B1639 Cinical Guide To Dentistry September 2023

Classification: Official
Publication reference: PR1639
Clinical guide for dentistry
Version 2, 28 October 2022
Updates to the previous version of this guide are highlighted in yellow.

Contents
Foreword .................................................................................................................. 3
1. Equality and health inequalities statement............................................................ 4
2. Executive summary .............................................................................................. 4
3. NHS dental specialties.......................................................................................... 5
3.1 Getting serious about prevention ................................................................. 7
3.2 Managed clinical networks (MCNs).............................................................. 7
3.3 The role of the MCN in developing the network ........................................... 7
3.4 Establishing a Managed Clinical Network .................................................... 8
3.5 Who will make sure the MCN is doing its job and hold it to account? .......... 9
3.6 Improving referral pathways for MCN effectiveness and improved patient
care ......................................................................................................... 9
3.7 Supporting the profession .......................................................................... 10
4. Factors to consider during implementation ......................................................... 11
4.1 Ethos .......................................................................................................... 11
4.2 Context ...................................................................................................... 11
4.3 Vulnerable and socially excluded patients ................................................. 12
4.4 Domiciliary care ......................................................................................... 13
5. The patient journey ............................................................................................. 17
5.1 The summarised illustrative patient journey ............................................... 17
5.2 Vision for the patient journey...................................................................... 17
5.3 Referral ...................................................................................................... 18
5.4 Other issues ............................................................................................... 18
6. Workforce and training........................................................................................ 19
6.1 Primary care providers ............................................................................... 19
6.2 Foundation and postgraduate training ....................................................... 19
6.3 Patient Reported Outcome Measures (PROMs)/ Patient Reported
Experience Measures (PREMs) ............................................................ 22
6.4 Data Compliance ....................................................................................... 23
7. Sustainability in dentistry .................................................................................... 25
Appendix 1 – What is a health needs assessment? ............................................... 26
Appendix 2: Relevant diseases and conditions ...................................................... 28
1 | Clinical guide for dentistry

Appendix 3 .............................................................................................................. 29
Appendix 4: Glossary of terms ................................................................................ 30

Foreword
In 2015 NHS England published the first of a series of Commissioning Guides and
Commissioning Standards, which were produced following publication of Securing
excellence in commissioning NHS dental services 2013.
The Commissioning Guides and Standards describe how dental care pathways
should develop to deliver consistency and excellence in commissioning NHS dental
services across the spectrum of providers to benefit patients.
Over the last 4 years NHS England has taken the opportunity to review the
Commissioning Standard programme and reformat for online use, in order to
provide a suite of Clinical Standards each linked to an overarching Commissioning
Standard. This document is the revised and updated overarching Commissioning
Standard which has evolved from the 2015 version.
This Overarching Standard includes associated appendices which will be derived

from the current suite of Commissioning Standards and Commissioning Guides
which look at specific dental specialties and areas of care. The move to an online
platform will allow regular review and revision in line with current policy and
practice; it will be necessary to review and update the standards regularly.
Implementation will require energy and momentum, together with a willingness to
share good practice, innovation and learning to enhance patient care.

1. Equality and health inequalities
statement
Promoting equality and addressing health inequalities are at the heart of NHS
England’s values. Throughout the development of the policies and processes cited
in this document, we have: Given due regard to the need to eliminate
discrimination, harassment and victimisation, to advance equality of opportunity,
and to foster good relations between people who share a relevant protected
characteristic (as cited under the Equality Act 2010) and those who do not share it;
and, regard to the need to reduce inequalities between patients in access to, and
outcomes from, healthcare services and to ensure services are provided in an
integrated way where this might reduce health inequalities.
2. Executive summary
NHS England has developed a suite of Clinical Standards for Dental Specialties
which intended offer a consistent and coherent qualitative approach for NHS
commissioned services. This approach reflects the need and complexity of patient
care and the competency of the clinician required to deliver the clinical intervention
rather than by the setting within which the care is delivered. Care is delivered via a
pathway approach which provides clarity and consistency for patients, the
profession and commissioners. There are nationally agreed minimum specifications
for each service, including how quality and outcomes are to be measured, which
can be enhanced locally.
These standards describe the concept of clinical engagement and leadership to the
Integrated Care System (ICS) through Managed Clinical Networks (MCNs) which
will work closely with local commissioners.
Needs-led dental specialist care pathways (as in appendix 1) rely on maintaining

and ensuring access to effective primary dental care services; particularly for those
groups in the population who do not access care routinely or have additional needs.
Commissioners who procure services should use these standards to complete
needs assessments, set minimum standards and service direction and ensure that
proposed outcomes and quality measures are included in service specifications.

The Standards including this overarching Commissioning Standard, should be
made available to potential bidders.
3. NHS dental specialties

NHS England commissions all NHS dental services. The benefit of a single
commissioner for dentistry is the ability to plan and produce more consistent
standards of delivery and better health outcomes for patients across the whole of
England.
A strong emphasis on prevention was underlined in the NHS England Long Term
Plan and the production of these standards supports NHS England’s pledge to
improve prevention:
“It does so while recognising that a comprehensive approach to preventing

ill-health also depends on action that only individuals, companies,
communities and national government can take to tackle wider threats to
health, and ensure health is hardwired into social and economic policy.”
These standards are intended to promote consistent quality of specialist dental care
provided to patients. Methods to describe population need and current services,
working jointly with the National Institute for Health Protection (NIHP), are modelled
and shared for commissioners and clinicians to inform local needs assessment and
the impact of existing services in meeting identified need. These Standards are
about supporting commissioners and clinicians to work together to ensure that
resources invested by the NHS in dental specialist care are used in the most
effective way to provide the best possible quality and quantity of care for patients.
The levels of complexity do not describe contracts, or practitioners or settings.

