DENTAL - NHS Business Services Authority

eview2002 - 2003DENTALof the general and personal dental services of the NHSMore dentists in training.More dentists inpractice?Raymond TongueProbity -a matter of riskSarah McCallum & Derrick StirlingHow may externalmonitoring of PDSschemes be improved?Ruth Gasser & Janet Clarke

ForewordMary WyllieChairman of theDental Practice BoardOnce again, I’m delighted to send you a copy of the Dental Review publication as part ofour obligation to provide information to dentists and others about the General and PersonalDental Services of the NHS. The features contained in the Dental Review complement thosein our other publications and are intended to provide you with an insight into what has beenhappening in primary care dentistry during the previous financial year.Our extensive database of dental treatment claims provides a unique picture of the provisionof primary care dentistry in England and Wales and we are keen that this valuableinformation resource is made accessible to as wide an audience as possible. We continue todevelop the ways in which we interpret the data and some of the articles included in thisyear’s Review show the progress being made.We received some valuable feedback on the new-style design introduced last year and I wouldlike to take this opportunity to thank everyone who contributed comments and suggestions.Your views are an important part of the development of the publication and I encourage youtocontinue to provide us with ideas for future editions. I hope that you enjoy the topics coveredthis year.FS 23436

ContentsForewordInside Front CoverMary WyllieThe General Dental Services April 2002 to March 2003 2A number of fillings... 7Brian RodgersMore dentists in training. More dentists in practice? 11Raymond TongueThe life of fillings - 11-year follow-up 15Steve LucarottiExceptio probat regulam 17John TaylorPeriodontal probing - does Delphi give us the answer? 19Ruth GasserDental provision - how fairly is it distributed? 22Rob Bain & Raymond TongueProbity - a matter of risk 28Sarah McCallum & Derrick StirlingHow may external monitoring of PDS schemes be improved? 34Ruth Gasser & Janet ClarkeFurther information and contact pointsInside back coverDENTALreview2002-20031

The General Dental ServicesApril 2002 to March 2003Practice Arrangements(Figures quoted are based on resource as at August 2002)•assistant or VDP support; four in ten practices were of this type14 per cent of practices were single-dentist practicesThere were over 9,000 surgery addresses• There were more than 27,000 open contracts.The most common practice arrangement was for two or more principals to be working at a single surgery address with noNumber of principal dentists at the surgery addressin August 2002Number of surgery % surgery %dentists at addresses dentiststhe address1 3,534 37.8 3,534 15.92 2,455 26.3 4,910 22.13 1,588 17.0 4,764 21.5Practice arrangements14% 2%10%13%21%40%4 ,874 9.3 3,496 15.85 ,447 4.8 2,235 10.16 or more ,452 4.8 3,253 14.7All 9,350 22,192Where percentages have been rounded, totals may not add to exactly100 per cent.Single principal, no assistant/VDPSingle principal with assistant/VDPAssociated principals, single address, no assistants/VDPsAssociated principals, multiple addresses, no assistants/VDPsAssociated principals, single address with assistants/VDPsAssociated principals, multiple addresses with assistants/VDPsGDS resourcechange onpreviousyearYear to March 1996 1997 1998 1999 2000 2001 2002 2003 %contracts 1 22,150 22,971 23,332 24,416 25,024 25,373 26,585 27,103 1.9GDS dentists (principals) 1 15,871 16,092 16,343 16,684 16,982 17,187 17,344 17,351 0.0HA dentists (principals) 1 18,057 18,456 18,824 19,312 19,594 19,809 19,943 19,775 -0.8Surgery dentists (principals) 2 20,515 20,952 21,229 21,796 22,256 22,371 22,477 22,192 -1.3Surgery addresses 2 9,081 9,135 9,164 9,244 9,300 9,352 9,366 9,350 -0.21at 30 September2in AugustWhen measuring total dental resource dentists who work at several addresses are counted at each address, and in the same way dentists whowork in more than one health authority are counted in each health authority. These two figures, the total number of surgery dentists and thetotal number of health authority dentists, will both exceed the number of GDS dentists.DENTAL2 review2002-2003

Manpower(Figures quoted are based on manpower as at September 2002)There were 19,388 dentists working in the GDSThree in ten principal dentists were femaleHalf of the vocational dental practitioners were female• Eight in ten principals qualified in England and Wales.reviewThe average age of male principals was 42.9 years and the average age of female principals was 37.8 yearsMore than four in ten male principals had 20 or more years’ service in the GDSDental manpower (GDS) 1992 to 2003* the yearly figure is counted as at 30 SeptemberYear to principals assistants vocational dental practitionersMarch* male female all male female all male female all1992 12,233 3,520 15,753 95 43 ,138 188 182 3701993 12,032 3,648 15,680 138 49 ,187 187 167 3541994 12,046 3,893 15,939 182 59 ,241 221 207 4281995 11,914 3,965 15,879 259 77 ,336 279 231 5101996 11,804 4,067 15,871 345 107 ,452 250 245 4951997 11,842 4,250 16,092 444 142 ,586 288 254 5421998 11,907 4,436 16,343 543 150 ,693 287 310 5971999 12,009 4,675 16,684 661 236 ,897 310 304 6142000 12,082 4,900 16,982 769 311 1,080 336 304 6402001 12,129 5,058 17,187 848 333 1,181 327 340 6672002 12,132 5,212 17,344 905 402 1,307 316 342 6582003 12,041 5,310 17,351 972 425 1,397 318 322 640Proportion of male and female dentists September 2002Principal dentists September 2002Number of years since qualification31%PrincipalsMales69%Females30%Assistants70%Principal dentists September 2002Age profile50045040050%VDPs50%MalesFemalesNumber of dentists60005000400030002000100005 yrsor lessMales6 to10 yrsFemales11 to15 yrs16 to20 yrsNumber of years qualifiedover 20yrsNumber of dentists350300250200150100Principal dentistsSeptember 2002Country of qualificationRest of the world 5%Other Europe 9%Other UK 7%50020232629323538414447505356596265England & Wales 79%Age as at 30 September 2002DENTAL2002-20033

The General Dental Services April 2002 to March 2003Registrations(Figures quoted are based on registrations as at March 2003)The number of adults registered with a dentist was 18,137,738The number of children registered with a dentist was 7,239,013Approximately 45 per cent of adults were registered with a GDS dentistApproximately 60 per cent of children were registered with a GDS dentist• The average list size for a GDS dentist was 1,465.Number of registrations at 31 Marchregistrations England Wales England and Wales2003 2002 per cent 2003 2002 per cent 2003 2002 per centchange change changeadults 17,064,344 17,134,304 -0.4 1,073,394 1,064,875 0.8 18,137,738 18,199,179 -0.3children 6,840,672 6,894,671 -0.8 ,398,341 ,401,666 -0.8 7,239,013 7,296,337 -0.8all 23,905,016 24,028,975 -0.5 1,471,735 1,466,541 0.4 25,376,751 25,495,516 -0.5Registration take-up rate by age band80Take-up rate by age group per 100 populationEngland Wales allPer 100 population604020EnglandWales0 to 9 years 53.4 53.2 53.410 to 17 years 71.2 68.1 71.118 to 24 years 42.5 48.3 42.800 to 9years10 to 17years18 to 24years25 to 34years35 to 44years45 to 54years55 to 64years65 to 74years75 yearsand over25 to 34 years 43.6 50.1 43.935 to 44 years 50.8 55.4 51.045 to 54 years 46.8 49.3 46.9Average number of patients registered with a dentist20001900180017001600150014001992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003by quarter55 to 64 years 49.8 50.8 49.965 to 74 years 43.4 44.1 43.475 years and over 31.7 30.1 31.6children 61.5 60.2 61.5adults 45.1 48.0 45.2all 48.8 50.8 48.9DENTAL4 review2002-2003

Gross Fees(Figures quoted are based on totals for the complete financial year)The total gross fees authorised was £1,634 millionGross fees increased by 2.8 per cent compared with the previous yearThe average item of service claim for adults paying full charge was £31.81• The average item of service claim for children was £36.41.The care and treatment of children accounted for 27 per cent of all gross fees authorisedOver half of all scale fees authorised (54 per cent) were for adults paying full chargeThe average item of service claim for adults entitled to exemption or remission of charges was £55.53Components of gross fees for the year to MarchEngland and Wales Wales 2003component 2003 2002 percentage gross percentage ofchange from 2002 fees E & W componentchild scale fees £223,350,080 £217,685,922 2.6 £11,527,024 5.2capitation £237,691,553 £230,913,662 2.9 £13,107,336 5.5child total £461,041,633 £448,599,584 2.8 £24,634,360 5.3adult scale fees £1,038,562,538 £1,011,334,312 2.7 £57,624,583 5.5continuing care £134,291,181 £130,025,535 3.3 £7,904,959 5.9adult total £1,172,853,719 £1,141,359,847 2.8 £65,529,542 5.6commitment payments £23,591,494 £22,950,828 2.8 £1,492,184 6.3total (excluding £1,633,895,352 £1,589,959,431 2.8 £90,163,901 5.5commitment payments)Distribution ofgross fees in theyear to March 2003Continuing care 8%Commitment payments 1%Child item ofservice 13%Capitation 14%Scale fees byremissionclaim typeDisabled Persons Tax Credit 3%Full Remission -Job Seekers Allowance 11%HC2 certificate 8%Partial Remission -HC3 certificate 2%Working Families'Tax Credit 19%Adult item of service64%Income Support 57%Scale fees byitem of serviceclaim typeRemitted 26%Exempt 3%Scale fees byexemptionclaim typeAged 18 andin full timeeducation 17%Expectantmother 27%Children 17%Full charges54%Nursing mother 56%Average fees England Wales England and WalesGross fees per 2003 2002 per cent 2003 2002 per cent 2003 2002 per centregistration change change changeadults £65.55 £63.48 3.3 £62.47 £59.78 4.5 £65.37 £63.27 3.3children £63.94 £61.51 4.0 £62.11 £62.04 0.1 £63.84 £61.54 3.7all £65.09 £62.92 3.4 £62.37 £60.40 3.3 £64.93 £62.77 3.4Scale fees per claimadults - all £37.42 £36.33 3.0 £35.88 £35.27 1.7 £37.33 £36.27 2.9adults - exempt £55.53 £53.61 3.6 £50.59 £49.49 2.2 £55.22 £53.36 3.5adults - not exempt £31.81 £31.06 2.4 £30.72 £30.18 1.8 £31.75 £31.02 2.4children £36.41 £34.53 5.5 £36.73 £37.93 -3.2 £36.43 £34.70 5.0all £37.24 £36.00 3.4 £36.02 £35.73 0.8 £37.17 £35.98 3.3DENTALreview2002-20035

The General Dental Services April 2002 to March 2003Treatments(Figures quoted are based on totals for the complete financial year)The total number of claims received was 34 million•Approximately one in two claims (48 per cent) were for treatments requiring no dental interventionCourses of treatment requiring intricate work accounted for 6 per cent of all claims receivedOne in four claim forms received were for patients entitled to exemption or remission of charges.Number of treatments by item or claimEngland and Wales 2003Percentage of remitted and exempt claim forms28adult child allexamination 21,558,883 2,164,612 23,723,495X-ray films 14,266,146 1,024,415 15,290,561percentage2624claims with X-ray films 6,969,258 ,652,393 7,621,651scaling and periodontal treatments 15,046,795 ,,10,768 15,057,563claims with fillings 7,982,660 2,131,837 10,114,497221993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003by quarterteeth filled 14,023,247 4,882,762 18,906,009claims with root fillings ,963,736 ,138,786 1,102,522Proportion of typesof claims authorisedintricate work 6%more than routine work 4%dentures 2%number of teeth root filled 1,086,620 ,160,609 1,247,229claims with inlays or crowns 1,062,951 ,, 23,008 1,085,959numbers of teeth crowns or inlaid 1,452,908 ,, 29,693 1,482,601claims with bridges ,150,418 ,, 3,028 ,153,446no dentalintervention 48%miscellaneous 2%routine work 34%repairs, refixing 4%number of teeth extracted normally 2,270,101 ,932,094 3,202,195number of teeth extracted withspecial difficulty ,613,251 , 39,615 ,652,866Proportion of treatment claims requiring no dentalintervention60claims with synthetic resin dentures ,718,395 , 5,904 ,722,299claims with metal dentures , 92,151 ,, 171 ,, 92,322claims with domiciliary visits ,116,076 ,, 759 ,116,835claims with recalled attendance ,129,999 , 25,068 ,155,067number of claims 28,019,862 6,131,168 34,151,030Percentage5040302010child01992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003by quarteradultDefinitions of treatment typesType Short title ContentType 1 Intricate work Case assessment, surgical periodontal, veneers, inlays, crowns, bridges, orthodontic appliances, obturatorsType 2 More than routine work Non surgical periodontal, endodontics, surgical removals, root canal & pulp extirpation, temporary bridges,temporary crownsType 3 Dentures Dentures (including incomplete)Type 4 Routine work Two visit periodontal, fillings, extraction, post-operative care, general anaesthetic, pre-operative scaling,domiciliary visits, recalled attendance, acute condition, dressings, abscess, relative analgesiaType 5 Repairs, refixing Repairs, refixing, recementing: inlays, crowns, bridges, dentures & obturators, orthodontic study modelsType 6 Miscellaneous Pathological/bacteriological examination, stoning, sensitive cementum, occlusal equilibration, prescription,referral, other treatmentType 7 No dental intervention Examination, simple scaling, x-ray, transfer, fissure sealant, topical fluorideDENTAL6 review2002-2003

