1.1 Clinical standards and the Faculty of General Dental Practice (UK)
The mission of the Faculty of General Dental Practice (FGDP) (UK) is “to positively influence oral health, through education of the dental profession and the provision of evidence-based guidance.”1 For over a quarter of a century, the FGDP(UK) has produced guidance describing and promoting standards in dentistry, beginning with the publication of the Self Assessment Manual and Standards (SAMS) in 1991.2 In 2006, under the editorship of Kenneth Eaton, the FGDP(UK) updated and brought together its existing standards and guidelines within the publication of Standards in Dentistry.3 More than a decade has now passed since the first edition, and the time has come to review and update Standards in Dentistry in the light of changes in the evidence base and in the clinical, organisational and dento-legal context in which dentistry is practiced.
This second edition of Standards in Dentistry adopts the following definitions:
- Clinical guidelines are systematically-developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.4,5
- A standard is a definable measure against which existing structures, processes or outcomes can be compared.6
1.3 The purpose of guidelines and standards
It might not be feasible, or even desirable, for all patients to receive identical healthcare. Care provision should be tailored to address individual need and the specific context in which the care is provided. Some variation in healthcare provision is accordingly both inevitable and essential. However, not all variation in practice is desirable, and the wellbeing of patients can be put at risk through unjustifiable variations, such as the provision of treatments that have been shown to be ineffective or poorly tolerated. Thus patients should not expect to receive identical care, but they do have the right to expect that the care they receive accords with evidence of good practice and is appropriate within the available resources.7
Guidelines provide recommendations in the management of clinical conditions where variations in practice occur and where effective care may not be delivered uniformly.5 Clinical standards are used to describe the specific elements of care that need to be correct in order to optimise the outcomes for patients. Standards must be unambiguous and measurable. These qualities enable practitioners to target and monitor efforts to improve the quality of care they provide and, when used transparently, their use serves an additional purpose of promoting public confidence and accountability.7
1.4 Levels of standards
Standards may be set at differing levels depending on their intended purpose, for example, minimal, normative and exemplary. Minimal levels are used to describe essential standards of care. Falling below minimal levels would indicate the need for remedial or possibly punitive action. At the other end of the spectrum, exemplary standards may be used to promote aspirational practice. Standards should represent an agreed level of performance and those involved in delivering and receiving the care should determine the standards.8
1.5 Types of standards
Standards may measure either the process or outcome of care. While outcome standards permit an understanding of what is ultimately achieved by healthcare, they remain difficult to apply due to the potential influence of factors that may not be within the control of healthcare providers, and they are often difficult to measure within realistic time scales (e.g. the outcomes of care aimed at reducing the risks of future disease often require long-term monitoring to establish their effectiveness). Consequently, process (and sometimes structure) measures are more commonly used, especially when there is evidence linking the process to the desired outcome. Poor performance on a process measure is used to indicate which aspects of care practice require remedial action.8
1.6 Compliance with standards
Compliance with standards can be promoted through clinical audit, educational activities and feedback from peers or patients. Where standards are considered to represent a minimum essential level of acceptable care, they may additionally be enforced through systems of governance.8
1.7 Dento-legal issues in relation to guidelines and standards
Within a dento-legal context when judging the performance of a practitioner, it is essential that any standards used are measured against a reasonable peer group. For a general dental practitioner (GDP), that means a peer group of other GDPs; not the standard that could be achieved by a specialist. While a GDP is not expected to achieve the same standard of care as a specialist, they should however refer to a specialist when it is appropriate to do so. There has been some debate within the profession as to whether appropriate standards have been applied when measuring the performance of practitioners. Clearly, it is easier to fall seriously short of a standard if the standard is being placed at an unreasonably high level in the first instance. This can occur when aspirational standards that might be achieved by a specialist are misinterpreted as being those of a general dentist. Under such circumstances, a practitioner may be at risk of criticism about their clinical care when their standard of care could have been deemed acceptable, or even desirable, if it were not for the elevated standard against which they are being judged. The standards against which a practitioner is judged are further complicated when guidelines intersperse opinion with evidence-based guidance; where there are multiple guidelines that provide conflicting advice; where guidelines change over time and/or the evidence base is poor, and; where some guidelines are given undue weight on the basis of eminence.
Therefore, any measure of performance has to:
a) Be judged against minimum (basic) standards, not aspirational standards, that were acceptable at the time.
b) Be considered within the specific context of the particular patient and environment; and
c) Take account of the practitioner’s justification which should be evident from the records.