Levels 1, 2 and 3 care descriptors reflect a case in terms of procedural difficulty,
patient modifying factors and competence required of a clinician to deliver care of
that level of complexity. Each supporting appendix will detail the requirements of
the three levels in regard to that specific clinical requirement.
The three levels of care are defined in table 1 below:

Table 1: Three levels of care
Complexity Description
Level 1 Skillsets and competencies that are covered by teaching and training in
the dental undergraduate and Dental Foundation (FD) programme. Such
skills are enhanced and improved with experience, so the development of
these skills is a career-long process. The provider is responsible for the
delivery and quality of mandatory services. Treatments that are not
specifically defined in Levels 2 or 3 are de facto Level 1
Level 2 Procedural and/or patient complexity requiring a clinician with enhanced

skills and experience who may or may not be on a specialist register. This
care may require additional equipment or environment standards but can
usually be provided in primary care. Level 2 case complexity may be
delivered as part of the continuing care of a patient or may require onward
referral. Providers of Level 2 care on referral will need a formal link to a
specialist, to quality assure the outcome of pathway delivery.
Level 3a Care that requires specialist practitioner or consultant led care due to
Level 3b complex clinical or patient factors. This care can be provided in a primary
care, dental hospital or in a secondary care setting depending on the
needs of the patient and/or local arrangements which may include current
training commitments.
These Standards are intended to inform and support Local Dental Networks and
commissioners, working within the local context of Primary Care Networks and
integrated care systems, to understand local need, impact of current investment
and what would enable them to transform services in their area to build on any
engagement work already undertaken with local partners such as Healthwatch and
patients and the public. There will be a need to establish, strengthen or formalise
clinical networks and specialist groups to implement system change which takes
into account local needs and circumstances, including reviewing progress to date
and required pace of change.

3.1 Getting serious about prevention
The concept of needs-led, evidenced-based, prevention-focused care pathways is
central to supporting change in dental service delivery. Specialist dental services
can dovetail this approach as advocated in these commissioning standards.
However, this relies on maintaining and continuing to improve access to primary
care dentistry and investing in primary care.
The aim of adopting a care pathway approach is to shift dental service delivery from
an interventional to a preventive focus with care based on individual need and risk;
with the main emphasis on outcomes and effectiveness of clinical care. Additionally,
the pathway model aims to encourage patients to take responsibility for protecting
and maintaining their own oral health and committing to the demands of receiving
specialist or advanced care, as part of a long-term continuing care relationship
between themselves and their dental teams.
3.2 Managed clinical networks (MCNs)

MCNs have been defined as ‘linked groups of health professionals and
organisations from primary, secondary and tertiary care working in a coordinated
manner, unconstrained by existing professional and organisational boundaries to
ensure equitable provision of high quality, clinically effective services’.
An MCN should be led by a local consultant in the appropriate specialty, who

commands the respect of the members and the LDN. Taking part in MCNs should
be agreed as part of a consultant’s job plan and a mechanism to fund the
programmed activities (PAs) that have been agreed. This must be achieved within
existing resources and is a matter for commissioners to facilitate using negotiations
with secondary care providers during contract discussions and/or through efficiency
savings. Clinicians, taking an active role in the MCN, need to be recognised and
this work supported within the contractual framework.
All providers of Level 2 and Level 3 services should be members of the relevant
local MCN. This should be stipulated in the service contracts.
3.3 The role of the MCN in developing the network

The role of the MCN in developing the network is illustrated in Table 2 below:

Table 2: MCN role in developing the network
Developing its education The educational and training potential for managed clinical
and training networks should be used to the full, through exchanges
between those working in primary care including specialist
practices and those working in dental hospitals or secondary
care settings. Networks’ potential to contribute to the
development of clinicians with enhanced skills and
experience concept should also be kept in mind, and
networks should develop appropriate affiliations to
universities, the Royal Colleges and Workforce & Education
(WT&E).
Have a CPD programme in All networks must include arrangements for the effective
place for all staff and delivery of training ensuring that those on specialist training
ensure that staff are able pathways have sufficient experience and supervision with
to move within the network cases of clinical and patient complexity. The networks can
in ways to improve patient also take an influential role in transforming undergraduate,
access and maintain postgraduate, remedial and training for clinicians with
professional skills enhanced skills and experience, so that training opportunities
follow patients receiving care rather than patients following
established training arrangements. This will need to be
influenced, implemented and monitored locally in an
environment which supports ambitions and innovation.
Explore the potential There must be evidence that networks allow professionals to
come together to explore the potential to generate better
value for money, service improvement and more interesting
career opportunities for clinicians.
3.4 Establishing a Managed Clinical Network

Commissioners must familiarise themselves with the National NHS England current
core MCN job description and MCN terms of reference and liaise with the local
dental network (LDN) to establish one.

MCNs will also link with LPN colleagues to ensure that the clinical voice of primary
care is heard and that primary care is linked to specialist care providers giving a
connection across historic boundaries to improve patient care. The group will
interact with and be governed within the commissioning system and all providers of
care on referral will require a formal link at least to submit and receive data but
more importantly to contribute to the improving quality and service delivery agenda.
3.5 Who will make sure the MCN is doing its job and
hold it to account?
Commissioners are responsible for establishing appropriate MCNs in their area and
are responsible for ensuring that it does what it is supposed to do, and also that it is
resourced appropriately. The MCN will provide reports to the LPN or dental system
leadership team. Commissioners and MCNs will together ensure that the correct
level of competence, quality (including equipment) and outcomes are being
achieved for patients, regardless of the setting.
There will need to be fair access to all aspects of specialist dentistry care and as is
the case now, patient choice and awareness of all options available to them will be
key features of the service.
3.6 Improving referral pathways for MCN effectiveness

and improved patient care
There should be a robust referral management process that recognises the needs
of the patient, the referring practitioner and the accepting dentist/specialist. The
Commissioners will also have requirements to ensure that referrals are appropriate
and that the care is being provided by those contracted to deliver that care.
At the point of making the decision to refer, the patient needs to know why they are
being referred and what is likely to happen at the first appointment. The referral
ideally needs to be as local as possible to the patient, however patient choice
should be considered. The patient needs to know how long they may have to wait
for an appointment following referral, how they will be contacted and how they can
change any given appointment.
If possible, patients should be given a choice of specialist provider, however this