A number of fillings...Around 34 million courses of treatment a year are scheduled forpayment. A large number of these contain claims for fillings - but howmany fillings? How many teeth? Which teeth? What type of filling? Arethere differences due to gender or age? Within the General DentalServices fillings are provided and paid for on an item by item basis, soit should be possible to find out the answers to these questions. To dothis the claims for the quarter ending December 2002 were analysed.The largest number of courses of treatment was in the 35 to44 age band with 17.8 per cent of the total. The proportion ofcourses for patients aged under 18 was 17.6 per cent.All courses of treatmentBrianRodgersExcluding orthodontic interim payments the total number ofcourses of treatment scheduled in the quarter to December2002 was 8,926,095. Female patients accounted for morecourses of treatment than did male patients in all age bandsexcept for 0 to 2 and the 3 to 5 age bands. However, these agebands accounted for only a small proportion of the coursesof treatment, 0.13 per cent and 1.06 per cent respectively.All courses of treatmentAll patients Male patients Female patientsAge band number % number number %of totalfemale0 to 2 11,341 0.1 5,814 5,527 48.73 to 5 94,334 1.1 48,483 45,851 48.66 to 12 890,907 10.0 443,055 447,852 50.313 to 17 578,353 6.5 280,908 297,445 51.4Under 18 1,574,935 17.6 778,260 796,675 50.618 to 24 ,605,395 6.8 252,237 353,158 58.325 to 34 1,209,048 13.5 466,453 742,595 61.435 to 44 1,589,356 17.8 664,976 924,380 58.245 to 54 1,385,530 15.5 626,687 758,843 54.855 to 64 1,225,875 13.7 567,253 658,622 53.765 to 74 851,688 9.5 403,054 448,634 52.775 & over 484,268 5.4 202,400 281,868 58.218 & over 7,351,160 82.4 3,183,060 4,168,100 56.7All ages 8,926,095 100.0 3,961,320 4,964,775 55.6Courses of treatment with fillingsThe number of courses of treatment with claims for fillingswas 2,626,209. Approximately 30 in every 100 claims werefor a course of treatment that included fillings. Male patientshad slightly more at 31 per 100 and female patients slightlyless at 28 per 100.Patients aged under 18 had proportionally more fillingcourses than did patients aged 18 and over. In particularpatients in the 3 to 5 age band had a large proportion offilling courses. Across the age bands male patients generallyhad the higher proportions.Care should be taken in comparisons involving patientsunder 18 years of age as the individual items of treatmentthey can receive are limited, the remainder being providedunder capitation. In particular the 0 to 2 age band and the 3to 5 age band would only have deciduous teeth, which wouldgenerally limit treatment to fillings or extractions.Courses of treatment with fillings as a percentage ofall courses of treatmentAge band Male Female All patients0 to 2 7.1 8.3 7.73 to 5 56.4 55.2 55.86 to 12 35.5 32.8 34.113 to 17 32.7 31.0 31.8Under 18 35.6 33.2 34.418 to 24 ,30.6 27.1 28.525 to 34 32.7 27.5 29.535 to 44 31.4 27.7 29.245 to 54 30.7 27.9 29.255 to 64 29.6 26.0 27.765 to 74 28.8 24.9 26.775 & over 27.2 22.5 24.518 & over 30.5 26.7 28.4All ages 31.5 27.8 29.4DENTALreview2002-20037

‘Approximately 30 in every 100 claims were for acourse of treatment that included fillings.’‘The total number of teeth filledwas 4,896,951.’Courses of treatment with fillings as a percentageof all courses of treatmentpercentage60504030201000 to 23 to 56 to 1213 to 1718 to 24Within the total of 2,626,209 courses of treatment with fillings,female patients accounted for more than half at 52.5 percent. Patients aged 18 and over accounted for 79.4 per centof filling courses.The bar graphs below show the profiles of the age bands forcourses of treatment with fillings and all courses oftreatment. The profiles are similar but with female patientshaving proportionally fewer filling courses.Considering only courses with fillings, female patients in the25 to 34 age band had the highest proportion at 57.3 per cent.For male patients the highest proportion was in the 3 to 5age band at 51.9 per cent.25 to 34Courses of treatment with fillings35 to 4445 to 5455 to 64MaleAllFemaleNumber Male Female All65 to 7475 &over18 & over 969,931 1,114,555 2,084,486Under 18 277,157 264,566 541,723All ages 1,247,088 1,379,121 2,626,209Percentage18 & over ,36.9 42.4 79.4Under 18 10.6 10.1 20.6All ages 47.5 52.5 100.0All courses of treatment75 & over65 to 7455 to 6445 to 5435 to 4425 to 3418 to 2413 to 176 to 123 to 50 to 2Male50% FemalepercentageCourses of treatmentwith fillingsMale50% Female0 20 40 60 80 100 0 20 40 60 80 100percentageNumber of teeth filledThe total number of teeth filled was 4,896,951 of which2,491,175 (50.9 per cent) were for male patients. Femalepatients under 18 had more teeth filled than male patients,but for those aged 18 and over the male patients had moreteeth filled than female patients. The bands with the mostfillings were the 6 to 12 age band for patients aged under 18years and the 35 to 44 age band for patients aged 18 and over.Teeth filledMale Female All0 to 2 871 843 1,7143 to 5 49,695 55,640 105,3356 to 12 318,884 336,223 655,10713 to 17 236,186 239,388 475,574Under 18 605,636 632,094 1,237,73018 to 24 ,214,924 189,389 404,31325 to 34 394,563 331,146 725,70935 to 44 420,896 374,329 795,22545 to 54 327,654 322,801 650,45555 to 64 258,523 277,448 535,97165 to 74 169,213 188,570 357,78375 & over 99,766 89,999 189,76518 & over 1,885,539 1,773,682 3,659,221All ages 2,491,175 2,405,776 4,896,951To allow meaningful comparisons of gender and age thenumber of fillings can be related to the number of claims.The rate of teeth filled is calculated as the number of teethfilled per 100 courses of treatment (or courses of treatmentwith fillings).Teeth filled per 100 coursesAll courses of Courses of treatmenttreatmentwith fillingsMale Female All Male Female All0 to 2 16 14 15 191 203 1973 to 5 108 115 112 196 204 2006 to 12 71 76 74 217 214 21513 to 17 79 85 82 256 260 258Under 18 76 81 79 229 228 22818 to 24 ,61 75 67 225 245 23425 to 34 53 71 60 193 217 20335 to 44 46 56 50 164 179 17145 to 54 43 52 47 155 168 16155 to 64 39 49 44 151 165 15865 to 74 38 47 42 151 163 15775 & over 35 44 39 157 164 16018 & over 45 56 50 169 183 176All ages 50 61 55 181 193 186DENTAL8 review2002-2003

‘Generally, male patients had fewer teeth filled per100 claims than did female patients.’‘The permanent teeth filled mostwere the lower 6s.’Considering all courses of treatment the rate of teeth filledper 100 claims was highest in the 3 to 5 age band for patientsunder 18 years old at 112. The highest for patients aged 18and over was 67 per 100 in the 18 to 24 age band. Therewere differences between the male and female patients ageprofiles, the biggest being in the 25 to 34 age band.If we consider only courses of treatment with fillings thehighest rate of teeth filled was in the 13 to 17 age band andthe lowest in the 65 to 74 age range. The biggest differencebetween male and female patients was again in the 25 to 34age band.Generally male patients had fewer teeth filled per 100 claimsthan did female patients both for overall claims and forclaims with fillings.Teeth filled per 100 courses of treatmentAll courses of treatmentrate per 100120100806040MaleAllFemaleDistribution of fillings across the mouthDeciduous teethThere were 419,813 deciduous teeth filled with the mostfilled teeth being in the lower Es (13.1 per cent right and13.2 per cent left) with the least filled teeth being the lowerAs and Bs (close to zero). Overall there were more teethfilled in the lower jaw than in the upper.Male patients had more teeth filled than did female patients(224,530 compared with 195,283). The distribution of fillingsshows that male patients had more fillings in the lower jawthan did female patients. For both sexes the numbers on theleft and right sides of the mouth were roughly the same.Distribution of fillings in deciduous teethUpper right Upper Upper left24.2 47.923.724.4 48.524.112.2 9.8 1.0 0.4 0.8 0.8 0.4 1.0 9.9 11.712.4 9.9 1.0 0.4 0.7 0.7 0.4 1.0 10.0 11.950.0 50.0E D C B A A B C D E50.0 50.013.5 11.6 0.4 0.0 0.0 0.0 0.0 0.4 11.9 13.612.7 12.6 0.5 0.0 0.0 0.0 0.0 0.5 12.9 12.825.5 51.525.925.9 52.126.3Lower right Lower Lower left20Male patientsFemale patientsrate per 10002802602402202001801601400 to 23 to 56 to 1213 to 1718 to 2425 to 3435 to 4445 to 54Courses of treatment with fillings0 to 23 to 56 to 1213 to 1718 to 2425 to 3435 to 4445 to 54Distribution of fillings in permanent teeth55 to 6455 to 6465 to 74MaleAllFemale65 to 7475 &over75 &overPermanent teethThere were 4,477,951 permanent teeth filled. Marginallymore teeth were filled on the left side of the mouth (50.4 percent) than on the right side, and more teeth were filled in theupper jaw than the lower. The permanent teeth filled mostwere the lower 6s (7.2 per cent each) followed by the upperleft 6 (7.1 per cent) and the upper right 6 (7.0 per cent). Theleast filled permanent teeth (apart from the supernumeraries)were the lower 1s and 2s.Female patients had more permanent teeth filled than didmale patients (2,295,892 compared with 2,181,246). Thepercentage of permanent teeth filled in the upper jaw wasmore for male patients at 55.9 per cent than for femalepatients at 55.6 per cent. The 6s were still the most filledpermanent teeth with female patients having higherpercentages than male patients.Upper right Upper Upper left27.9 55.928.127.6 55.628.11.2 4.6 6.9 3.2 3.1 2.6 2.7 3.7 3.7 2.7 2.8 2.9 3.1 6.9 4.8 1.21.0 4.6 7.2 3.3 3.1 2.4 2.5 3.6 3.6 2.6 2.5 2.9 3.2 7.2 4.9 1.049.7 50.38 7 6 5 4 3 2 1 1 2 3 4 5 6 7 849.5 50.51.3 5.3 7.3 3.2 2.2 1.1 0.8 0.8 0.8 0.8 1.2 2.2 3.1 7.4 5.5 1.41.4 5.2 7.0 3.0 2.2 1.3 0.9 0.9 0.9 0.9 1.3 2.2 3.0 7.0 5.3 1.522.0 44.422.421.8 44.122.2Lower right Lower Lower leftDENTALreview2002-20039

‘There was a total of 2,135,277 amalgamfillings provided.’‘Patients in the 13 to 17 age band had more teethfilled per course than any other age band.’Fillings by toothWhere conservation of a deciduous tooth is carried out byfilling only one conservation fee can be claimed for thattooth, except in exceptional circumstances. There are veryfew exceptions. As claims involving deciduous teeth do notgive individual filling types or material, the comparisonsfollowing are based on permanent teeth.Permanent fillings per 100 teeth filledPermanent teeth sometimes require more than one filling ina course of treatment. There was a total of 4,673,100 fillingson the 4,477,951 permanent teeth filled giving a rate of 104fillings per 100 teeth filled. Rates on all teeth were at least102 fillings per 100 teeth, except supernumeraries.* Theupper 1s and 2s have the highest rates at 111 fillings per100 teeth.Upper right Upper Upper left105 105105102 102 103 102 103 109 111 111 111 111 109 103 102 102 102 102104 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 104102 103 103 102 103 108 108 108 108 108 108 103 102 103 103 102104 104104Lower right Lower Lower leftFillings by filling material - amalgam fillingsThere was a total of 2,135,277 amalgam fillings provided.The distribution of these fillings is shown in the diagram.Normally, the 1s, 2s and 3s do not have amalgam fillings, sothe percentages on these teeth are small. The higherpercentages are on the 6s with the upper left 6 being thehighest with 9.3 per cent of all amalgam fillings. The left sideof the mouth had 50.6 per cent of amalgam fillings and theupper jaw has 52.1 per cent.Percentages of amalgam fillings in each toothUpper right Upper Upper left25.7 52.126.51.7 6.8 9.1 4.4 3.4 0.1 0.1 0.1 0.1 0.1 0.1 3.3 4.4 9.3 7.3 1.949.4 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 50.62.1 7.3 8.8 3.8 1.6 0.1 0.0 0.0 0.0 0.0 0.1 1.6 3.8 8.9 7.6 2.323.7 47.924.2Lower right Lower Lower leftFillings by filling material - white fillingsThere was a total of 2,533,216 white fillings provided. Thepercentage of this total in each tooth is at its highest on theupper 1s at 7.0 and 7.1 per cent. Generally the upper frontteeth have the higher rates but the upper and lower 6s arealso high. The left side of the mouth has 50.2 per cent ofwhite fillings and the upper jaw has 59.4 per cent.Percentages of white fillings in each toothUpper right Upper Upper left29.7 59.429.70.5 2.5 5.1 2.1 2.7 4.7 5.1 7.0 7.1 5.2 5.0 2.5 1.9 5.0 2.6 0.549.8 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 50.20.7 3.4 5.7 2.4 2.6 2.2 1.6 1.6 1.6 1.6 2.3 2.7 2.4 5.6 3.4 0.723.7 40.620.5Lower right Lower Lower leftOn average one tooth was filled for every two claims (55 per 100)• Female patients had more courses with claims for fillings thandid male patientsfemale patients had more teeth filled per 100 courses•patients in the 13 to 17 age band had more teeth filled percourse than any other age bandFor all courses of treatment:•DENTAL10 review2002-200329.4 per cent contained claims for conservation by fillingsfemale patients had more teeth filled per 100 courses thanmale patientsFor courses of treatment that involved a filling:• there were 186 fillings per 100 courses*In this article supernumerary teeth have been omitted from the diagrams asindividual notation entries but are included in the totals.Of permanent teeth:• the lower left 6 was the most filled with 7.4 per cent of allfillings• the upper left 6 had the most amalgam fillings with9.3 per cent of all amalgam fillings• the upper left 1 had the most white fillings with 7.1 per centof all white fillingsBrian Rodgers is a Project Officer at the DPB.

