.

Training should be reviewed annually and

audited at intervals. e sta members should

accept responsibility for how to manage

themselves in this regard once adequate

training has taken place.

Paper trail of safe disposal

It is essential that all documentation to

and from your registered waste collection

company is kept on le. Your waste collection

company will also be able to give you a copy

of their licence and policies for your le.

is article was originally published in Vital

in 2011 as e whys and wherefores of waste.

To take part in the veriable CPD questions

associated with this BDJ Team article,

visit www.nature.com/bdjteamcpd

(free subscription required).

bdjteam201537

Table 3 EWC codes

18 01 01

Sharps (except 18 01 03)

LA cartridges for example

18 01 02

Body parts and organs

including blood bags and

blood preserves (except

18 01 03)

18 01 03 Infectious waste

18 01 04 Offensive waste

18 01 08

Cytotoxic and

cytostatic medicines

18 01 09

Medicines other than those

mentioned in 18 01 08

18 01 10 Dental amalgam waste

‘ All staff

handling

waste must

have access

to appropriate

PPE.’

PRODUCTS

Products

& services

HELPING YOU IDENTIFY ACID WEAR

Product news is provided as a service to readers using text and images from

the manufacturer, supplier or distributor and does not imply endorsement

by BDJ Team. Normal and prudent research should be exercised before

purchase or use of any product mentioned.

CELEBRATING

THREE DECADES

OF TALKING POINTS

GSK, manufacturers of

Aquafresh, Corsodyl,

Poligrip, Pronamel

and Sensodyne,

is inviting dental

professionals

to join them to

celebrate 30 years of

Talking Points in Dentistry.

The postgraduate lecture series ﬁrst

launched in 1985 and is open to all

members of the dental team.

This year in celebration of the 30-year

heritage of the programme we ask:

‘Who will be the patient in 2045 and

what will they want?’ The lectures will

reﬂect on the changes that have

occurred in the dental industry over

the last 30 years and how delivery of

dental care will continue to evolve in

the future.

Over the last 30 years more than

60 industry experts and professionals

have delivered lectures to thousands

of delegates. Many things have

evolved during that time, but the core

focus has remained to provide topical

and thought provoking content.

The lecture series will visit ﬁve venues

across the UK during May:

■

12 May 2015 – Titanic Belfast

■

14 May 2015 – Dynamic Earth,

Edinburgh

■

18 May 2015 – National Motorcycle

Museum, Solihull

■

20 May 2015 – National Museum,

Cardiff

■

27 May 2015 – Royal Institute,

London.

To book your place at your nearest

venue simply visit www.gsk-dentalpro-

fessionals.co.uk. Tickets are allocated

on a ﬁrst come, ﬁrst served basis and

limited to a total of six per practice, so

book now!

TAKE ACTION AGAINST PERIODONTITIS

New from oral healthcare specialist Curaprox is the perfect pocket minimiser for the

treatment of chronic and aggressive periodontitis.

Adjusan combines the active ingredient doxycycline with a novel design for easy

subgingival application, high tolerability and optimum efﬁciency. The effective and

uncomplicated single administration is easily applied via the practical cylinder

cartridge. The local antibiotic has the ability to kill key

microorganisms whilst remaining safe for the patient.

Adjusan’s most impressive characteristic is its

innovative gel-like consistency. The initial ﬂowable form

allows you to reach the deep areas of the periodontal

pocket, remaining in place as its viscosity increases

in the aqueous environment. The active ingredient is

released continuously over at least 12 days, enabling

pocket depth to be reduced and attachment

level enhanced.

For more information call 01480 862084 or visit www.

curaprox.co.uk

The results of ESCARCEL, the ﬁrst and

largest pan-European Epidemiology

study to assess the prevalence and risk

factors for acid wear, offers unparalleled

insights into the condition.

The study revealed just how

widespread acid wear is in young

adults across Europe, with one in three

exhibiting clinical signs. Of particular

concern is the evidence that this ﬁgure

is signiﬁcantly higher in the UK.

ESCARCEL found that those aged

26-35 years were most affected by acid

wear, and exposed to what extent

conditions such as frequent heartburn

or acid reﬂux contribute.