may not always be possible particularly in the shorter term. The benefits and risks

of treatment together with information on the time needed and the number of
appointments should also be provided.
An RMS should assist the referring practitioner to know who to refer to and how.
The system should also have clear acceptance criteria. The RMS needs to
acknowledge receipt of the referral and the referrer ideally needs to be informed of
the patient’s appointment. Once the patient has been assessed, should this just be
for advice and support, there needs to be prompt reply / treatment plan to the
referrer with a clear treatment pathway for the patient.
The receiving practitioner/specialist needs clear and concise referral data that
meets the agreed acceptance criteria and contains all the information required.
Standardised pro-formas will assist in this. Transmission of all relevant information,
including x-rays must be secure utilising the nhs.net system.
The referral data needs to be auditable and available to the MCN. This will help to
improve the referral process, to better understand the needs of the patient base and
will help commissioners plan for future service delivery.
3.7 Supporting the profession

The MCN can provide an effective role in being able to support those professionals
undertaking care. There may be some tell-tale signs that practitioners are
experiencing problems or difficulties through the referrals that are being received.
An above average number of referrals or a continued number of referrals not
meeting acceptance criteria could be such triggers. A complete absence of any
referrals from a practice may also be a trigger.
The MCN with commissioners and Health Education England (WT&E) should
consider how they can best support these individuals and how services might offer
opportunities to ensure continued sustainability of care to patients.

4. Factors to consider during
implementation
4.1 Ethos
England is too diverse for a ‘one size fits all’ care model to apply everywhere.
These clinical standards provide a national framework for care delivery models.
Regional teams have flexibility over pace and scale of change to reflect local
circumstances and needs, but are expected to adhere to standards, measures and
vision.
Transformational and transactional change is required in the delivery of dental

specialist services and commissioners must regularly review population need,
investment and impact of existing local services in meeting that need, using the
enablers set out in the patient journeys within these standards as a benchmark.
4.2 Context
An emphasis on improving outcomes and effectiveness, consistency and clarity,
regardless of setting, is needed in several areas and the individual specialist
standards provide a framework and some detail for clinicians to achieve that by
offering:
• clarity of what is expected as a minimum by primary care providers treating
patients with Level 1 complexity, dentists with enhanced skills and
experience or specialists treating patients with Level 2 complexities on
referral and specialist and consultant-led care treating patients with Level 3
complexity
• expected clinical competencies and outcomes at each level of care
• consistent environment and equipment standards within outline model
specifications
• generic and specialty specific clinical outcomes, quality standards and
patient reported outcome and experience measures (PROMS) (PREMS) for
England
• consistent referral core data set, coding and tariff expectations for care
pathways

• access to services across each pathway to ensure that people with
disabilities and all other ‘hard to hear’ groups of people have equitable
access to specialist dental care when required.
For each clinical standard a common format has been used. The individual
standards include the following:
• Brief description of the speciality

• Brief overview of workforce and training
• Specific population need and delivery at a national and regional level,
(giving commissioners a method) to collate and understand local need and
to assess the impact of current services in meeting that need
• Quality standards and metrics for competency of clinicians, environment
including equipment
• Generic and specialty-specific PROMs and PREMs. Commissioners,
clinicians and service leads can add additional measures, if capacity to
measure and report on more exists.
4.3 Vulnerable and socially excluded patients

The NHS typically defines at-risk adults as:
“A person who is 18 years of age or over, and who is or may be in need of

community care services by reason of mental or other disability, age or
illness and who is or may be unable to take care of him/herself, or unable to
protect him/herself against significant harm or serious exploitation.”
Section 59 of the Safeguarding At Risk Groups Act 2006 states that:
A person is an at-risk adult if, having attained the age of 18, s/he:
1. is in residential accommodation
2. is in sheltered housing
3. receives domiciliary care
4. receives any form of health care
5. is detained in lawful custody

6. by virtue of an order of a court, is under supervision per Criminal Justice Act
2003 sections regarding community sentences
7. receives a welfare service of a prescribed description
8. receives any service or participates in any activity provided specifically for

persons who has particular needs because of his/her age, has any form of
disability or has a prescribed physical or mental problem. (Dyslexia,
dyscalculia and dyspraxia are excluded disabilities)
9. has payments made to him/her or to an accepted representative in

pursuance of arrangements under Health and Social Care Act 2012, and/or
10. requires assistance in the conduct of own affairs.
While these definitions are helpful, they are not comprehensive, and further groups
can be found within The national framework for NHS – action on inclusion health
2023, which describes inclusion healthcare for patients who are within the
vulnerable and socially excluded groups.
4.4 Domiciliary care

There will always be a requirement for a level of domiciliary care for those patients
who are housebound. This is a growing area due to an aging population many of
whom are dentate but with complex health needs.
Undertaking care and treatment for these patients can be difficult and therefore,
wherever possible, dental care should be provided in an appropriate clinical
environment where comprehensive treatment can be provided. Commissioners
could consider options such as transport provision which would minimise the need
for some domiciliary care.
Commissioners should work with their special care dentistry MCN and general
dental practitioners to develop care pathways together with a clear set of guidelines
for accessing domiciliary care services and similarly a clear set of expectations of
the care that should be provided for those practitioners and services whose
contracts contain domiciliary care services. These guidelines should take account
of factors such as:
• equipment to manage medical emergencies,