More dentists in training.More dentists in practice?General Dental Services (GDS) manpower figures show an increasing numberof vocational dental practitioners. The statistics for September 2002 include640 vocational dental practitioners (VDPs), an increase of 73 per cent on theSeptember 1991 figure of 370. How will this increase affect future numbers ofprincipal dentists in the GDS? Does an increase in VDP numbers translatedirectly into an increase in the number of GDS principals and assistants?than the number of male VDPs. In September 1991 nearlyhalf (48 per cent) of female VDPs were aged 23 or less andone in ten were over 25 years of age, whilst for males thecorresponding proportions were smaller with 44 per cent aged23 or less and 9 per cent aged over 25.The VDP profileRaymondTongueIn September 2002 three in ten principals (5,310 out of17,351) and just over half of the VDPs (322 out of 640) werefemale. Although always close to the 50 per cent mark, since1997 the number of female VDPs has regularly been greaterAn increase in the length of the dental training course in themid 1990s resulted in the change in the age profile of VDPsthat was observed in the late 1990s. In September 1996 theproportion of female VDPs aged over 25 was approaching onein five (19 per cent) and in September 1998 the proportion ofmales aged over 25 was more than one in four (26 per cent).The average age of VDPs in September 2002 was 24.5 yearsas compared with 24 years in September 1991.The proportion of VDPs qualified in England and Wales hasfluctuated for both males and females, though until veryrecently the proportion has always been higher for males thanfor females. In September 1991 there were 93 per cent ofmale VDPs who had qualified in England and Wales ascompared with 90 per cent of females. By September 2002the proportions were similar with 96 per cent of females and95 per cent of males having qualified in England and Wales.VDP profile September 1991 to September 2002Number of dentistswith a VDP contractin the followingNumber of VDPsSeptemberProportion aged23 yrs or lessProportion agedover 25 yrsProportion qualifiedin England & WalesSeptember females males total females males females males females males females males1991 182 (49%) 188 370 0 0 48 44 10 9 90 931992 167 (47%) 187 354 1 0 43 48 13 12 89 931993 207 (48%) 221 428 3 1 49 52 11 13 87 901994 231 (45%) 279 510 5 2 46 41 10 16 88 941995 246 (50%) 249 495 7 1 43 39 16 18 91 941996 254 (47%) 288 542 11 5 35 30 19 18 93 961997 310 (52%) 287 597 10 8 44 36 18 21 91 911998 304 (50%) 310 614 13 7 36 35 18 26 90 941999 304 (48%) 336 640 8 10 41 32 15 24 88 942000 340 (51%) 327 667 10 5 44 32 16 23 95 922001 342 (52%) 316 658 7 7 43 40 13 18 93 932002 322 (50%) 318 640 n/a n/a 41 41 13 15 96 95Note: The table shows proportions for those dentists whose age as at 30 September was 23 years or under and for those whose age was over25 years. All other dentists were aged 24 or 25 years as at 30 September.DENTALreview2002-200311

‘In September 2002 three in ten principals and justover half the VDPs were female.’‘Changes in the VDP profile over time provide anindication of the future size and demography ofGDS dentistry as a whole.’VDP age profileFemales100%80%60%40%20%0%1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002SeptemberAge Over 25 25 24 21 to 23The annual figures include all dentists with an open contracton 30 September of that year. Consequently a dentist with aVDP contract in consecutive Septembers will be counted inthe VDP numbers for both years. It is noticeable that whilstthe majority of VDPs are counted in only one year’sstatistics, the number appearing in the figures forconsecutive years is increasing. Whereas none of the VDPscounted in September 1991 had a VDP contract thefollowing September, there were 14 dentists with a VDPcontract in September 2001 who were also under contract asa VDP in September 2002. In total over the periodSeptember 1991 to September 2001 there were 115 differentdentists who held a VDP contract in more than oneconsecutive September, including six who held a VDPcontract in three consecutive Septembers. Of these 115dentists more than half (61 per cent) were female.Dentists with a VDP contract in consecutiveSeptembersVDP age profileMales4035FemaleMale100%80%60%number of VDPs302520151040%20%505 6 7 8 9number of consecutive quarters with a VDP contract0%1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002SeptemberAge Over 25 25 24 21 to 23VDP profileProportion of VDPs qualified in England and Wales98FemaleMaleMovements into and out of the GDSChanges in the VDP profile over time provide an indication ofthe future size and demography of GDS dentistry as awhole. Another significant clue is provided by identified trendsin the movement of dentists into and out of the GDS; thelength of time that dentists spend in the GDS before leaving,and outside the GDS before returning. An examination of thedelay between a dentist terminating a VDP contract andopening a contract as either a principal or as an assistantprovides a first insight.proportion96949290888684821991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002SeptemberThe proportion of male dentists with a VDP contract inSeptember 1991 who had opened a contract as an assistantor as principal by the following September was 87 per cent.With the exceptions of 1993 and 2001 the correspondingproportion has decreased each year; by September 2001 1the proportion had fallen to 74 per cent. The proportions forfemale dentists evidenced a similar downward trend; 83 percent in September 1991 and 63 per cent in September 2001.In general the proportion for male VDPs has been higher thanfor female VDPs throughout the period 1991 to 2001. 2DENTAL12 review2002-2003

‘Of those dentists with a VDP contract inSeptember 1991 there are 6.5 per cent who remainoutside the GDS.’‘Approximately 85 per cent of the September 1991VDPs took up a contract as a principal or as anassistant within one year.’Proportion of VDPs with a contract as a principal oras an assistant within one year of terminating theirVDP contractproportion908580757065601991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001SeptemberFemaleMaleIf proportionately fewer dentists are going directly intopractice as a principal or as an assistant, how long are theydelaying their entry and is the proportion who remain outsidethe GDS increasing or decreasing? Between 1991 and 2001the proportion of male VDPs taking up a contract as anassistant or as principal within three years of terminatingtheir VDP contract ranged from 89 to 94 per cent, as comparedwith 81 to 91 per cent for female dentists. For both male andfemale dentists the proportion has fluctuated from year toyear, though the peaks and troughs have not always coincided.The picture is similar when looking at the proportion ofdentists taking up a contract as an assistant or as a principalwithin five years of terminating a contract as a VDP. Whetherconsidering the five-year or the three-year period, theproportions for male dentists have always exceeded thosefor females. There is a suggestion in the figures that the gapis widening. If so, this would indicate that for female dentiststhe number who delay their entry into the GDS for a longerperiod is growing at a faster rate than it is for male dentists.Proportion of VDPs with a contract as principal or asan assistant within three years and five years ofterminating their VDP contractproportion989694929088868482801991 1992 1993 1994 1995 1996 1997 1998 1999Females within three yrsFemales within five yrsSeptemberMales within three yrsMales within five yrsThe fact that a dentist has not taken up a contract as anassistant or as a principal within a given period following thetermination of a VDP contract does not imply that he or shewill never move into the GDS. That said, it is of interest toexamine the profile of such dentists. Of the dentists whoheld a VDP contract in September 1991 the proportion whohad not taken up a contract as an assistant or as a principalby September 2002 was 6.5 per cent. For the September1992 contingent the proportion was a little higher (7.6 percent). Compared with the year as a whole in both 1991 and1992 there were proportionately more females,proportionately fewer in the 23-and-under age range, andproportionately fewer who had qualified in England andWales. It would seem that the dentist who does not take up acontract as a principal or as an assistant having terminated aVDP contract (or at least delays doing so for a considerablelength of time) is likely to be female, is probably older thanthe majority of VDPs, and more likely to have qualifiedoutside of England and Wales.The 1991 VDP cohortThe statistics show a high proportion of VDPs who, within afew years of terminating a VDP contract, take up a contractas either an assistant or as a principal. How many years arethese dentists likely to spend in the GDS without a break inservice? Are they more or less likely to take an extendedbreak than dentists who delay taking up a contract as aprincipal? A closer examination of the 1991 VDPs mayhighlight lines of research that could be further investigatedusing more extensive data sets.Approximately 85 per cent of the September 1991 VDPs(314 dentists) took up a GDS contract as either a principal oras an assistant within one year of terminating their VDPcontract. This group forms a large proportion of the cohortand its profile is consequently very similar to that of thecohort as a whole. Within this group there are twocategories; those who remained within the GDS more or lessthroughout the period to September 2002, and those whoeither left the GDS before September 2002 or who had asubstantive break in their GDS service. 3 There were 219dentists who held a GDS contract more or less throughoutthe period to September 2002. The profile of this group ascompared with that of the cohort as a whole showsproportionately fewer females, more qualified in England andWales, and more in the age range 23 and younger.The profile of the 95 dentists who either had a substantivebreak in their GDS service or who left before September2002 showed a marked difference to that of the cohort as awhole. There were proportionately more females (54 percent as compared with 49 per cent), proportionately fewerqualified in England and Wales (85 per cent as comparedDENTALreview2002-200313

‘There were 59 dentists from the 1991 cohort whohaving taken up a contract as a principalsubsequently left the GDS.’‘As the number of VDPs increases then the careertraits of definable groups will have more impact onthe overall manpower picture.’Dentists with a VDP contract in September 1991Proportion of these dentists who wereCategory number femalequalified inEng & Wales23 yrs oldor youngerover 25yrs oldDentists who, having terminated their VDP contract, 24 75 71 33 4remain outside the GDS (as at September 2002)Dentists who took up a contract as an assistant or a 314 48 92 48 9principal within one yr of terminating their VDPcontractDentists who took up a contract as an assistant or as 219 45 95 53 8a principal within one yr of terminating their VDPcontract and have remained within the GDSDentists who took up a contract as an assistant or as 95 54 85 39 11a principal within one yr of terminating their VDPcontract, had an extended period outside the GDSand then returned to the GDSAll dentists with a VDP contract in September 370 49 91 46 91991with 91 per cent) and proportionately fewer in the 23 andunder age group (39 per cent as compared with 46 per cent).These differences were (perhaps) not unexpected and maybe related to known career patterns for female dentists andfor those who join the GDS having qualified outside theUnited Kingdom.There were 59 dentists (33 females and 26 males) whohaving taken up a contract as a principal subsequently leftthe GDS. Of these 35 (17 females and 18 males) left withinthe first five years of having taken up a contract as aprincipal.Dentists who opened a contract as an assistant or asa principal then left the GDS (1991 VDP cohort)This analysis only relates to the first 11 years of the dentist’scareer and to one group of dentists. It is important thereforeto be circumspect when deducing conclusions or makinggeneralised statements. For example, dentists who haveterminated a contract may be starting a substantive break inservice rather than severing all connections with the GDS.As the number of VDPs increases then the career traits ofidentifiable groups will have more of an impact on the overallmanpower picture. Identifying the profiles of the variousgroupings and monitoring changes and trends will be animportant aid to successfully estimating the future manpowerresource of the General Dental Services.Raymond Tongue is a Statistician at the DPB.number of dentists18161412108642FemaleMale0in firstyearin secondyearin thirdyearin fourthyearin fifthyearafter fiveyearsnumber of years from opening contract to date of termination123Details of changes to contractual status may be notified to the DPB at adate some time after the change has been effected. This will haveimplications for the figures quoted in the article, particularly for those basedon the contractual status in September 2002.For this and all subsequent analyses, each dentist is counted in only oneyear group - the last September in which (s)he held a contract as a VDP.Contractual status was recorded at each quarter. Where there was a periodof at least four consecutive quarters without a contract this was defined asbeing a substantive break in service, otherwise odd gaps were discountedand continuous service was assumed.DENTAL14 review2002-2003