Acid wear is an irreversible condition.

The best way to manage it is prevention.

As identiﬁcation of the early clinical

signs is the ﬁrst step in helping to

protect patients from further damage,

the BEWE (basic erosive wear

examination) tool can help support

your understanding. Developed

with Professor David Bartlett, Head of

Prosthodontics from King’s College

London Dental Institute, the tool is split

into three simple steps which can help

you to assess patients’ level of risk and

ultimately aid your treatment decision.

GSK has launched the Pronamel

BEWE and acid wear mobile app to help

support you in detecting acid wear. Use

the simple app on-the-go as an easy

reference guide for the background to

the condition, the BEWE tool and tips for

patient management. Download the

app from the iTunes App Store now, just

search ‘bewe’.

1. Bartlett D W,

Lussi A, West N X,

Bouchard P, Sanz

M, Bourgeois D.

Prevalence of

tooth wear on

buccal and

lingual surfaces

and possible risk

factors in young

European adults.

J Dent 2013; 41:

1007–1013.

If you would like to promote your

products or services direct to the

dental industry in BDJ Team, call

Andy May on 020 7843 4785 or

email a.may@nature.com.

www.nature.com/BDJTeam BDJ Team 28

Let us help your career

The most successful course available. Learn this crucial skill in your

own practice with support from our tutors at BDA Education and

gain the BDA qualication in dental radiography.

Dental Radiography

“ Very easy to follow and I would recommend

the course to anyone.”

For more information

visit www.bda.org/radcourse or call 020 7563 6888

Online course for DCPs

Over 600 dental nurses have used BDA Education’s Oral Health Education

course to boost their career. Why not join them and gain the BDA

qualication in oral health education.

Oral Health Education

“My OHE qualication has opened up so many

opportunities for me.”

For more information

visit www.bda.org/ohecourse or call 020 7563 4551

Online course for DCPs

www.nature.com/BDJTeam BDJ Team 30

CPD

CPD questions – March 2015

BDJ Team continuing

professional development

CPD ARTICLE: How to dispose of hazardous waste

1. Which of the following is categorised

as hazardous waste?

A. grounds waste

B. ink cartridges

C. nappies

D. sphygmomanometer spillage

2. According to HTM 01-05, who is

responsible for ensuring that waste

is described accurately and fully on

the accompanying documentation

when removed?

A. the cleaner

B. the Registered Manager

C. the bin men

D. whoever is last to leave the practice

3. Which of the following is incorrect?

A. red bags are for healthcare waste for

special recovery

B. yellow bags with black stripes are for

infectious or anatomical waste which

requires incineration

C. extracted teeth with no amalgam in

them should be placed in orange

lidded sharps bins

D. after removal from the

clinical area waste bags

should be kept in locked

wheeled bins

4. What is the correct

European Waste

Catalogue code for a

body part or organ?

A. 18 01 08

B. 18 01 10

C. 18 01 02

D. 18 01 01

CORE

CPD:

ONE HOUR

How do I take part

in BDJ Team CPD?

BDJ Team is offering all readers TEN hours

of free CPD in 2015 through our website.

The ten free hours of free CPD that we

offered in 2014 are also still available until

the end of 2015.

Just go to www.nature.com/bdjteam/

cpd to take part!

Missed core CPD?

You can complete BDJ Team CPD

through our website, any time

in 2014 and 2015.

Just go to www.nature.com/

bdjteam/cpd to find out how!

Topics covered so far

 April 2014: Disposing of clinical and

dental waste

 May 2014: Emergency oxygen

therapy in the dental practice

 July 2014: Needlestick and

occupational exposure to infections

 August 2014: Medical emergencies:

the drug box, equipment and

basic principles

 October 2014: Radiation protection

in dental X-ray surgeries

CORE

CPD:

ONE HOUR

31 BDJ Team www.nature.com/BDJTeam

CPD

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BDJ TEAM POSTAL CPD FORM

Can I take part in BDJ Team CPD through the post?

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You can now participate in this BDJ Team CPD through the post until the end of December 2015.

BDJ Team CPD – through the post