• maintenance of infection control standards,
• management of clinical records.
It is likely that two sets of locally commissioned pathways will exist. One for general
dental services providers who may see particular groups of patients and another for
specialist service providers addressing the more specific needs of their patients.
These local guidelines should be widely shared to ensure that everyone
understands for who these services exist, how they can be accessed and the
treatments that might be available.
There may be practitioners who have domiciliary care elements within their
contracts but who do not undertake these or undertake them to the levels specified
within their contracts. Commissioners should ensure that where practitioners wish
to continue delivery of these services, that referrals for such services are
appropriately directed to these practices so that delivery of care can take place.
By working in collaboration local information packs and resources could be

developed to better ensure that individuals and their carers, such as residential and
nursing homes, can ensure that good oral healthcare is maintained or improved.
4.4.1 Better resources available to practices

While there is a large amount of information available regarding patient charges
and how to claim for exemption against payment, much of this information is not in
a format that is easily understood by many vulnerable patients. Consideration
should be given to the provision of easy to interpret information for these patients.
4.4.2 Solutions for patients

There are a wider number of ways that commissioners could consider working with
their partners and practices to improve access to services for vulnerable patients:
• Autistic adults, children and young people and/or those with a learning
disability: practices should consider appropriate appointment times for
these patients. It may be better to offer appointments to these patients at
the start of a treatment session to minimise their waiting times and the
number of additional patients who may be in the practice which may cause
them additional anxiety.

• Extended/alternative hours will provide greater flexibility for those patients
who may have difficulty accessing services within ‘normal operating hours’
• Continuity of care with the same dentist could help some patients overcome
additional anxieties and problems caused merely by attending the dentist.
• Provision of easily accessible information for patients that explains how the
services work, how to access them and explains more about treatment and
how any potential referral pathways work. It would be beneficial to ensure
that this information was more widely available and if the overarching
principles above were adopted then it should be relatively easy for this
information to be available where it could best be accessed.
• Improving signage both outside and inside the practice can help many
patients particularly where this is a larger practice or perhaps a practice
located within a large health facility.
• Having support for individuals who may require additional help in

completing ‘paperwork’ such as medical and social histories.
Homeless people should not be denied treatment on the basis that they do not have
an address which is a requirement for completion of an FP17 claim form which
dental practices need to complete following treatment. If the patient is of ‘No fixed
abode’ the dentist can use their dental surgery address. A note regarding this
should be made on the patients' dental records for reference.
4.4.3 General legislation and guidance

General legislation and guidance will cover elements such as:
• Health Technical Memorandum 01-05: Decontamination in primary care

dental practices
• Ionising Radiation (Medical Exposure) Regulations (IRMER),
• HIV-infected health care workers: Guidance on management and patient
notification – no the original document (which was withdrawn in February
2021) but a more generic document regarding bloodborne illnesses
• Equality Act
• Dental Practitioners’ Formulary
• GDC Scope of Practice guidance

• GDC Fitness to Practice advice
• GDC Standards for the Dental Team guidance
• General Data Protection Regulations
• Compliance with Health and Safety at Work etc. Act,
• Compliance with Employers’ Liability (Compulsory Insurance) Act,
• Compliance with Electrical safety at work regulations
• Compliance with safety requirements for autoclaves
• Compliance with Control of Substances Hazardous to Health (COSHH)
• Compliance with Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations
• Compliance with Water Supply (Water Fittings) Regulations, 1999
• Disability access requirements
• CQC registration
4.4.4 Continuity of care

For some patients seeing the same practitioner can make a difference to their
experience of attending the dental surgery. They are able to build a level of trust
and there is the opportunity to develop an ongoing relationship which can help
overcome fears and anxieties. There will always be a level of staff turnover in
practices but it may be possible within some practices to make minor adjustments
which could allow for better continuity of care. Long term planning for these patients
is also important, particularly if they have a progressive disease such as dementia.
4.4.5 Developing partnerships with key stakeholders

Better working relationships with key stakeholders and advocacy groups could help
improve access to dental services for all vulnerable adults through ensuring
accessible, up to date and accurate information on how to access care is available.
Some of these groups would also be able to provide information and support for
transport systems to enable patients, who otherwise might expect domiciliary care,
to access more appropriate services within a practice environment where a greater
range of treatment options are available.

5. The patient journey
5.1 The summarised illustrative patient journey
Referred from
Walk in
non-dental
appointment
setting**
Does patient
no END
require treatment?
yes
Can GDP END

perform required yes Provide
treatment? treatment
no
Patient referral
GDP
Referral management system
MC N consultant-led assessment and triage
Level 1 care Level 2 care Level 3 care
Discharge/
recall protocol/
shared care
** Examples of where referrals into GDPs may come from:

• Healthcare professionals
• Relatives and carers
• Learning disability teams
• Day centre and residential/ care home staff
• Community mental health teams
• Social services
• Tertiary referral
• GMPs
• 111
5.2 Vision for the patient journey

Every patient journey to specialist dental care should begin with a visit to a primary
dental care practitioner (GDS or CDS) from whom they receive regular care; this
may be an NHS or private primary care provider.

The dentist will complete a comprehensive examination to assess risk and need. If
a patient needs dental treatment, the primary care provider delivers comprehensive
primary dental care. If a patient requires a complex procedure, has modifying
factors that make routine dental care complex, or requires additional equipment or
facilities to deliver care then a referral to a specialist service maybe required.
In many cases the dentist may be competent to provide level 2 care complexity and
will do so for their own patients; however, some may need to make a referral to a
specialist provider in a primary or a secondary care setting.
It is important the referral process, at the beginning of the patient journey to

specialist dental care, captures GP referrals, those from private dental providers
and patients who attend A&E to ensure that these patients have access to an
appropriate primary or specialist care to meet their needs. Reporting on these and
working with the relevant MCN enables commissioners to identify variances which
may need to be discussed with providers.
5.3 Referral
The referral will be made by a primary care dentist within one week of a decision to
refer a patient. Other sources of referrals to dental specialties will be identified and
managed. A core data set will be provided by the referrer (as detailed in individual
specialty standards). It will allow an appropriate triage decision within specified
timescales. Referrals are then directed to an appropriate level of specialist service
taking account of any local arrangements and patient choice.
Dentistry must legally use NHS numbers as this underpins robust data collection
and reporting to enable integration of dental services within NHS England. The
patient may also have a unique reference number to track progress of their referral.
In anonymised form this data set will also allow commissioners to understand the
complexity of referred cases to support needs assessment.
5.4 Other issues

Patients often prefer more familiar surroundings. It is not the intention of these
standards to change this care delivery model but with the advent of the ICS patients
may go to a different practice to receive their treatment where appropriate.