The life of fillings -11-year follow-upIn the last two annual reviews, we looked in some detail at what happensin the way of re-intervention within the first year after a filling has beenplaced. This review looks at what happens over a longer period.OverviewSteveLucarottiThe value, to the patient, to the dentist, and to any co-payer,of reliable information about the likely future performance ofa dental restoration is obvious. One component of thisperformance is the interval between placing the restorationand the next occasion when intervention is required on thatsame tooth. The objective of this research was to quantifythis interval in the GDS, and to provide a reliable statisticalbaseline against which performance in other areas and atother times could be compared. For the purpose of this study,‘intervention’ was defined to exclude ‘maintenance’ activitiessuch as stoning and smoothing, which imply that anyrestoration remains in place.The Dental Practice Board (DPB) holds data on interventionson individual teeth on a comprehensive basis on all patientstreated within the General Dental Services (GDS) in Englandand Wales. From these data twenty large samples have beenretained, defined by the dates of birth of the patients,extending back to 1990. This article describes the headlinefindings from an analysis of one such sample, comprising therecords of 82,537 patients, who between them received719,009 adult courses of dental treatment between 1January 1991 and 31 December 2002. Most patients had atleast one tooth directly restored, and a total of 843,894directly placed restorations were included in this analysis.Over a short time interval, up to a year say, it is relativelystraightforward to measure a re-intervention rate by simplyMain points for busy readers:The medium term performance of directly placedrestorations provided in the GDS has now been revealed.With the power of the DPB’s database we have produced arobust set of statistical norms against which individualdentists, local commissioning bodies, and the national NHSpolicy-makers can review past and future activity andoutcomes in primary dental care.dividing the number of re-interventions within the period bythe number of restorations placed. Over a longer period, inthis case up to 11 years, the analysis is more challenging.The main problem is that there is no direct evidence as towhether a given patient is still available under the samepatient identity details, at a given time, to attend the GDS. Forexample, a patient may be recorded under a different name,or go private, emigrate or die. It is also unknown, for a patientwho has become unavailable, the time at which the patientbecame unavailable. Special statistical techniques have beendeveloped at the DPB to solve this problem, using amodification of the Kaplan-Meier product-limit method.Using these techniques, statistical survival curves have beenplotted for a wide range of different subgroups of the sampleof dental restorations, and comparisons drawn between them.Main findingsOverall, restorations enjoy a median interval to nextintervention of just over 3000 days - slightly more than eightyears. After 10 years, 46 per cent of restored teeth can beexpected to have survived without requiring re-intervention.Eleven-year survival - by patient ageproportion without re-intervention1.0 Overall18 or 190.920 to 2930 to 3940 to 490.850 to 5960 to 690.770 to 7980 or older0.60.50.40.30 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000time in days from placement to re-interventionDENTALreview2002-200315

‘After 10 years, 46 per cent of restored teeth canbe expected to have survived without requiringre-intervention.’‘Median survival ranged from around 11 years forpatients aged under 30, to under five years for theover-80s.’Apart from clinical concerns about the individual patient andtooth to be restored, which can be inferred only by indirectmeans such as the average annual cost of dental treatmentfor the patient, the main factors to be taken into account arethe age of the patient at the date of restoration, the toothposition, and the type of restoration. The three charts showhow these factors, taken in isolation, are associated withdifferent likelihoods of re-intervention. In practice, there arestrong associations between them: most restorations of anteriorteeth, for example, are carried out with composite resin. Thisshould be taken into account when interpreting the charts.It can be seen that the age of the patient continued to beimportant throughout the 11-year follow-up period, withrestored teeth in younger patients having much better prospectsof a long interval before re-intervention than those in olderpatients. Median survival ranged from around 11 years forpatients aged under 30, to under five years for the over-80s.As for tooth position, posterior teeth had an appreciablygreater expectation of a long interval to re-intervention thananterior teeth, and third molars had the longest expectationoverall. The median survival interval for front teeth was underseven years, while that for third molars was over 11 years.Eleven-year survival - by tooth positionproportion without re-interventionFront teeth are usually restored with composite resin, andmost restorations of third molars are single-surfaceamalgams. Restorations of third molars lasted well, with aproportion without re-intervention1.00.90.80.70.60.50.40.30 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000Eleven-year survival - by type of restoration1.00.90.80.70.60.50.4time in days from placement to re-interventionOverallSingle surface amalgamTwo surface amalgam, not MO or DOMO or DO amalgamMOD amalgamResin compositeGlass ionomer0.30 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000time in days from placement to re-interventionOverallTooth 1Tooth 2Tooth 3Tooth 4Tooth 5Tooth 6Tooth 7Tooth 8median survival interval of over 11 years, while those ofincisors and canines had a median interval of less than eightyears. It is of course open to debate whether the toothposition or the material used for restoration is more closelyassociated with the subsequent interval to re-intervention.The two extreme positions for type of restoration are takenby single surface amalgams, with median survival intervalwell in excess of 11 years, and glass ionomer, with medianinterval to re-intervention at under six years.Other findingsThe analysis has been extended to cover other possiblefactors, such as the attendance history of the patient and theage and country of qualification of the dentist. Altogether 32different covariates have been identified. Most of these havethe relationship with interval to re-intervention which wouldnaturally be expected. Having a root filling in addition to adirectly placed restoration, for example, is associated with aconsiderably reduced expectation of interval to nextintervention on the tooth.Further work has considered the association between thetype of re-intervention and the type of the original filling, andhow this association varies with the interval betweenrestoration and re-intervention. One finding is that theproportion of ‘like with like’ re-interventions in the first year islower than for interventions after longer intervals. Theseanalyses will be published in due course.A statistical model has also been created to describe, inmathematical terms, the relationship between the 32identified covariates and the time interval from restoration tore-intervention. The model fits the observed data well, but italso enables the prediction of how future restorations mayperform, with combinations of the covariates which have notyet been observed, and even over time intervals longer thanare contained within the existing database.This means that it is now possible to estimate, with a definedlevel of confidence, the probability of an adult GDS patientrequiring re-intervention on a restored tooth within any givenperiod, up to at least 10 years into the future, given theanswers to a set of questions about the patient, the dentist,and the detail of the restoration.Finally, the whole analysis has been replicated on a secondsample of restorations, selected in the same way, but notoverlapping the original sample. This has confirmed thereproducibility of the findings, and in particular the estimatesand relative survival characteristics of different subgroups ofrestorations.Steve Lucarotti is the Senior Statistician at the DPB.DENTAL16 review2002-2003

Exceptio probat regulamOur policy is to follow dental opinion, and not to lead it. When we makea decision it should be the same as the decision that would be made bya body of expert opinion in similar circumstances; what then do we dowhen expert opinion divides? We are in just such a difficulty overperiodontal probing for an administrative purpose. John TaylorSometimes an unexpected event makes us uneasy bycreating doubt where previously we enjoyed the comfort ofunexamined certainty. Late in November 1999 the parents ofa young woman wrote to me. A little over two weeks earliertheir daughter had been examined at our request by anofficer of the Dental Reference Service. Three days after theexamination the young woman was admitted to hospital withendocarditis. Her parents reported that the officer hadexamined their daughter with a dental instrument and infectedher bloodstream. Although a basic periodontal examination(unless ruled out by the safeguard of a full medical history) isour established practice for patient examinations, our enquirysatisfied us that the officer, alerted by the young woman’sreported history of heart problems, had not carried out aperiodontal examination using a dental probe. Happily theyoung woman recovered but the possibility that she might nothave recovered cannot lightly be set aside.Safety firstI am the responsible manager. I have a duty of care. Myresponsibility requires me to pay attention to safety, to takeprecautions and to provide and maintain systems of work thatare, so far as is reasonably practicable, safe and without riskto health. 1 My attitude is that no administrative advantage canjustify taking any risk with anyone’s well being. This extends toavoiding a known risk, no matter how small, to a real person,even where there is a large potential advantage to anabstraction, such as the general interest. Periodontal probingfor an administrative purpose however is not simply a matterin which an individual interest may be opposed to a collectiveinterest, there may be in addition competing risks and benefitsfor the individual to be weighed in the balance. It is the latterpossibility which calls for a process of risk management.Risk managementTypically when risky actions are approached one or anotherof two attitudes is dominant: how can I avoid blame if it goeswrong; how can I avoid it going wrong. The second attitude isappropriate, the first is not. Taking precautions is part of riskmanagement. Before doing something, think carefully aboutwhether or not it is safe to go ahead and don’t unlessreasonably convinced that it is safe. This common sense ruleMain points for busy readers:• when a dental officer decides whether or not to includeperiodontal probing in a patient examination the balanceof risk must favour safety;• a minority fraction of expert opinion does not regardperiodontal probing to be justified for an administrativepurpose;• observing good risk management practice the riskinvolved in periodontal probing for an administrativepurpose should be taken only when there is convincingevidence the risk is small and potential benefits large.has become known as the precautionary principle. 2 Use of theprecautionary principle is appropriate where a policy decisionhas been made - in this case to examine patients - and thereis uncertainty about the risks involved. Implementation of anapproach to risk management based on the precautionaryprinciple starts with a scientific evaluation. What we need is asound method clearly to establish the current state of expertopinion on periodontal probing. A secondary advantage of asuccess would be that we might be able to use a similarapproach for other difficult policy questions. We decided to trythe Delphi method.Expert opinionPyrrhus, being about to make war against Rome, was told bythe oracle “I say Pyrrhus, that you the Romans can conquer.”It was a temple of Apollo and a celebrated oracle that madefamous the town of Delphi. In modern times a technique fortechnological forecasting, developed by the RandCorporation, was named Delphi; maybe surprisingly given theoracular habit of obscurity and ambiguity illustrated by theinscrutable response to Pyrrhus. In the Delphi method,experts work together to crystallise their reasoning and reachconsensus. A consensus of expert dental opinion is the verything on which we want to base all our clinical policies and inthis case our use of periodontal probing. Our adventure withthe Delphi technique to discover expert opinion onperiodontal probing for an administrative purpose is describedDENTALreview2002-200317

‘A consensus of expert dental opinion is the verything on which we want to base all our clinicalpolicies.’‘A total ban on probing may not be a proportionalresponse to the balance of risks involved in adental officer examination.’in the companion article by Ruth Gasser. All that I want tonote at this stage is that none of the experts invited tocontribute appear to me to give as much weight as we do, tothe distinction between, on the one hand, an examination ofa patient by a dentist responsible for that patient’s dental wellbeing, with a view to treatment and, on the other hand, anexamination of another dentist’s patient by an officer of theDental Reference Service for an administrative purpose. Wereached a position in which the experts taking part aredivided by two strongly held opinions: probing is necessaryand it is not necessary. For us this is a dilemma.Middle way?Originally dilemma was a debating tactic. A pair of propositionsis offered which prove something against an opponent ineither case. With time dilemma has come to mean anunpleasant choice. For us this is not a debate, it is a difficultchoice. If we probe we risk damage to a person for anadministrative reason: if we do not probe we deny that sameperson and a collective the benefits of a periodontalexamination. If our own experience has not taught us wecannot complain that the ancients did not warn us: faced withopposed courses of action the best choice rarely lies betweenthem but typically is one or the other. So, do we continue withour present approach, or do we stop probing or can we escapebetween the horns of our dilemma by finding a middle way?Weighing in the balanceOur Delphic exercise did not find a consensus of expertopinion on periodontal probing. A minority fraction of expertopinion, from credible and reputable sources, regardsprobing as unnecessary. Existence of diverse views byqualified people itself is an indication of uncertainty. Underthe precautionary principle due account must be taken of theviews of a minority fraction. This is not a new idea. Over twothousand years ago Marcus Cicero suggested that no onecan be a sound judge if he does not give due weight toconvincing suspicion. 3 My safety responsibilities accept thatwhen competing risks must be weighed in the balance safetymeasures cannot aim at zero risk but they must beproportional. A total ban on probing may not be aproportional response to the balance of risks involved in adental officer examination. As the responsible manager Imust balance a decision on risk in favour of safety especiallywhere - as in this case - damage could be serious andirredeemable. There is a balance to be weighed herebetween on one hand a very small risk (we do not probe ifruled out by the safeguard of a full medical history) ofcausing by probing immediate and possibly fatal damage to aperson and on the other hand a larger though still small riskof failing by not probing to discover something of benefit tothat same person and in addition foregoing the benefit to thegeneral interest of a full examination of a selected patient.This is a difficult choice, one in which it would not, as I see itnow, be a proportional response to ban probing outright.Burden of proofUnder the precautionary principle the burden of proof lies onthose wishing to act to show that it is safe. If there aregenuine doubts about whether something is safe it should notbe done until there is convincing evidence that risks are smalland outweighed by benefits. Large risks cannot beoutweighed by large benefits. No matter how large a potentialbenefit may be risks must still be small to consider action. Onthe other hand if the burden of proof is placed on thosewishing to act it should not be placed on them in anunreasonable or impossible way. The aim is to minimisedamage should mistakes be made.Shifting the balanceThere is a Latin phrase exceptio probat regulam, whichtranslates as, the exception proves the rule. The Latin verbprobare, as used in this phrase, means to prove in the senseof to probe or to examine or to test. An exceptional event, theillness of a young woman, has prompted us to examine ourpolicy on periodontal probing. My proposal is to shift the biasof our policy from probe unless there is convincing evidencenot to, to do not probe unless there is convincing evidencethat the risk is small and clearly outweighed by the benefits.Even if in most circumstances moving the burden of proofdoes not change the decision to probe or not on the evidenceavailable, the shift in policy emphasis in favour of safety isimportant to me. This is a difficult decision. Any contributionyou would like to make will be appreciated.John Taylor is chief executive of the Dental PracticeBoard.1 An important change in approach to legislation dealing with protection ofhealth and safety at work was adopted in the Health and Safety at Work Act1974. Following work by the Robens Committee this change was fromdealing with particular abuses to establishing a general standard of care.I revised my understanding of the change by referring to my copy ofRideout’s Principles of Labour Law, Fourth Edition.2 I am grateful to Steve Lucarotti for drawing to my attention a communicationfrom the Commission of the European Communities on the precautionaryprinciple (Brussels, 02.02.2000 COM [2000] 1) which is available on theInternet at www.shef.ac.uk/~sible/source2.pdf.3 Cicero offered this opinion in a speech prepared for the prosecution ofGaius Verres in 70 BC for dishonest administration while governor of Sicily.DENTAL18 review2002-2003

