By Adrian O'Dowd
Within the wide spectrum of oral healthcare needs, some patients need the services of specialists which means there will always be a need for specialty training in dentistry to give practitioners the skills needed for this care.
However, there are some concerns that what is needed most is not always what dentists are choosing to train in.
According to the latest BDJ White Paper on Recruitment1, the current position is that the numbers of people on the General Dental Council’s (GDC) specialist lists has remained stable in recent years and in 2021, there were 4,274 dentists registered with a specialty – slightly higher (21 more) on 2020’s figure.
Orthodontics remains the largest specialty (1,363 dentists) with nearly double the number of the next largest area – oral surgery (719) – followed by the likes of prosthodontics (445), periodontics (382) and endodontics (312).
Dr Tim O’Brien, Associate Professor in Clinical Education and a Consultant in Restorative Dentistry at the Peninsula Dental School (Faculty of Health), University of Plymouth, believes that the numbers of dentists with specialisms will grow over time especially as demand for private care seems to be rising.
‘I think it is likely to stay static for a while, but grow in the longer term,’ says O’Brien. ‘When the lists were first set up, there were a lot of people who were grand-parented onto it but, as these dentists currently on the list retire, the numbers risk decreasing.
‘However, as the plans for reforming the way in which dental care is delivered progress with more complex work being commissioned in practices, the need for specialists to contribute to Tier 2 and 3 NHS services will increase. Coupled with the increased demand for private care, I think that there will be an increased need for specialists and demand usually dictates supply.’
The current situation in terms of availability of training for specialisms around the UK is not ideal, with room for improvement.
A government-commissioned report Hospital Dentistry: GIRFT Programme National Specialty Report2 published in February 2021, looked at six of the 12 dental clinical specialties in hospitals.
Among its many recommendations was a call for a review of workforce planning and training for each dental specialty in order to meet current and future needs. This should include provision for more specialists in primary care and dental practitioners with enhanced skills to provide Level 2 services outside hospital.
Changes are afoot, as set out in the Advancing Dental Care Review3 final report published by Health Education England (HEE) in September 2021.
This three-year review sought to identify and develop a future dental education and training infrastructure aimed at producing a skilled, multi-professional oral healthcare workforce that would meet patient and population needs within the NHS.
While carrying out their work, the review’s authors had found that the existing postgraduate training programme was too rigid and neither able to meet trainees’ expectations nor the changing oral healthcare needs of the population.
Their research also found that inequalities still existed across some population groups including the elderly, vulnerable people, and deprived communities who required targeted or specialist dental care.
Professor Wendy Reid, Executive Director of Education & Quality and Medical Director at HEE, said at the time of the final report’s publication: ‘As we move into the four-year Dental Education Reform Programme (DERP) we will continue to collaborate with trainees, the oral health workforce and our partners in health and education to build a world class professional dental workforce with the right mix of specialist, generalist and extended skills, distributed equitably across England.’
The four-year plan has proposed more flexible entry routes into training to widen access and participation and develop more dental professionals in areas of greatest need; better coordination and distribution of postgraduate training posts so they are better aligned to areas with the highest levels of oral health inequalities; and flexible models of dental core and specialty training.
The reasons why orthodontics is so popular with dentists and by far the specialty most often chosen by them reflects patient demand, say experts.
Alan Goldie, Managing Director and Partner at the VSSAcademy, a provider of continuing dental education, says: ‘I feel that this is an area of growth because the general population are more focussed on their teeth health and appearance in recent years.
‘Also, the companies providing the products and programmes are growing rapidly, which also fuels the growth of this sector.’
O’Brien adds: ‘I can understand the attraction of dealing with this subject area, and the changes to patients’ lives that my orthodontic colleagues make are incredible and quite rightfully lauded.
‘In addition to job satisfaction though, I suspect that the funding for training has had a significant part to play in this, as well as the overall number of training places being offered in comparison to the other specialities.’
Those in the education sector hope there is potential for all the specialties to grow in popularity as O’Brien explains: ‘I hope that they all will grow, as that is what is needed to deliver Advancing Dental Care. In practical terms though, I suspect that those with potential for private work will grow more.’
Goldie adds: ‘I'd expect to see continued growth in the dental implant market. Although not technically a speciality, it is a complex area.
‘The market penetration of implants is lower than in many countries in Europe, globally and Asia in particular. As people become more and more aware that implants are a viable treatment option and more and more clinicians are able to provide the service, I can't see the sector not grow.’
Of his own organisation and the most popular specialties, he says: ‘Our focus is squarely on dental implants so for now, about 95% of our work is that.’
The potential benefits of gaining specialist qualifications are worthwhile, argues the Dominic Hassall Training Institute near Birmingham, which provides postgraduate education and training.