6. Workforce and training
6.1 Primary care providers
NHS and private primary care providers deliver most of the dental care in England.
Many NHS practices provide both to their patients. Most dental practices will
employ dental care professionals who will include nurses, hygienists, and
therapists. Occasionally services may also be provided by clinical dental
technicians and dental technicians.
6.1.1 Greater use of skill mix

Practices could look to employ their skill mix to support oral health improvements
for patients. As well as providing services within the practice environment practices
could also:
• Work with groups within the community to identify the best ways for them to
interact with dental services
• Build relationships with organisations and individuals within the community
• Organise visits, events and promotions in the community designed to raise
awareness of good oral health and access to dental treatment
The Scope of Practice for Dental Care Professionals sets out their individual skills
and abilities which can change over the course of their respective careers and can
be found on the GDC website. It is recommended that the service specifications
that are developed that allow DCPs to use the full scope of their practice. This will
improve skill mix and enable dentists to also utilise their full range of skills and
competences.
6.2 Foundation and postgraduate training

Dental training at all levels requires trainees to carry out regular direct patient care
under supervision. All dental service contracts should clarify that trainees can be
involved in service delivery where the training post has been approved by the
Postgraduate Dental Dean. WT&E and its constituent Local Education and Training
Boards (LETBs) are responsible for workforce development and commissioning of
education and training for the healthcare workforce and need to reflect the
requirements of NHS England.

They ensure that the workforce has the right numbers, skills, values, and
behaviours to support patients and thus enhance patient care by providing
guidance, education, and training to the healthcare workforce. This includes
developing a multi-professional primary dental care workforce that can meet the
needs of current and future service requirements.
WT&E can provide an integrated approach to educating clinicians to address the

needs of vulnerable patients and to plan for changing population demographics.
Commissioners should therefore work with Health Education England (WT&E) and
teaching hospitals to identify the training requirements for local service delivery.
Then ensure that education on delivery of services to vulnerable groups forms part
of any outreach during foundation training and dental workforce development
opportunities.
Commissioners should ensure they have formal arrangements to share dental

service commissioning plans with their LETB dental lead (usually the Postgraduate
Dental Dean or Director) and should be aware of the training needs and delivery in
place. Changes to service commissioning and delivery can have a significant
impact on training provision and the best outcomes for all concerned are achieved
when training is considered at the outline planning stage.
Completion of dental foundation training in primary dental care is compulsory to

enable UK trained dentists to join the NHS Performers List without conditions. This
allows practitioners to deliver primary care dental services to Level 1 complexity, as
a minimum competency.
Dental specialty training lasts between 3 and 5 years and is undertaken by dentists
who will join a GDC Specialist Register on completion of the programme.

1. Mental Capacity This training will ensure that staff understand and can navigate the
Act training process for obtaining consent for treatment.
2. Communication This type of training facilitates service provision for all vulnerable
adults and particularly those with dementia. The General Dental
training
Council highlights the importance of effective communication with
patients, the dental team, and others across dentistry, including
when obtaining consent, dealing with complaints, and raising
concerns when patients are at risk. It recommends that all dental
registrants undertake training in communication as part of their
Enhanced Continuing Professional Development.
3. Dementia People living with dementia will encounter a range of people on a

friendly training day to day basis as they go about their business. They may
experience a range of problems associated with dementia that
have the potential to impact on their ability to interact with those
they encounter. Similarly, those they encounter may be unsure
how and whether to help people who appear to be experiencing
difficulties.
People with dementia all differ in the way they experience their
dementia, but generally speaking in public situations people with
dementia may have a range of difficulties, including:
Have problems remembering what they are doing
Have difficulties in communicating clearly
Have problems handling money
Have problems navigating in complex or confusing environments
How others respond to people who may be experiencing these
kinds of problems can make a real difference.
The College of General Dentistry has developed Dementia-
Friendly Dentistry: Good Practice Guidelines which enables dental
professionals to understand dementia and its implications for
dental practice, and adapt their patient management and clinical
decisions accordingly

4. Safeguarding Working with vulnerable adults can be incredibly rewarding but it
training also comes with responsibilities. Safeguarding training can help
improve the dental teams’ communication ability.
The ability to communicate to vulnerable adults about their needs
and well-being lies at the core of safeguarding. Therefore,
safeguarding training has a serious focus on the different ways in
which staff can talk to vulnerable adults about abuse and neglect.
Abuse and neglect of any type may happen to anyone, however
vulnerable adults may be more likely to suffer neglect and harm,
therefore it is important for all dental professionals to be aware of
the issues related to safeguarding.
Every dental professional should be trained in safeguarding. The
practice should have a safeguarding lead and a straightforward
policy when concerns arise. It may be that an individual's only
external contact is with a dental professional; in turn it becomes
their duty of care that the matter is reported as deemed
appropriate.
5. Equality and This training demonstrates commitment to ensuring a fully inclusive

diversity training patient centered service. It can help practices ensure that their
service users can feel confident that their dental practice
understands and can respond to specific patient need. Quality
assurance services such as the LGBT Foundation Pride in Practice
initiative provides useful training for primary care providers.
6.3 Patient Reported Outcome Measures (PROMs)/

Patient Reported Experience Measures (PREMs)
The Core set of PROMS and PREMs below should be included in all service
specifications with additional specialty specific PROMS and PREMs added as
appropriate.