Periodontal probing -does Delphi give us the answer?The Dental Reference Service (DRS) has responsibility for monitoringclinical standards in the General Dental Services (GDS) of the NHS.Dental Reference Officers (DROs) carry out over 90,000 patientexaminations annually, in both the GDS and the Personal DentalServices (PDS) to check on standards of treatment and prescribing. TheDRO is normally required to make an assessment of the patient’speriodontal status in order to determine whether treatment carried outhas secured and maintained oral health, or whether the proposedtreatment is necessary to do so. A basic periodontal examination (BPE)may be carried out for this purpose.RuthGasserpractitioner when assessing periodontal status. Forexample, some respondents considered that fullperiodontal charting should be employed for all patientsand that if necessary this should be deferred until a fullmedical history is available. Where the patient’s medicalhistory indicated that antibiotic prophylaxis would berequired, periodontal charting should be deferred until itcould be combined with other treatment when the useof antibiotic prophylaxis might be justified. It wouldclearly not be justified for antibiotic prophylaxis to beprescribed for the purpose of a DRO examinationalone.Following an incident, which is described in John Taylor’sarticle on page 17, a Delphi-style exercise was employedas part of a re-evaluation of the DPB’s policy on the useof subgingival probing as part of DRO examinations.The Delphi ExerciseA pilot questionnaire was drawn up and distributed tosome 38 recipients chosen to reflect a balance of interestand expertise in the healthcare professions. Questionsrelated to the use of periodontal probing for assessmentof periodontal status, the usefulness of BPE andassociated risks.It was clear following evaluation of the responses thatsome of the respondents had not fully understood thatthe DRO is in a different position to the treatingThe questions were refined to reflect and build on theresponses from the first round, with a secondquestionnaire being circulated to 58 individuals, includingall of those from the first round.From the responses to the first and secondquestionnaires there appeared to be a consensus viewthat the use of visual clinical examination alone would beinsufficient to assess the quality or effectiveness ofperiodontal treatment and that some use of a probe isnecessary. However, there was also agreement that theuse of BPE alone should not be relied on and that otherclinical and/or radiographic findings were necessary inaddition to BPE.There was less agreement over the various medicalconditions, which might contraindicate probing in theabsence of antibiotic prophylaxis. Where probing couldDENTALreview2002-200319

‘It would clearly not be justified for antibioticprophylaxis to be prescribed for the purpose of aDRO examination.’‘There was less agreement over the variousmedical conditions, which might contraindicateprobing in the absence of antibiotic prophylaxis.’not be carried out in the absence of antibiotic prophylaxisthere was some agreement that the use of radiographsand visual examination might provide some usefuldiagnostic information.Based on the responses to the two questionnaires a draftpolicy was drawn up regarding the use of subgingivalprobing for DRO examinations. In broad terms the draftpolicy agreed with the use of a BPE examination as partof the DRO examination, together with other appropriateperiodontal indices or full periodontal charting asindicated. Where a full medical history was not available,or where there were medical contraindications to the useof subgingival probing in the absence of antibioticprophylaxis, no examination involving the use ofsubgingival probing would be carried out. Appropriateradiographs might be requested from the treatingpractitioner in order to assist the DRO in reporting onthese cases.The draft policy was circulated to UK dental schools anda number of professional bodies for comment.Responses to the draft policy indicated that there weretwo clearly defined and contrary views.The case ‘against’ the use of subgingivalprobing for DRO examinationsA small but significant number of respondents questionedthe use of subgingival probing. One of the respondentssuggested that a Delphic exercise was an inappropriateway to determine current clinical opinion and bestpractice, as by using such an exercise to achieveconsensus merely presents a view which least offendsthe majority. The view was put forward that while the useof subgingival probing to detect periodontal disease maybe appropriate, where it is carried out for anadministrative purpose there could be no potentialtherapeutic advantage to a patient and therefore any risk,however small, could not be justified. It was alsosuggested that since potentially damaging bacteraemiasmay occur in seemingly healthy patients, the absence ofany contraindicating medical history might be misleading.It was conceded that where a practitioner had soughtadvice on treatment planning a potential benefit to thepatient from the procedure might exist.Another respondent suggested that the use of probingcould damage a healthy pocket and questioned thereliability of probing measurements, which may showconsiderable intra and inter observer variability. Theargument was made that gingivitis is a normal andhealthy inflammatory response and that it is entirelyreversible, with no evidence existing to suggest that it willprogress to periodontal disease. It was also stated thatthe measurement of the depth of a pocket does nothingto quantify the extent of the disease and that bleeding onprobing does not necessarily indicate that a pocket isactive.The case ‘for’ the use of subgingivalprobing for DRO examinationsThe majority of those responding were wholly or broadlysupportive of the policy, although a number of usefulcomments were made about the wording of the policystatement.The limitations of radiographs were commented onparticularly where their use instead of, rather than inaddition to, probing was proposed. The lack ofgeometrical accuracy of images taken over a period oftime and the limitations of a two-dimensionalrepresentation of a three-dimensional object werediscussed. However, as an adjunct to probing,radiographs were considered to have some value.Indeed, it was commented on by one respondent thatBPE as defined in the Faculty of Dental SurgeryGuidelines 1 requires a clinical assessment of periodontalstatus and appropriate radiographic examination asindicated.The view was put forward that probing does not causesignificant damage to healthy tissues and that bleedingon probing normally indicates the presence ofinflammation. Probing was considered by those in favourof its use to be the only universally accepted andpractical way to detect breakdown of the periodontaltissues. However, one respondent suggested that the useof subgingival probing to evaluate the effectiveness ofperiodontal treatment might be less useful.There was agreement that the use of antibioticprophylaxis purely to facilitate a BPE examination wasnot justified, although some felt that in its absence norealistic periodontal assessment could be made. Itremained clear, however, that for some the issuescontinued to be around the use of probes and BPE as aDENTAL20 review2002-2003

‘The Delphi exercise brought to the fore someinteresting, and in some cases very strongly held,opinions and ideas.’‘The DPB continues to review its policy on the useof subgingival probing for DRO examinations.’diagnostic tool in general, rather than their use for anadministrative purpose.Interestingly, one respondent pointed out that a DROshould not discriminate against any individual or group.The view was put forward that for those individualswhose medical history is uncertain where subgingivalprobing cannot be carried out at a DRO examination, thetreating practitioner should be asked to provide a recordof a thorough periodontal examination.DiscussionThe Delphi exercise brought to the fore some interesting,and in some cases very strongly held, opinions andideas.The Faculty of General Dental Practitioners (UK), GoodPractice Guidelines on Clinical Examination and Record-Keeping 2 state ‘The clinical diagnosis of periodontaltreatment is still problematic despite much research inthe past decade. These infections are still primarilyclassified and diagnosed on the basis of traditionalclinical assessments. Probing to determine clinicalattachment loss and any sites with bleeding on probing isthe preferred way to assess damage’.It is clear that there is a considerable body of expertopinion, which considers the use of subgingival probingnecessary to make an assessment of periodontal statusand which also considers that in its absence no reliableassessment can be made. The actual risk of causing abacteraemia by dental probing cannot be reliablyquantified and indeed many believe the risk may be nogreater than the risk to a patient of a bacteraemiacaused by normal tooth brushing.itself and any associated risks. Others did not appear tofully understand the context in which they were beingasked to consider the questions. However, this may be areflection on the way the questions were structured andthe information provided to panellists. The Delphitechnique is generally considered to be most suited toanswering a single, specific question. Panellists wereasked to consider a number of issues and risks and,when evaluating the Delphi method, the appropriatenessof its application in this particular context is consideredquestionable.The DPB continues to review its policy on the use ofsubgingival probing for DRO examinations. However, inview of the limitations described above, the Delphiexercise does not appear to have helped significantly inthis regard. DROs examine patients to determine whethertreatment carried out has secured and maintained oralhealth and whether treatment proposed is necessary. Ourpolicy must be developed to reflect the need to carry outthis clinical monitoring function satisfactorily, while takingdue consideration of any potential risks.References1 Screening of Patients to Detect Periodontal Diseases; ClinicalGuidelines, Royal College of Surgeons, Faculty of DentalSurgery. www.rcseng.ac.uk/dental/fds/clinicalguidelines2 Clinical Examination and Record-Keeping, Good PracticeGuidelines; Faculty of General Dental Practitioners (UK)2001.Ruth Gasser is Clinical Policy Manager at the DPB.There is a small but significant minority who believe thatthe use of subgingival probing for DRO examinations isneither necessary, nor justified in view of the potentialrisks.The usefulness of the Delphi technique as a method ofcapturing expert clinical opinion will clearly depend onthe panellists chosen to take part and their understandingof the process. Some panellists did not appear toappreciate the aims of the exercise and seemed to focuson particular issues, such as the usefulness of BPE as adiagnostic tool, rather than the use of subgingival probingDENTALreview2002-200321

Dental provision -how fairly is it distributed?To assemble the complete picture of dental provision across thecountry is not straightforward with private dentistry, the Personal DentalServices and the Community Dental Services each making a contributionalongside that of the General Dental Services (GDS). However, usinginformation from the 34 million claims for dental treatment submittedduring the year it is possible to assemble a reasonably detaileddescription of GDS provision.Rob Bain Raymond TongueThe number of dentists provides a first indicator of dentalprovision. The September manpower statistics show thatyear on year the number of dentists with a GDS contract hasbeen increasing; in September 2002 it stood at 19,388.Although this is an encouraging statistic, on its own it doesnot necessarily indicate there being greater access. Thedistribution of dentists and surgery addresses across theregions, the number of registrations in relation to localpopulation, the type of treatment carried out and theavailability of specialist treatments (such as orthodontics)are all factors that need to be considered. Whilst average listsizes and registration numbers provide some measure oflocal dental access, a comparison of one region againstanother needs to account for factors such as populationdensity, local geography and the economic and demographicprofiles of the regions.into line with those for adults. Whilst registration ratescontinued to vary from one region to another, the effect ofthese changes on the total number of registrations was toproduce reasonably stable registration rates over time forboth children and adults. The peaks and troughs, acharacteristic feature of child registration graphs, gave wayto a roughly horizontal line. In September 2002 there were18.16 million adults (about 45 per cent of the adultpopulation of England and Wales) and 7.26 million children(about 60 per cent of the child population) registered with aGDS dentist. Comparisons with local population numbersshow that take-up rates for adults across the healthauthorities ranged from a low of 27.7 in Gloucestershire to ahigh of 60.7 in Morgannwg. For children, take-up ratesranged from 34.5 (East London and the City) to 73.3 (Avon).Registration take up rates for England and Walesrate70656055504540Under 1818 and overMar 92Sep 92Mar 93Sep 93Mar 94Sep 94Mar 95Sep 95Mar 96Sep 96Mar 97Sep 97Mar 98Sep 98Mar 99Sep 99Mar 00Sep 00Mar 01Sep 01Mar 02Sep 02Mar 03quarterThe number of registrationsIn 1996 the regulations relating to registrations were alteredwith the period of time before an adult registration wasconsidered to have lapsed changing to 15 months. At thesame time the regulations for child registration were broughtComparing the number of patients registered with a dentistagainst local population figures does provide an indication ofdental activity, but it also has the effect of masking theextent to which patients travel (whether by choice or throughDENTAL22 review2002-2003

‘In September 2002 there were 18.16 million adultsand 7.26 million children registered with aGDS dentist.’‘At postcode district level, the August 2002registration statistics showed that over half theregistered patients attended locally.’Rate of registrations per 100 members of population by health authority for the quarter ending September 2002AdultRate per 100ChildRate per 100Maximum 60.7Upper quartile 50.3Lower quartile 40.2Minimum 27.7Maximum 73.3Upper quartile 65.7Lower quartile 58.6Minimum 34.5necessity) to obtain dental treatment. Not every patientregistered for dental care will attend a local dentist andequally not every dental list will be comprised exclusively oflocal residents. Therefore, when reporting registration data itis useful to identify two ratios. Firstly, the proportion of adentist list which is comprised of local residents andsecondly, the proportion of registered patients living in anarea who attend a local dentist. Here ‘local’ implies acommonality between dentist and patient. For example, inthe context of postcode areas ‘local’ implies that the addressof the registered patient and the dentist share a commonpostcode area. 1adults. Again proportions varied considerably from onepostcode district to another as is illustrated by thedistribution across the Manchester postcode districts.Proportion of dentist list comprised of local residentsManchester postcode districtsThe August 2002 patient registration statistics 2 indicatedthat for England and Wales as a whole a little over nine inten registered patients attended a dentist whose practicewas in the patient’s postcode area; the proportions for adultsand children were very similar, 91 per cent for adults and 92per cent for children. This proportion varied considerablyover the country with, not surprisingly, the larger valuesoccurring in more rural regions and the smaller values ininner city areas in general and in London in particular. Fordentists working in the EC postcode area only 29 per cent ofadults and 15 per cent of children on their lists were residentin the London EC postcode area.At postcode district level the August 2002 registrationstatistics showed that over half the registered patientsattended locally; 54 per cent of children and 50 per cent of65.3 to 80.755.4 to 65.338.4 to 55.40 to 38.4Measures of this kind do give an indication of the flow ofpatients between regions. However, the location of dentalsurgeries in relation to the boundaries of the designatedregions, the actual size of the region, the nature of theterrain, and the availability of public transport are all factorsthat must be kept in mind when interpreting the figures.DENTALreview2002-200323