1.8 The Faculty of General Dental Practice (UK) position
The Faculty of General Dental Practice (UK) recognises that clinical guidelines and standards are often used by dental advisers and experts in both a court setting or during General Dental Council (GDC) Fitness to Practise proceedings. The issue of misinterpretation of Faculty guidelines was explicitly addressed in the third edition of Clinical Examination and Record Keeping (2016). The FGDP(UK) makes a clear distinction between essential/baseline practice and aspirational/gold standard practice. In line with the Faculty’s Clinical Examination and Record-Keeping and subsequent guidelines, recommendations in this document are categorised as A (Aspirational), B (Basic) and C (Conditional upon circumstances). No practitioner should be censured for failing to meet A grade recommendations. Nor does a failure to meet B or C grade recommendations necessarily imply negligence on the part of the clinician. A clinician must assess each clinical situation on its merits, in the circumstances in which they find themselves, and with the evidence available to them, they must use their clinical judgement to settle on a course of action. It is possible to fail to adhere to our recommendations and still be acting in the patient’s best interests. However, we would recommend that when taking a course of action other than that recommended in these guidelines, a clinician should clearly justify their reasoning in the records.
1.9 Approach adopted in the second edition
In light of the context in which primary care dentistry is delivered, this second edition is based on three fundamental principles:
- The clinical standards described relate specifically to process measures. They describe standards associated with how dentistry is delivered/provided. They do not refer to outcomes of dental care since these may be influenced by a diverse array of factors, many of which are outside the control of practitioners. Thus, for example while we recognise that a good standard of oral hygiene may be an important factor in the likelihood of success of many types of care, it is not listed as a ‘standard’ within this book since it is an outcome in its own right and is highly dependent on the efforts of the patient.
- We have endeavoured to produce standards that are appropriate to the dental primary care environment. Specialist societies often produce standards and guidelines of their own, often as a result of expert consensus and evidence review. However, these may on occasions relate to a specialised or ideal level of care that is beyond the scope of even aspirational primary care practice. As such we have not reproduced the content of those guidelines and standards in the following chapters as we do not wish to risk perpetuating a dento-legal framework in which practitioners may be unduly sanctioned as the standard they are judged against is not one of a reasonable peer group. We have however, provided signposting to these in the appendix for those seeking further information.
- The recommendations for clinical standards provided follow the classification system introduced in the third edition of Clinical Examination and Record Keeping (2016) and should be viewed in the same way.
- Various tables in this edition present percentages for standards; particularly with regard to radiography. These refer to published standards that apply to practice audits, not to the provision of individual items or the care of individual patients.
1.10 Structure of the second edition
This edition is structured in a similar manner to the first edition in so far as the following chapters distinguish between Clinical standards (now chapter 2) and Guidelines for structure and process in dental practice (now chapter 3). Chapter 2 consists of tables of clinical standards that have been produced by the authors using the FGDP(UK)’s ABC categorisation. In all cases, the standards have undergone peer review prior to publication in order to calibrate them as being appropriate for the dental primary care setting. Chapter 3 signposts readers to current sources of relevant guidance for practice management that are available at the time of writing.
The first edition of Standards in Dentistry highlighted the dynamic nature of standards and guidelines. This is no less the case now than it was in 2006. While it is impossible to ‘future proof’ any guidance, the second edition now includes an additional section on Keeping up to date (chapter 4) which directs readers towards some of the most relevant sources of clinical guidelines and standards, and provides some hints and tips so that practitioners can check reasonably rapidly whether they are accessing the most contemporary evidence-based guidance.
1. FGDP(UK). Faculty of General Dental Practice (UK). Available at: www.fgdp.org.uk.
2. Royal College of Surgeons of England. Self-assessment manual and standards. London: Royal College of Surgeons of England; 1991.
3. Eaton K. Standards in Dentistry. London: Faculty of General Dental Practice; 2006.
4. Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington, DC: National Academies Press; 1990.
5. Scottish Intercollegiate Guidelines Network. SIGN 50: A guideline developer's handbook. Edinburgh: Scottish Intercollegiate Guidelines Network; 2011.
6. Health Information and Quality Authority. National quality assurance criteria for clinical guidelines. Dublin: Health Information and Quality Authority; 2011.
7. Steel D. From evidence-based medicine to clinical standards. Proceedings of the Royal College of Physicians of Edinburgh 2001;31:74-76.
8. Nathwani D. From evidence-based guideline methodology to quality of care standards. Journal of Antimicrobial Chemotherapy 2003;51:1103-1107.
Copyright © FGDP(UK) 2019. This work is distributed under the terms of the Creative Commons Attribution NonCommerical 4.0 International licence (CC-BY-NC). Notification of use is appreciated via email to FGDP@fgdp.org.uk