Patient Reported Outcome Measures
Question How much of a problem are your teeth for you?
Responses A lot
A bit
Not at all
Global rating of oral health (Gilchrist 2015)
Question Since your last treatment, do you think your teeth are:
Responses Better
The same
Worse?
Global change in oral health condition (following treatment) (Gilchrist 2015)
6.3.1 Patient Reported Experience Measures
Question Did the clinical team (clinician) involve you in your

treatment decision in terms that you understood?
Responses Yes
No
Not sure
Question Were you given the opportunity to ask questions?
Responses Yes
No
Not sure
6.4 Data Compliance

Following recommendation by the Standardisation Committee for Care Information
(SCCI), the Department of Health and Social Care approved a change to an

existing information standard which states that systems used within Dentistry and
all other providers of health and social care - for the direct management of care of
an individual - must use the International standard of Systematised Nomenclature
of Medicine - Clinical Terms (SNOMED CT) as the clinical terminology standard
within all electronic patient level recording and communications by 1 April 2020.
Commissioners must ensure that all data is recorded in SNOMED terminology and
that the information systems utilised in the input, storage and transmission of
electronic patient data comply with extant NHS standards.
The registration of a dental practice and its team members to the NHSmail system
must be a pre-requisite to the issuing of an NHS contract to ensure integrity of the
transmission of patient clinical information.

7. Sustainability in dentistry
As of April 2023, every Integrated Care System (ICS) in England has a Green Plan,
borne of NHS England’s response to the UK Climate Change Act 2008. The Clinical
guidelines for environmental sustainability in dentistry provides a set of guidelines,
accompanied by indications for the costs and time taken to implement in Primary
Care settings. Sustainability in dentistry: Leading for change provides a scoping
review to facilitate discussions and relationships between the dental profession,
dental industry, and wider oral health and dental care infrastructure.

Appendix 1 – What is a health needs assessment?
A health need can only exist when an individual has an illness or disability for which there is
an acceptable cure (Matthew, 1971). Health needs may be described from the perspective of
the service recipient or that of the service provider (Chestnutt et al., 2013). Different types of
health need exist, including need defined by health professionals (normative need), needs
defined by service users (felt need), actions taken by service recipients to utilise health
services (expressed need or demand), need between similar groups of people (comparative
need) and the difference between need for health services and service provision (unmet need)
(Bradshaw, 1972; Carr and Wolfe, 1976). A health needs assessment usually aims to identify
the unmet health needs of a defined population to enable targeting of resources to improve
health and reduce health inequalities.
Commissioning of healthcare comprises a range of activities 1 including:
• planning services
• procuring services
• monitoring quality
Planning oral healthcare services should be underpinned by a needs assessment. Oral health
needs assessment (OHNA) should be used to determine if current oral healthcare services
for patients are meeting local oral health needs. The method utilised should aim to answer
the following questions:
• What is the health problem?
• What is the size and nature of the problem of the population?
• What are the current services available?
• What do professionals, patients and the public and other stakeholders
want/need?
• What are the most appropriate and cost-effective interventions?
• What are the resource implications?
An oral health needs assessment (OHNA) therefore involves establishing and describing the
oral health of a population, ascertaining their needs, measuring the capacity of existing
services to meet these needs. Where these gaps exist, identifying new or alternative ways in
which such gaps can be prioritised and filled (Chestnutt et al., 2013). Consultants in dental
public health as public health advisors to the NHS have the expertise to undertake oral health
needs assessments and support NHS England to commission high quality, safe and effective
oral healthcare services, leading to improved access, patient outcomes and experience.
However, there are difficulties in determining need, uptake and demand for oral healthcare
services due to limited information sources. Commissioning services that meet the needs of
the population within available resources remains challenging.
A recent review (Chestnutt et al., 2013) 1 of existing methods for undertaking oral health needs
assessments found that there was no one format for an OHNA and no evidence was available
on how to conduct an ideal OHNA that results in changes that are clinically- and cost- effective.
Chestnutt et al. proposed a 10 step approach for carrying out an OHNA (Figure 1).
The needs assessment undertaken as part of the process to implement this commissioning
guide should include:
• A description of the oral health needs of the local population;
• A description of the special care groups in the local population;
• A description of the current oral healthcare service provision for special care
groups;
• Identification of gaps in service provision against local needs; and

• Recommendations for the future development of special care dental services
in line with the commissioning guide.

Appendix 2: Relevant diseases and conditions
Condition Description and Data Source
Dental caries Destruction of tooth tissue by toxins produced by bacteria living in the mouth reacting with sugars in the diet.
(teeth) https://fingertips.phe.org.uk/search/caries#page/0/gid/1/pat/6/par/E12000005/ati/102/are/E08000025
Periodontal Periodontal disease affects the gums, ligaments and bone that support teeth.
disease https://files.digital.nhs.uk/publicationimport/pub01xxx/pub01086/adul-dent-heal-surv-summ-them-the2-2009-rep4.pdf
(gums)
Oral Cancer The main risk factors for oral cancer are tobacco and alcohol usage and these have a synergistic effect.
https://fingertips.phe.org.uk/search/oral%20cancer
Tooth wear Tooth tissue can dissolve because of exposure to dietary or other acids, it can be worn away by contact with something else
(such as a toothbrush and abrasive paste) or the two arches of teeth can grind against each other and be worn away.
https://files.digital.nhs.uk/publicationimport/pub01xxx/pub01086/adul-dent-heal-surv-summ-them-the2-2009-rep4.pdf
Cleft Lip and This condition often results in orthodontic and restorative specialist care and impacts on oral and maxillofacial surgery.
Palate https://www.clapa.com/treatment/research/the-crane-database/
Orthodontics Orthodontic treatment is treatment to correct irregularities of the teeth or developing jaws and to improve the function and
appearance of the mouth and face.
https://files.digital.nhs.uk/publicationimport/pub17xxx/pub17137/cdhs2013-report4-burden-of-dental-disease.pdf
Dental Anxiety The control of pain and anxiety means that some patients clearly need sedation for routine dental treatment while others do
not. The services provided should integrate the use of behavioural management techniques including Cognitive Behavioural
Therapy (CBT) with conscious sedation and, if necessary, General Anaesthesia.
https://files.digital.nhs.uk/publicationimport/pub17xxx/pub17137/cdhs2013-report1-attitudes-and-behaviours.pdf
https://files.digital.nhs.uk/publicationimport/pub01xxx/pub01086/adul-dent-heal-surv-summ-them-the8-2009-re10.pdf