‘Where the deprivation level is higher there is agreater inflow of patients boosting the list sizes ofthe dentists working there.’‘ “Options for Change” may well make the conceptof registration redundant.’Registration and deprivationUnder the Early Years Targeted Registration Incentive, theDepartment of Health makes a payment to dentists whoaccept children into capitation who are ‘under the age of fiveand resident in one of a prescribed list of electoral wards’.The proportion of postcodes within a postcode area thatbelong to one of these wards provides a device, albeit arather crude one, for differentiating postcode areas. Is thereany evidence that in those postcode areas where thisproportion is high more children attend a local dentist?An initial inspection of the associated scatter diagram wouldsuggest a lack of any obvious trend, leaving the answer tothe question somewhat ambiguous.Proportion of registered child patients attending alocal dentistEngland and Wales postcode areasproportion of registered child patientsattending a local dentist9575550 10 20 30 40 50 60 70 80proportion of 'deprived' postcodes in postcode areaA more sensitive discriminator is provided by the Index ofMultiple Deprivation. The index is produced by theDepartment of Environment and combines measures ofemployment, income, child poverty, education, housing andaccess. Using the August 2002 registration figures, but nowassociating the patient with the primary care trust (PCT) inwhich they live and the dentist with the PCT in which theywork, it is possible to provide a more sophisticated analysisProportion of dental list comprised of local residentsProportion of registered patients attending a localdentistproportion1.00.90.80.70.60.50.40.30.20 10 20 30 40 50 60 70PCT deprivation scoreof registration levels and deprivation. 3 In general, the higherthe deprivation level of the PCT (as measured by the index)the smaller is the proportion of the PCT dentist lists that arecomprised of local residents. There is also some evidence,though it is not a strong trend, that where the deprivationscore is higher a greater proportion of residents who attenda dentist attend one who is contracted to the same PCT asthat in which the patient is a resident.The conclusion may be drawn that whilst in all PCTsindividuals are more likely to be registered with a localdentist, where the deprivation level is higher there is agreater inflow of patients boosting the list sizes of thedentists working there. It may well be that a furtherdistinction can be drawn between areas of low deprivationwhere there are high commuter numbers (eg inner London)and the more rural areas.Treatment not registration‘Options for Change’ may well make the concept ofregistration redundant with measures of dental provision andoral health becoming more significant. In planning for, andmeasuring the effectiveness of, dental initiatives baselinemeasures of the existing levels of provision as well asmeasures of general oral health will be required.proportion10.90.80.70.60.50.40.30 10 20 30 40 50 60 70PCT deprivation scoreCourses of treatment can be classified broadly according tothe complexity of the work carried out. These classificationsrange from ‘no dental intervention’ which describes a courseof treatment that consists of nothing other than anexamination, simple scaling, x-ray, transfer, fissure sealantand topical fluoride to ‘intricate work’ which includes coursesof treatment that involve case assessment, surgicalperiodontal, veneers, inlays and crowns, bridges, orthodonticappliances and obturators. Applying this categorisation tocourses of treatment for which a claim was received in24 reviewDENTAL2002-2003

‘The proportion of claims for “intricate work”increases with the level of deprivation.’‘For some treatments, there is a close connectionbetween the treatment rate and the deprivationscore for the PCT.’December 2002 4 it is possible to investigate the extent of anyrelationship between the deprivation score of a PCT and thetype of treatment carried out by dentists working in the PCT.Percentage of treatment claims requiring no dentalinterventionpercentage65605550454035300 10 20 30 40 50 60 7065PCT deprivation scorePercentage of claims requiring intricate workAs would be expected there is a strong association betweenthe proportion of claims for patients exempt from or remittedof charges and the deprivation score of the PCT; the higherthe index score, the larger the proportion. As the scatterdiagram indicates there are a number of outliers, and thissuggests the possibility of other discriminating factors. Amap showing claim rates across the postcode areasillustrates regional variation.Patients attending a local dentistProportion of claims for patients exempt or remitted ofchargesproportion of claims90807060504030201000 10 20 30 40 50 60 70PCT deprivation scorepercentage432100 10 20 30 40 50 60 70PCT deprivation score36.7 to 53.325.8 to 36.721.1 to 25.817.8 to 21.112.2 to 17.8Whether considering the patients on the PCT dentist lists orregistered patients living in the PCT, a smaller proportion ofcourses of treatment are classified as requiring ‘no dentalintervention’ in those PCTs where the deprivation score ishighest. By contrast, the proportion of claims for ‘intricatework’ increases with the level of deprivation, although thereis a greater degree of spread within the scatter. Undoubtedlythis says something about the dental health of the patients,but it may equally relate to the willingness (or ability) of thepatient to pay for treatment. Is it the case that more privatedentistry within the relatively more affluent areas distorts thepicture, or is the general dental health better in these areas?Is it the case that in the less affluent areas more dental workis required, or is it the case that in places where there aremore people entitled to exemption or remission of chargesthere is less resistance on the part of the patient toundergoing more extensive courses of treatment? Therelationship between the various underlying determinants ismore complex than can be gleaned from a first analysis.For some treatments, such as fillings and the provision ofdentures, there is a close connection between the treatmentrate and the deprivation score for the PCT; in both cases thehigher the deprivation score the larger is the treatment rate.For other treatments, such as periodontal treatment (two ormore visits) the scatter is far more random. The regionalvariations are illustrated by the postcode area maps. 5DENTALreview2002-200325

Number of teeth extracted99.3 to 127.4claim rate1816141210864200 10 20 30 40 50 60 70PCT deprivation score85.7 to 99.375.4 to 85.763.5 to 75.448.6 to 63.5Scatter diagram - per 100 claims receivedMap - per 1000 claims receivedProvision of synthetic resin denturesclaim rate76543230.3 to 4025.3 to 30.321.4 to 25.317.7 to 21.410.3 to 17.7100 10 20 30 40 50 60 70PCT deprivation scoreScatter diagram - per 100 claims receivedMap - per 1000 claims receivedPeriodontal treatment (two or more visits)claim rate3025201510125 to 20357 to 12534 to 5723 to 3412 to 23500 10 20 30 40 50 60 70PCT deprivation scoreScatter diagram - per 100 claims receivedMap - per 1000 claims receivedDENTAL26 review2002-2003

‘Is it the case that in the less affluent areasmore dental work is required?’‘Mini profiles have been constructed for five PCTsselected to reflect the range of deprivation scores.’Treatment profilesIt has long been the practice of the Dental Practice Board toprovide dentists with prescribing profiles which set out theyearly activity carried out on a contract. It seems a naturalprogression to extend the concept to provide a profile for agroup of dentists, a geographical region or a health body. Asan illustration mini profiles have been constructed for fivePCTs selected to reflect the range of deprivation scores. Theprofiles show that for certain treatment types (eg claimsinvolving a root filling treatment) the treatment rates aresimilar whilst for others (eg ordinary fillings) there is aconsiderable difference from one PCT to the next.Primary Care TrustPCT treatment profiles A B C D ETreatment typeClaims including diagnosis and/or prevention treatments only 50.0 53.5 44.8 44.7 43.4Claims including one or more small radiograph 26.6 30.3 24.7 23.9 23.0Claims including scale and polish 55.9 49.2 48.5 51.1 49.2Claims including periodontal treatment 2 or more visits 3.3 5.2 3.4 6.3 4.9Claims including filling treatment 32.0 30.2 33.2 28.5 27.9Claims including root filling treatment 3.5 3.6 3.5 4.0 4.0Claims including provision of crowns or inlays 3.2 2.2 2.8 3.5 6.9Claims involving extraction 4.2 3.4 5.9 9.2 8.3Claims including the provision of synthetic resin dentures 1.1 2.0 2.1 3.9 4.6Claims including provision of bridges 0.4 0.3 0.4 0.5 1.1Claims including recalled attendance 0.4 0.2 1.8 0.3 0.2Claims including domiciliary visit 0.3 0.8 1.5 0.3 0.6The figures in the table indicate the percentage of claims which include the named treatmentPatient categoryAdult patients who pay full patient charge 86.2 83.9 80.3 54.7 54.0Adult patients who are exempt or remitted of patient charges 13.8 16.1 19.7 45.3 46.0Adult patients over the age of 18 in full time education 1.3 1.5 0.7 0.9 0.8The figures in the table indicate the percentage of claims for the named category of patientAverage cost per claimAdults who pay full patient charge £32.00 £30.86 £33.77 £31.51 £36.77Adults who are exempt or remitted of patient charges £50.26 £50.36 £49.84 £48.07 £65.43IMPDEV index 6.71 7.32 22.86 58.14 57.81ConclusionThe purpose of this article has been to pose questionsrather than to propose definitive answers. In doing so anattempt has been made to illustrate the range and scope ofthe analysis that is currently available to describe patienttreatment and dental provision within an region, whetherdefined by postcode or by health body. It will be analyses ofthis type that will be needed to inform primary care trusts andother health bodies as they prepare for ‘Options for Change’.Raymond Tongue is a Statistician at the DPB.Rob Bain is an Information Development Analystat the DPB.1 As illustration, in the postcode BN20 8AD ‘BN20’ defines the postcodedistrict and ‘BN’ the postcode area.2 In the August 2002 snapshot, about 7 per cent of patient postcode areadata held on file was invalid and excluded from the analysis. If we reduce thearea of measure to postcode districts then a slightly higher proportion (12 percent) of the August 2002 snapshot must be excluded as invalid.3 The allocation to PCT is on the basis of where they would have been hadthose health bodies been in place in August 2002. In fact, the new PCTstructure came into being in October 2002.4 The choice of December was arbitrary.5 Maps for PCTs were not available at the time of publication.DENTALreview2002-200327

Probity - a matter of riskThe Dental Practice Board (DPB) is a statutory body accountable to theSecretary of State for Health and the National Assembly for Wales. Oneof our roles is to provide an evidence-based assurance of the costeffectiveness of the provision of General Dental Services (GDS). Weare, therefore, required to report on the probity of sampled GDS activityand to put in place such processes and systems as are necessary tobring about the level of probity assurance agreed by Government.SarahMcCallumDENTAL28 review2002-2003DerrickStirlingWe provide specific assessments of the service provided byGDS in respect of the:• quality of diagnosis, treatment planning, and treatmentprovision,accuracy and validity of claims submitted for payment,• dentists’ compliance with their terms of service.So, what evidence do we produce to provide the assurancerequired, how do we manage risks to the probity of the GDSin order to achieve appropriate levels of probity assurance, andwhat happens when evidence suggesting inappropriateactivity by an individual or individuals is uncovered?Evidence not assertionsWe provide evidence on the level of probity assurance fromthe checks that we carry out. These fall into two categories:random (known as screening) and risk-based or targetedchecks. The minimum number of checks are, to an extent,determined by Service Level Agreements (SLAs) that we havesigned with the Department of Health and the NationalAssembly of Wales.The purpose of the checks is to establish where possible that:• the treatment proposed is necessary and adequate tosecure the oral health of the patient,• any treatment provided was necessary and provided to anacceptable standard, and that• claims for payment have been made in accordance withthe regulations and for treatment that has been provided.We select courses of treatment at random and try toestablish, by means of Dental Reference Officer (DRO)examinations, patient record checks, and patientquestionnaires that these principles of the regulations havebeen upheld. Some categories of dentist, for example, thosewho submit larger volumes of claims, may represent astatistically greater probity risk than other categories. Theywill, therefore, attract a greater intensity of checks. Similarly,some categories of patient or treatment may also represent astatistically greater probity risk. Where the overall probity riskpattern, or profile, indicates a significantly higher level of risk,an enhanced level of checking may be employed for allcourses of treatment matching that profile. In these instancesthe checks are known as targeted. The proportion of riskbased,or targeted, checks is being increased as part of thecontinuous improvement in the effectiveness of the DPB’smonitoring process but there will always be a random element(see Probity Assurance Management System section).Screening and targeted checksDRO examinationsDuring the last financial year 97,591 patients were examined.These examinations represent:• a sample of courses of treatment selected by the DentalReference Service (DRS) of estimate claims submitted forprior approval,• all prior approval estimate claims that involve complextreatment,• a sample of courses of treatment selected by the DRS ofcompleted treatment claims,• a random sample of courses of completedtreatment selected by probity,• examinations requested as a result of more detailedinquiries; either for internal inquiry purposes or to supportour colleagues within NHS health bodies or the CounterFraud Services (CFS).Targeted examinations comprise only the latter category; allother categories are screening examinations.The table overleaf shows the numbers of outcomes for thescreening and targeted treatment and estimate references for