Dominic Hassall, Director of the Institute, who is a Restorative, Prosthodontic, Periodontal and Endodontic Specialist, says: ‘We are committed to promoting clinical excellence in dentistry through world leading postgraduate training that challenges outdated concepts and philosophies, enabling participants to provide cutting edge predictable and profitable private clinical restorative aesthetic dentistry.
‘For personal attention we focus on small groups with a maximum of 12 and include clinical case support/mentoring as part of the learning experience.’
A crucial issue is what patients are increasingly seeking from specialist dentists and whether that matches with what dentists are seeking to train in.
O’Brien says: ‘Looking at the GDC’s Registration report and the adverts placed for specialists, I get the impression that orthodontists, along with oral surgeons and specialists in the restorative disciplines are most frequently sought.
‘Yes, there are specialties for which there is demand but which don’t seem to attract people to seek GDC certification of them. Areas like paediatrics, special care, oral medicine and others need more specialists.’
Persuading dentists to seek certification for these specialties that are in demand can be tackled in various ways, as he explains: ‘Talking to young dentists, the biggest barrier seems to be the funding. I think that there need to be more funded training posts to help with this, rather than alterations to the routes to inclusion on a specialist list.’
One area of concern is paediatric dentistry within which shortages of specialists has been an issue highlighted for some time.
In May of this year, data4 from the Office for Health Improvement and Disparities showed that the number of extractions (35,190) performed on decayed teeth in children aged 0-19 in 2019-20 more than halved to just 14,645 in 2020-21 – a 58% fall which is thought to be partly caused by interruption to services due to the Covid-19 pandemic.
The BDA has urged the government to act decisively to deal with the backlog for child tooth extractions but the figures also show that regardless of the pandemic, the proportion of extractions as a result of decay was virtually unchanged from levels seen a decade ago.
Professor Sondos Albadri, President of the British Society of Paediatric Dentistry (BSPD) said at the time of the data being published: “Paediatric dentistry has been one of the hardest hit specialties and the slowest to recover. Members are working hard, going above and beyond to prioritise the wellbeing of children.
‘However, there is a clear shortage in the number of specialists and their distribution across the country - and the society continues to call for investment in training.
‘BSPD believes that the oral health of children must be re-thought with revised models of care, including joint working with other health professionals and the upskilling of primary care colleagues to provide oral health intervention where needed.’
Any dentists keen to specialise have to be seriously committed to such a goal as gaining the formal qualification is not a simple nor short-term matter.
For oral medicine, a five-year long training programme is needed to gain a Certificate of Completion of Specialist Training in Oral Medicine, which can be trimmed to just three years for people applying with a medical and dental degree.
To even gain entry to the training requires a minimum of two years of postgraduate training in dentistry including experience in primary and secondary care settings.
Another example is oral microbiology, for which the training is a five-year full-time programme (previously joint with medical microbiology) and passing the Fellowship examination of the Royal College of Pathologists in Medical Microbiology.
There are also geographical considerations given that not all dentists will have easy access to specialty training, which is predominantly delivered in teaching hospitals in urban areas.
Securing specialist training is still not easy, as O’Brien explains: ‘Currently we have the situation whereby people need to do a recognised training programme which in many cases, is either really hard to get into or extremely expensive to do.
‘There probably is going to be more call for specialty training because that's the direction that many young dentists want to take their careers and if the number of people working in Tier 1 general practice is reducing as hygienists and therapists play a bigger role in the delivery of care, then it makes sense to equip yourself to do more specialised stuff.
‘The problem at the moment is the cost of training – if funded posts are not available, and a self-funded three-year full-time masters course is the only option. There are concerns that not enough funded specialty training programmes are currently available.’
Another issue is that the self-funded option does not directly lead to registration as a specialist and the GDC’s current process for this is not always straightforward.
Hopefully, the changes ahead signalled by the Advancing Dental Care report coupled with growing awareness of specialties that are currently neglected could mean that all dental specialties will eventually attract the right numbers of dentists, but the process is unlikely to be plain sailing.
BDJ Jobs Recruitment Whitepaper 2021 (22 December 2021) BDA and Springer Nature https://www.bdjjobs.com/article/download-our-free-white-paper-on-the-state-of-the-uk-dentistry-recruitment-market Hospital Dentistry: GIRFT Programme National Specialty Report (Getting It Right Frist Time) February 2021 https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/HospitalDentistryReport-Sept21j-1.pdf Advancing Dental Care Review: Final Report. Health Education England (9 September 2021) https://www.hee.nhs.uk/our-work/advancing-dental-care Office for Health Improvement and Disparities. Hospital tooth extractions of 0 to 19 year olds 2021 (10 May 2022) https://www.gov.uk/government/publications/hospital-tooth-extractions-of-0-to-19-year-olds#:~:text=For%20the%20financial%20year%202019%2cgeneral%20anaesthetic%20for%20the%20procedure
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