Appendix 3
Acknowledgement
Membership of the production of the clinical standards, collective endeavour.
Clinical Guide for Dentistry Revised October 2022 OCDO

(Overarching document
Clinical standard for Revised January 2023 David Craig
Anxiety Management
Clinical standard: Special Revised October 2022 Deborah Manger
care dentistry
Clinical standard: Revised October 2022 Avi Banerjee
Restorative dentistry
Clinical standard for Urgent Revised January 2023 Divyash Patel
Dental Care
Clinical standard: Oral Revised May 2023 Paul Coulthard
Surgery
Clinical standard: Oral Revised May 2023 Pepe Shirlaw
Medicine
Clinical standard : Revised May 2023 Deborah Manger
Paediatric Dentistry
The information in the clinical standards can be made available in alternative

formats, such as easy read or large print, upon request. Please contact
england.ocdo-cdo-england@nhs.net for any enquires regarding the documents.

Appendix 4: Glossary of terms
A&E Accident & Emergency
ADHD Attention Deficit Hyperactivity Disorder
AoMRC Academy of Medical Royal Colleges
ARCP Annual Review of Competence Progression
ASA3 American Society of Anesthesiology Classification – A Patient
with server systemic disease
ASA4 American Society of Anesthesiology Classification – A Patient with
server systemic disease that is a constant threat to life
ASD Autism Spectrum Disorders
BDA British Dental Association – A national professional association
for dentists
ASD Autism Spectrum Disorders
BDA British Society of Paediatric Dentistry
BSA NHS Business Services Authority – http://www.nhsbsa.nhs.uk/
BPSD British Society of Paediatric Dentistry
BPE Basic Periodontal Examination
BSP British Society of Periodontology
CBT Cognitive Behaviour Therapy – A talking therapy that can help
manage problems by changing the way one thinks and behaves.
CCG Clinical commissioning groups are NHS organisations set up by
the Health and Social Care Act 2012 to organise the delivery of
NHS services in England
CCST Certificate of Completion of Training
CDS Community Dental Services
CDGA Comprehensive Dental Care Under GA
CsDPH Consultants in Dental Public Health
Commissioning The Department of Health defines commissioning as the means to
secure the best value health care for the local population and
taxpayers
CPD Continuing professional development
CPQ Child Perceptions Questionnaire
CSUs Commissioning Support Units
CQC Care Quality Commission is the independent regulator of health
and social care in England.
CQUIN The Commissioning for Quality and Innovation payment framework
enables commissioners to reward excellence, by linking a
proportion of English healthcare providers' income to the
achievement of local quality improvement goals.
CYP Children and Young People
DBOH Delivering Better Oral Health
DCP Dental Care Professional – Dental nurses, dental hygienists,
dental therapists, orthodontic therapists, dental technicians

and clinical dental technicians.
DGA General Anaesthesia for Dental Care
DGI Dentinogenesis Imperfecta
DHSC The Department of Health and Social Care
Dt/DT Decayed Teeth
Dental WT&E Dental Health Education England Advisory Group
AG
DNA Did Not Attend
DSTG Dental Sedation Teachers Group GA
ECOHIS Early Childhood Oral Health Impact Scale
EHCP Education, Health and Care Plan
FFT Friends and Family Test
FP17 Form Processing 17 - Providers submit forms (FP17) to us
detailing dental activity data. The data recorded on the FP17
show the patient charge collected, the number of units of activity
performed and treatment banding information
FTs Dental Sedation Teachers Group GA
FYFT Five Year Forward View
GA A medication used to cause a loss of consciousness rendering
the patient unaware of the surgery
GDC General Dental Council – Organisation that regulates dental
professionals in the UK www.gdc-uk.org/
GDS Contracts General Dental Services Contracts.
GDP General Dental Practitioner – Dentist
GMP General Medical Practitioner
GMC General Medical Council
GPs General Practitioners
HbA1C Glyceated Haemoglobin Index
HEA The Higher Education Academy (HEA) is the national body for
enhancing learning and teaching in higher education (HE)
WT&E Workforce Training and Education - Its function is to provide
national leadership and coordination for the education and
training within the health and public health workforce within
England.
WT&E (SIFT) Health Education England Service Increment for Training
HEFCE The Higher Education Funding Council for England promotes and
funds high quality, cost-effective teaching and research, meeting
the diverse needs of students, the economy and society.
HES Hospital Episodes Statistics contains details of all admissions to
NHS hospitals and all NHS outpatient appointments in England
HNA Health Needs Assessment
HSCIC Health and Social Care Information Centre
HTM 01-05 Health Technical Memoranda are guidance documents providing
comprehensive advice and guidance on the design, installation,
and operation, of specialised building and engineering technology
used in the delivery of healthcare. HTM01-05 is focuses on the
quality of decontamination