‘The proportion of risk-based, or targeted, checks is beingincreased as part of the continuous improvement in theeffectiveness of the DPB’s monitoring process.’‘Clinical records checks are also a central partof our risk-based inquiry processes as arequestionnaires and DRO examinations.’lack ofinformationagreedminordisagreementmajordisagreementfundamentaldisagreementtotalScreening estimate references 73 689 2042 61 2 2867Screening treatment references 2321 40343 18539 401 24 61628Targeted estimate references 431 4695 22474 832 66 28498Targeted treatment references 442 2558 1512 78 8 4598Total 3267 48285 44567 1372 100 97591Percentage of total 3.35 49.48 45.67 1.41 0.10examinationsthe year ending 31 March 2003. The subsequent chartshows the proportions of each outcome type across allreferences. As can be seen, across all examinations lessthan 2 per cent of examinations highlighted major orfundamental disagreements.Outcomes (as at 6 May 2003) for probityquestionnaires sent out in the year to 31 March 2003100AwaitinginformationUnsatisfactorySatisfactoryOutcomes of all examinations carried out during theyear to 31 March 2003605049.4845.67percentage80604020percentage4030200Apr-02May-02Jun-02Jul-02Aug-02Sep-02monthOct-02Nov-02Dec-02Jan-03Feb-03Mar-031003.35Lack ofinformationAgreedMinorDisagreementoutcome1.41 0.10MajorDisagreementFundamentalDisagreementPatient questionnairesQuestionnaires are sent as part of our probity audit activities(screening) and are of a standard format. We also send outquestionnaires that have been designed in order to elicitinformation which it is hoped will allay specific concerns thathave been raised as the consequence of previous screeningactivity or targeted inquiries.During the year to 31 March 2003 we sent out 3,442questionnaires in respect of courses of treatment providedunder GDS arrangements. We also hold individual SLAs withall Personal Dental Services (PDS) schemes and sent out 4,160questionnaires for those schemes during the same period.The following chart details the percentage of probityquestionnaires which gave satisfactory or unsatisfactoryoutcomes, together with those for which we were stillawaiting information as at 6 May 2003.Patient questionnaires are used to confirm that the treatmentclaimed (for a particular course) matches the patient’srecollection of events. Where a discrepancy is foundbetween the treatment claimed and the patient’s recollection,further inquiries are carried out which aim to establish thatthe claim was appropriate. These further inquiries typicallyinvolve requests for record cards.Clinical record checksClinical records are requested when there is a need toresolve discrepancies highlighted by DRO examinations orcompleted patient questionnaires. In the year to 31 March2003, 1179 requests were made as a direct result of probityaudit activity in respect of GDS treatment and 681 in respectof PDS treatment. In addition clinical records are alwaysrequested (along with an invitation to the dentist to submitobservations) where a DRO examination has highlighted adiscrepancy or lack of information that it is considered by asenior DRO to require resolution. Clinical records checks arealso a central part of our risk-based inquiry processes as arequestionnaires and DRO examinations.With the strength of the assuranceprocedures about us?As stated earlier, in addition to reporting on the quality andlegitimacy of treatment and claims activity within the GDS weprovide a further implicit assurance by way of our approachto the management of risks to, and breaches of, probity.Probity Assurance Management SystemThe DPB has developed an integrated risk managementsystem for the organisation of activities, processes,procedures and decision-making that is known as our ProbityAssurance Management System (PAMS). This systemenables us to coordinate our evaluation and prioritisation ofrisks in line with developments in our control procedures andother probity inquiry activities.DENTALreview2002-200329

‘Risk assessment projects provide us withinformation about particular areas of concern.’‘The Probity Case Management System enables usto assess the “probity profile” of any dentist whoprovides or has provided GDS treatment.’At the heart of PAMS lies a risk control matrix (this has beendetailed in previous Reviews). It provides a quantification ofthe financial risk (eg claims for treatment not provided)associated with all manner of scenarios that have beenidentified as occurring or possible. Non-financial risks (egclinical impact of over-prescription) are similarly assessed. Itis this quantification of risk that allows us to prioritise ourprobity activities. In turn, it is our primary role (processing,authorisation and payment of claims) that provides us withmuch of the data that are necessary for us quickly andaccurately to assess potential risks to the GDS.ProjectsRisk assessment projects provide us with informationabout particular areas of concern. The topics covered bythese projects during the year to 31 March 2003 includeassessments of the risks in relation to claiming for:• more than one simple scale and polish within a twomonth period,high volumes of photographs,temporary crowns,• and discretionary fees.orthodontic case assessments with no further treatment,These projects may conclude with recommendations forimprovements to our control processes and, whereappropriate, estimate the level of inappropriate claiming.The estimates are in turn used to inform and update therisk control matrix.MatrixThe risk control matrix is a mathematical representation ofthe perceived threats to, and controls for, the probity of theGDS. Threats to probity are identified as part of ourscreening and inquiry activities and are investigated furtherby means of risk assessment projects. The risks may relateto the patient, the treatment or the dentist. The controlscomprise the alerts eg leads, validation checks, screeningchecks and targeted inquiries.Data from the alerts, checks, inquiries and risk assessmentprojects are used to estimate the level of detriment(financial or otherwise) associated with each risk. This inturn allows us to prioritise our work more effectively.Within PAMS there is an electronic Probity Case ManagementSystem (PCMS) that provides a link to all the relevantgeneral data held by the DPB (eg contracts and registrationinformation) with probity specific information. This enables usto assess the ‘probity profile’ of any dentist who provides orhas provided GDS treatment and to record the checks andinquiries that may be called for along with the results.Looking at it from a different perspectiveAn alternative way to conceptualise our approach to probityrisk management is within the context of the goals of theprocess: these are prevention, detection and deterrence.PreventionAs an organisation, we provide as our primary role a claimspayment system that operates in line with the government’sprompt payment code. We can do this because, other thanstatutory checks, we use post-payment rather than prepaymentverification methods and this is enabled by theassumption of a dentist’s personal integrity that registrationwith the General Dental Council (GDC) affords.We check every claim that is received for payment in order toensure that payments are only made to dentists who areauthorised to provide treatment under the GDS, and byextension, are registered with the GDC. Beyond this, ourclaims processing system performs other validation checkson claims submitted for payment. Where possible claims thatfail to conform to the provisions of the Statement of DentalRemuneration (SDR) are pulled out of the system and mayeither be stopped altogether and returned to the submittingdentist, or processed to completion once the item that hascaused the claim to be filtered out has been removed oradjusted.Validation checksValidation checks are automatically applied to all claims.The checks reflect the requirements of the narrative andprovisos of the SDR and will, where appropriate effect thedeletion, replacement or addition of an item of service froma claim. For example where a treatment item cannot beclaimed under capitation arrangements the item will beremoved from the claim during processing and a ‘comment’indicating the scenario applied to the claim. A commentcode is applied to each claim for each scenario detected.These will appear on the dentist’s schedule of payments.Where a simple adjustment cannot be effected automatically,the claim will be pulled out of the system and resolved by amember of staff (sometimes in consultation with a DRO orthe dentist concerned) or returned to the dentist. In theseinstances a marker code may be allocated to the claim.It is estimated that during the year to 31 March 2003 theaddition, deletion and replacement of items of service bythe validation suite prevented inappropriate payments of£13,494,889 being made. The estimate reflects a figurecalculated from the full frequency data (based only oncomment codes) using weighted averages and assumesthe most conservative scenario. In the example describedabove, this would be that the item claimed was a simpleexamination. The estimate is, therefore, highly conservative.30 reviewDENTAL2002-2003

‘There has been a significant increase in thenumber of leads received from patients.’‘Imposing penalties in the GDS is not theresponsibility of the DPB.’DetectionThe checks that were detailed earlier play a part in ourdetection of probity breaches and often generate leads.Leads are indications that something may not be right or mayneed questioning. Each lead that is received is entered ontoPCMS and assessed within the PAMS framework. This mayraise the probity profile of the dentist, patient or treatment.Most leads are generated internally, as a result of ourrandom and targeted checks, but a significant number ofleads about individuals are also received from externalsources. These external leads are typically received fromother practitioners, practice staff, patients, our colleagueswithin primary care trusts and elsewhere in the NationalHealth Service and, occasionally, the police or the GDC.LeadsEvery lead that is received is registered and recorded on theProbity Case Management System (PCMS). It will then beassessed within the context of the probity profile of thedentist concerned and with reference to the PAMS risk matrix.Leads received by years ending 31 Marchno. of leads25002000150010005000Internal leadsExternal leads1997 1998 1999 2000 2001 2002 2003yearThe chart above shows the number of internal and externalleads received for each of the last seven years. There hasbeen a substantial increase in the amount of informationrecorded as leads. Since the year to March 1997 the totalnumber of leads received annually has more than doubled.Types of external leads received by years ending31 Marchno. of leads6005004003002001000Counter FraudServicesHealth AuthorityDental PracticePatient1997 1998 1999 2000 2001 2002 2003yearOtherTo an extent these increases represent an improvement in ourinformation capture processes. However, the previous graphwhich shows the number of leads received for the mainexternal lead categories, indicates that there has been asignificant increase in the number of leads received frompatients. This may be because patients are becoming morediscerning NHS consumers or simply because more patientsare now aware of the DPB and its role through contact withthe DRS. In addition, we are now receiving leads from ourpartners within the Counter Fraud Services via their inquiriesand contacts.We also have at our disposal a number of other tools thatmay alert us to a possible problem or help to build a largerpicture. Every time a claim is stopped or has an item deletedfrom it during the validation checks (described earlier) acomment code is recorded against that claim. Similarly, thewealth of data that we hold in respect of all treatmentprovided under the GDS means that we are able to identifytypical patterns of treatment across the country, withingeographic boundaries identified by postcode or by types ofpatient or dentist. From this it is a simple matter to define thelevel at which a dentist’s activity becomes statisticallyabnormal and we have used these levels to buildmechanisms into our systems to identify those individuals. Inaddition, we undertake a large number of checks on patienteligibility for full or partial remission of dental charges wherethis has been claimed.While neither patterns of treatment nor comment codesprovide evidence in and of themselves of a probity breach,they may be useful and relevant as part of an emerging pictureof claiming activity. Indeed, certain risks are monitoreddirectly by these means. By this mechanism we can identifythose dentists who appear to pose a higher risk in this respect.Deterrence and risk managementOne important element in deterring those who are temptedinto doing wrong is the probability of detection and anotherthe sanction or penalty imposed on those detected. Imposingpenalties in the GDS is not the responsibility of the DPB. Weconcentrate on making it as certain as possible that detectionwill follow any infringement of the regulations that govern theprobity of activity in the GDS. We do this by refining ourdetection procedures constantly to reflect the concernsidentified and evaluated by the PAMS risk-control matrix andits associated risk assessments.When an individual is identified as requiring closer scrutiny, acomprehensive assessment of his or her activity is carriedout. This allows as many of the latent concerns to beidentified and addressed at the same time as possible. Thisgenerally happens when a number of concerns takentogether have raised a dentist’s probity profile but it may alsoDENTALreview2002-200331

‘The DPB has a responsibility to act in caseswhere appropriate standards have not been met.’‘We work closely with health bodies after caseshave been referred in order to support anydisciplinary action they may decide to take.’be triggered by the receipt of a lead that indicates a concernthat is categorised within our risk matrix as being of highpriority. Assessments are made on the basis of informationcontained within the PCMS, patterns of prescribing andclaiming in comparison with suitable peer groups and anumber of other analytical reports that may be called for.Once an assessment has been carried out the results will bereviewed and the appropriate further actions decided. Theexamination of patients’ dental status, their clinical records,and their responses to questionnaires are central to anyinquiries that we may decide to carry out and any evidencethat we may subsequently present to other agencies. At allstages we will be looking for evidence or explanations thatwill either allay or support our concerns. The results of ourinquiries will again be reviewed and the process reiterateduntil such time as a clear decision on the appropriate courseof action is possible.And when the assurance fails?The DPB has a responsibility to act in cases whereappropriate standards have not been met (for both treatmentand claims related issues). In effect the DPB provides afurther assurance to the Secretary of State for Health andthe National Assembly for Wales, that where concernsremain, we will refer the matter to our partners within theprimary care trusts, the GDC or the NHS Counter FraudServices (CFS). Referrals are made on the basis not only ofthe results from risk-based or targeted inquiries, but also ofour screening activity.The invocation of sanctions is the responsibility of otherbodies, notably the primary care trusts, local health bodiesand the GDC. Where fraud is suspected the matter isreferred to the Dental Fraud Team (DFT), an operational unitof the CFS.As a result of our checks, we may send a letter of concernabout the particular circumstances of a case, or a warningletter to indicate that repetition of a particular event may leadto referral to other agencies or other action. On otheroccasions we may request an adjustment (usuallyrepayment) of fees. In cases where there appears to bewidespread misunderstanding of the regulations weundertake educational visits to the dentist at his or herpractice. These options should serve to prevent any repetitionof unintentional breaches of the terms of service.In a very small number of cases where a dentist’s activitygives rise to great concern or continues not to comply withthe terms of service, all claims submitted may becomesubject to full pre-payment verification procedures. In theseinstances, every claim that is relevant to the concerns heldhas to be positively verified before payment is made.OutcomesDuring the year to 31 March 2003, 301 cases were heard ata Reference Committee. Just over half of those hearingsresulted in referrals to a health body for consideration.The following chart shows the outcomes for all cases heardduring that period.Reference committee decisions for the year to31 March 2003number1501301109070503010-10131Referto HA30InformalwarningFormalwarningletterLetter ofconcernNo furtheractionInformal referrals are a new category of outcome that wasintroduced in January 2002. These referrals reflect caseswhere there is a consensus among our dental officers that anexamination has raised significant concerns about the qualityof diagnosis, treatment planning or treatment provision thatmay be part of an emerging picture, but where it is felt thatthe health body would be better served by an informalreferral which should allow for resolution under the principlesof Clinical Governance.During the last financial year 136 cases were referredformally for consideration of disciplinary proceedings. Wework closely with health bodies after cases have beenreferred in order to support any disciplinary action they maydecide to take and follow up all referrals so that we are ableto record the actions taken in respect of each case.Cases referred to health bodies for years ending31 Marchnumber250200150100500Cases referred341997 1998 1999 2000 2001 2002 2003year2977Health authority action knownDENTAL32 review2002-2003