IACSD Intercollegiate Advisory Committee for Sedation in Dentistry
ICO Information Commissioners Office
ICS Integrated Care System
ILS Intermediate Life Support – Management of a patient in cardiac
arrest until the arrival of a cardiac team
IMOS Intermediate Minor Oral Surgery
IOPDN Index of Paediatric Dental Need
IOSN Indicator of Sedation Need
IOTN Index of Orthodontic Treatment Need
ISFE Intercollegiate Specialty Fellowship Examination
LA Local Anaesthesia
LD Learning Difficulties
LDC Local Dental Committee – statutory bodies which are the
professional organisations representing GDPs
LDN Local Dental Network
LETBs Local and Education Training Boards
Level 1 Care/procedures/conditions to be performed or managed by a
dentist commensurate with level of competence as defined by the
Curriculum for Dental Foundation Training or its equivalent
Level 2 Care is defined as procedural and/or patient complexity requiring
a clinician with enhanced skills and experience who may or may
not be on a specialist register
Level 3a Care and procedures/conditions to be performed or managed by
a dentist recognised as a specialist in Paediatric Dentistry by the
GDC
Level 3b Complex level of care and should be delivered by a dentist
recognised as consultant in Paediatric Dentistry
LPN Local Professional Network – Dental LPNs cover dentistry,
pharmacy and eye health, and help drive service improvements
and reduce health inequalities.
MCN Managed Clinical Networks. See Guide for Commissioning Dental
Specialty Services
MDAS Modified Dental Anxiety Scale
MDT Multi-disciplinary Team
MSc Master’s Degree
NDH Non-diabetic Hyperglycaemia
NICE National Institute of Health and Care Excellence PDS
NSPCC National Society for the Prevention of Cruelty to Children
OHNA Oral Health Needs Assessment
ONS Office for National Statistics – https://www.ons.gov.uk/
OPCS Codes The Office of Population Censuses and Surveys (OPCS). This is
a published procedural classification and coding of operations,
procedures and interventions. This is a 4-character code system.
The first character is always a letter and the other three are
numbers. All codes beginning with “F” are related to the mouth.
OPG Orthopantomogram

PANSI Projecting Adult Needs and Information Systems – Programme to
explore the possible impact that demography and certain
conditions may have on populations aged 18 to 64.
PAR Peer Assessment Review
PbR Payment by Results – A set of prices and rules to help local NHS
providers and Commissioners provide best value to their patients
P-CQP Parental Caregivers Perception Questionnaire
PCR Patient Charge Revenue is generated by the fees charged for
PDS Personal Dental Services
PDS Contracts Personal Dental Services Contracts
Performer A qualified clinician who is contracted to perform the service
OHID Office for Health Improvement and Disparities
PIA Privacy Impact Assessment
PREMs Patient Reported Experience Measures
PROMs Patient Reported Outcome Measures
Provider The contract holder to provide a service.
RCS Royal College of Surgeons
RCOA Royal College of Anaesthetists
RMS Referral Management System
SAAD Society for the Advancement of Anaesthesia in Dentistry
SCD Special Care Dentistry
SDCEP Scottish Dental Clinical Effectiveness Programme
SDEB Specialist Dental Education Board Securing Excellence in
Commissioning NHS Dental Services.
SEICD Securing Excellence in Commissioning NHS Dental Services.
SEN Special Educational Need
SEND Special Educational Needs and/or Disability
SNOMED CT Systematized Nomenclature of Medicine - Clinical Terms
SOHO Scale of Oral Health Outcomes
SLA Service Level Agreement - Agreement between service provider
and user on scope, quality, and responsibilities Sedation Training
Accreditation Committee of the Faculty of Dental Surgery of the
Royal Surgeons of England
STAC Sedation Training Accreditation Committee of the Faculty of
Dental Surgery of the Royal Surgeons of England
UDA Units of Dental Activity - Units of measure by which GDPs are paid
and, against which, performance is measured
UOA Units of Orthodontic Activity
WHO World Health Organisation - www.who.int/
WNB Was Not Brought
XGA Exodontia with General Anaesthetic

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Publication reference: PR1639

Clinical guide for dentistry

Version 2, 28 October 2022

Updates to the previous version of this guide are highlighted in yellow.

1 | Clinical guide for dentistry

2 | Clinical guide for dentistry

This Overarching Standard includes associated appendices which will be derived

3 | Clinical guide for dentistry

Needs-led dental specialist care pathways (as in appendix 1) rely on maintaining

4 | Clinical guide for dentistry

3. NHS dental specialties

“It does so while recognising that a comprehensive approach to preventing

The levels of complexity do not describe contracts, or practitioners or settings.

The three levels of care are defined in table 1 below:

5 | Clinical guide for dentistry

Level 2 Procedural and/or patient complexity requiring a clinician with enhanced

6 | Clinical guide for dentistry

3.2 Managed clinical networks (MCNs)

An MCN should be led by a local consultant in the appropriate specialty, who

3.3 The role of the MCN in developing the network

7 | Clinical guide for dentistry

3.4 Establishing a Managed Clinical Network

8 | Clinical guide for dentistry

3.6 Improving referral pathways for MCN effectiveness

If possible, patients should be given a choice of specialist provider, however this

9 | Clinical guide for dentistry

3.7 Supporting the profession

10 | Clinical guide for dentistry

Transformational and transactional change is required in the delivery of dental

11 | Clinical guide for dentistry

• Brief description of the speciality

4.3 Vulnerable and socially excluded patients

“A person who is 18 years of age or over, and who is or may be in need of

Section 59 of the Safeguarding At Risk Groups Act 2006 states that:

3. receives domiciliary care

4. receives any form of health care

5. is detained in lawful custody

12 | Clinical guide for dentistry

7. receives a welfare service of a prescribed description

8. receives any service or participates in any activity provided specifically for

9. has payments made to him/her or to an accepted representative in

10. requires assistance in the conduct of own affairs.

4.4 Domiciliary care

• equipment to manage medical emergencies,

13 | Clinical guide for dentistry

By working in collaboration local information packs and resources could be

4.4.1 Better resources available to practices

4.4.2 Solutions for patients

14 | Clinical guide for dentistry

• Having support for individuals who may require additional help in

4.4.3 General legislation and guidance

• Health Technical Memorandum 01-05: Decontamination in primary care

15 | Clinical guide for dentistry

4.4.4 Continuity of care

4.4.5 Developing partnerships with key stakeholders

16 | Clinical guide for dentistry

Can GDP END

Level 1 care Level 2 care Level 3 care