‘We continue to support the ongoing inquiries ofregional counter fraud specialists working within theCFS as well as the inquiries of the Dental Fraud Team.’‘Our role is to prevent, detect and deterinappropriate claims and poor qualitytreatment.’The following chart shows the outcome of cases as apercentage of cases where the outcome is known.During the year ending 31 March 2003, £741,110 wasrecovered in respect of adjustments to dentists’ schedulesrelating to matters that were not formally referred.The status of the 65 cases that were referred directly to thepolice by us prior to the introduction of the CFS are detailedin the following chart.Outcome of 65 cases referred to the police during theperiod 1991 to 2001Outcomes of cases referred to health bodies as aproportion of the known outcomes504040percentage100806040200NotinvestigatedReferredto GDC1997 1998 1999 2000 2001 2002 2003year referredInformalactionFormalinvestigationWe continue to support the ongoing inquiries of regionalcounter fraud specialists working within the CFS as well asthe inquiries of the DFT, where they have become aware ofpossible fraudulent claiming either by a dental practitioner orby a patient.Support and information for the DFT• We refer all cases where we have found what webelieve to be evidence of fraud direct to the DFT.During the period from 1 April 2001 to 31 May 2003we referred 23 such cases to CFS and DFT.• With effect from December 2002 we have beennotifying the DFT of referrals made to health bodieswhere there appears to have been a breach of theterms of service. Thirty-one notifications were madeduring the year ending 31 March 2003 and 10 weremade in April and May 2003.• We provide support and information to the DFT forother inquiries that have not been directly referredfrom ourselves. We became involved in 43 of thesecases during the year ending 31 March 2003.number30201001UnderinquiryNotchargedGuilty Not guilty Caution WarningIt is important to restate that the DPB has no direct role indisciplining or prosecuting dentists. Our role is to prevent,detect and deter inappropriate claims and poor qualitytreatment in order that we can continue to assure theDepartment of Health and National Assembly of Wales thatmonies allocated to the General Dental Services are spentas Parliament intends, and that patients and taxpayers arewell served by it.Sarah McCallum is Probity Liaison Manager andDerrick Stirling is Head of Information and Probityat the DPB.1462 2DENTALreview2002-200333

How may external monitoringof PDS schemes be improved?Results of a pilot monitoring project carried out by theDental Reference Service and Birmingham PDS schemeThere are presently around 100 Personal Dental Services (PDS)schemes; these may be based on dental access, salaried dentalservices, specialist services, or combine elements of all three. TheDental Practice Board (DPB) offers monitoring by the Dental ReferenceService (DRS) to PDS schemes as part of its service levelagreement (SLA), together with the provision of quality assurancechecks by patient questionnaires and examination of patient recordsand radiographs.care, a dental access element and the provision of dentalcare to special needs patients. Over 60 dentists in total areinvolved in the scheme, although a number of these are onlyemployed in the provision of emergency care on a rota basis.Ruth Gasser Janet ClarkeThe standard DRS monitoring of PDS schemes applies asimilar process of patient selection and appointment to thatused for monitoring in the General Dental Services (GDS) ofthe NHS. Patients are selected randomly by computer fromforms submitted to the DPB following completion of coursesof dental treatment. Patients selected and their treatingpractitioners are notified. Patients are asked to attend forexamination by a dental reference officer (DRO) at one of anumber of clinics in their local area. Following examinationby a DRO an administrative coding is given to the case and areport may be produced.Birmingham PDS schemeIn the summer of 2002, the DRS was approached byBirmingham PDS scheme regarding some of the difficulties itwas experiencing with this standard method of DRSmonitoring. Birmingham PDS scheme is a wide-rangingscheme, which includes the provision of emergency dentalA number of specific problems were identified:i) The selection of patients. References placed onpatients who have been provided with emergencytreatment provided on a ‘one-off basis’ wereconsidered to be of limited valueii) Patients selected for examination have shown a poorresponse rate to requests from the DPB to attend forexaminationiii) DRS already monitors dentists who practise in the GDSthrough their personal contract numbers. A number ofGDS dentists and PDS (daytime) dentists alsoparticipate in the emergency dental rotaiv) The need for a more appropriate method of selectingpatients and subsequent arrangements for them to beseen. It can be difficult to make suitable arrangementsfor PDS patients to be seen and the attendance rate ofthose who are made appointments is low. Many ofthese PDS patients have additional needs, such asmental or physical disabilities. Others may live inresidential care, or be in-patients in hospital. Whentheir personal circumstances are taken account of, therequest to attend a further dental examination formonitoring purposes only may prove excessivelyonerous, or simply not practicable for some patientsand their carers.DENTAL34 review2002-2003

‘Dentists and dental surgery assistants were notedto be very patient-focused and worked welltogether to put patients at their ease.’‘It was felt that the process largely resolved theissues around patient selection and accesshighlighted by the scheme.’v) Cancellation of references. A number of referenceshave to be cancelled in view of the difficulties detailedabove. Further references are then selected in order tomeet the SLA of three examinations per dentist peryear. The implication of this is a significant amount ofpaperwork for the PDS practitioners involved in thescheme, which has no outcomevi) Despite a large number of patients who were originallyselected, the DRS has successfully examined only asmall number of patients for the scheme. Additionally,the SLA of three references per dentist per year isconsidered relatively low. The benefit of monitoring atsuch a level was questioned by the PDS dentiststhemselves.Following discussion, it was decided that treatmentsincluding the occasional treatment code 4701 (for adviceand assessment) would be excluded from DRS monitoring.This would effectively exclude from PDS monitoring thedentists who participate in the emergency rota and who arealready monitored through their GDS contract numbers ordaytime PDS contracts. In order to resolve the other issuesaround the selection and appointment of patients, analternative method of DRS monitoring would be piloted.The pilotThe pilot was carried out over two weeks in January 2003.Birmingham PDS scheme made available its own clinics forthe purposes of the pilot. DROs attended each clinic on aday agreed with the clinical director to examine patientsfor a particular clinician in the scheme. In order to preservethe random nature of monitoring only the clinical directorwas informed when a DRO would be attending each clinic.Individual dentists within the scheme were told only that aDRO would be visiting within a specified fortnight. A DROspent part of a clinical session (am or pm) with the dentistwhile they were working. They also examined a number ofpatients seen during the session and were able to look atpatient records and radiographs.The existing style of DRO report was not consideredsuitable for this method of monitoring and was replaced byan overall report of the DRO visit, rather than a number ofseparate reports on individual patients. The report includeddetails of the patients examined, together with any clinicalissues identified and comments on the practitioner’s crossinfectioncontrol, patient management skills, treatmentplanning, treatment and record keeping. Comments werealso included regarding any patient co-operation orbehavioural problems, which may have affected thetreatment outcome. No codings were applied, as it was notfelt to be appropriate to this style of report. However, aconclusion was included where any clinical governanceissues or training issues were highlighted. It would then beup to the clinical director of the PDS scheme to assess theimportance of these and how they might be addressed.ResultsTwo DROs visited 19 dentists at 12 clinics and one mobiledental unit based at a special school. More than 100patients were seen with a large percentage of these beingexamined by the DROs. In all cases, the minimum (previousSLA) requirement of three patients per dentist were seenand in the majority of cases this was exceeded. The patientsseen included a mix of children and adults with specialneeds.DiscussionDROs attending the clinics found the staff at clinics to bevery helpful and largely positive about the process. Whilstthe range of treatments seen was quite small, this was to beexpected with the patient groups being treated, many ofwhom have special needs. Standards of cross-infectioncontrol, diagnosis, treatment planning and treatment weregenerally high. Dentists and dental surgery assistants(DSAs) were noted to be very patient-focused and workedwell together to put patients at their ease. Althoughmonitoring of DSAs was not an objective of the pilot, it isworth noting that the standards of cross-infection controland surgery management demonstrated by the DSAs werealso observed to be generally of a high standard. While aPDS claim form may indicate relatively little treatmentcarried out, by being present in the surgery while patientswere treated, DROs were better able to appreciate theparticular needs and treatment difficulties encountered withthese patient groups. When the pilot as a whole wasconsidered, several clinical issues were highlighted which theprimary care trust (PCT) may, or may not considersignificant.Dentists employed in the scheme were asked to fill outanonymous feedback sheets following the pilot, the resultsof which were generally positive. The majority of the dentistsDENTALreview2002-200335

‘The modified monitoring process was felt to bettercomplement the existing quality assurance andclinical governance processes in place within the PCT.’‘This pilot has generated considerable interest,both from other PDS schemes and from anumber of field sites.’found the process to be largely as they expected. Only twoof the dentists expressed discomfort at another clinicianbeing present to observe while they were examining andtreating patients, however, it is worth noting that studentdentists and hygienists from Birmingham Dental Hospitalvisit a number of Birmingham PDS clinics regularly andconsequently staff are accustomed to the presence of otherindividuals in the surgery when treating patients. A numberof dentists indicated they would have liked more time todiscuss cases and would have liked advance warning of theDRO visit, in order to prepare specific cases they wished todiscuss. There was a common theme in the responsesregarding the need for a clear understanding of the differingrequirements of PDS schemes and the different aims of asalaried service.Benefits of such a method of monitoringIt was felt that taken as a whole the process largely resolvedthe issues around patient selection and access highlightedby the scheme.ConclusionThe document ‘Options for Change’ published by theDepartment of Health in 2002, highlighted the need todevelop primary dental care services where ‘CDS, PDS andGDS are properly integrated to meet the changing demandsand needs of local communities’. While services will bemanaged to similar standards, their differing requirementsmust be identified and recognised. Furthermore, there willbe a move away from a fee per item remuneration systemand a move towards practice-based GDS contracts.In view of the above it is clear that the existing method of DRSmonitoring may not be suitable for these purposes and that adifferent method, or methods of monitoring may be required.This pilot has generated considerable interest, both fromother PDS schemes and from a number of field sites. Whilethe process may require further review, the Birmingham PDSpilot for DRS monitoring outlined represents a model, whichcould be developed to meet the future requirements ofdental monitoring of primary care dental services.i) Since the patients seen were simply those who hadbeen booked to attend on the day of the clinicalsession the sample monitored effectively selected itself.An element of randomisation was retained, as thedentists did not know exactly when DROs would beattending. The need to have such randomisation isdebatable. In view of the dentists’ comments, theprocess may have more value from a clinicalgovernance perspective if dentists knew when theDRO would be attendingii) Minimal inconvenience to patients and practitioners.The process did not present any additional burden topatients and caused minimal inconvenience topractitioners, whilst at the same time providing anadequate level of quality assuranceiii) Dentists were able to discuss cases with the attendingDRO. Over a period of time this should facilitate betterunderstanding and communication between DROsand dentists involved in the PDS schemeiv) The modified monitoring process was felt to bettercomplement the existing quality assurance and clinicalgovernance processes in place within the PCT andprovide better external validation of those processesthan the standard method of DRS monitoringv) In all cases the previous SLA was met and in themajority that requirement was exceeded.Ruth Gasser is Clinical Policy Manager and Janet Clarkeis Clinical Director of Birmingham PDS.DENTAL36 review2002-2003

Further information andcontact pointsAnnual Report and AccountsHead of Finance and Operations 01323 433463Helpdesk for NHS General Dental Services01323 433550open Monday to Friday 8.00am - 6.00pme-mail: helpdesk@dpb.nhs.ukComplaints about the services provided by the DentalPractice BoardDPB Helpdesk 01323 433550e-mail: complaints@dpb.nhs.ukDPB roadshows and eventsCustomer Relations 01323 433307Dental Reference ServiceHelpdesk 01323 433554open Monday to Friday 8.00am - 6.00pme-mail: drs@dpb.nhs.ukDental PaymentsHelpdesk 01323 433553open Monday to Friday 8.00am - 6.00pme-mail: dentalpayments@dpb.nhs.ukPublicationsDPB Helpdesk 01323 433550Enquiries about GDS statistical dataInformation Services 01323 433218DPB Research UnitExternal Projects Department 01323 433512Dental Profile magazineCustomer Relations 01323 433395FacsimileHelpdesk for NHS General Dental Services 01323 433222other enquiries 01323 433517DPB websitewww.dpb.nhs.uke-mail: webmaster@dpb.nhs.ukWelsh languageA copy of this review is available in WelshDental Practice BoardCompton Place RoadEastbourneEast Sussex BN20 8ADThis review is printed on fully recyclable paper whichmeets the strictest environmental standards set byISO 14001 and EMAS (the European Union’sEco-Management and Audit Scheme).

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