Dental therapists/hygienists working in remote-rural primary care: a structured review of effectiveness, efficiency, sustainability, acceptability and affordability

Abstract

Aim: To examine the use of dental therapist/hygienists to provide primary dental treatment in remote-rural areas with regard to their effectiveness, efficiency, sustainability, acceptability and costs (affordability). Method: The structured literature review of studies indexed in Medline, Embase and CinAHL was conducted using search terms relevant to ‘dental therapists’ and ‘remote-rural’. Remote-rural was defined as ‘those (individuals) with a greater than 30-minute drive time to the nearest settlement with a population of greater than 10,000’. Results: From 1,175 publications screened, 21 studies from 19 publications were initially included. Only seven studies were included that explicitly focused on remote-rural areas. Four were surveys and three were qualitative studies. All of the included studies were reported within the last 7 years. The methodological quality of the surveys varied, particularly with regard to their response rates. All three of the qualitative studies were assessed as potentially weak methodologies. Regarding the research question, none of the studies included provided data relevant to understanding efficiency, cost issues or the acceptability of dental therapists. The available empirical evidence contained only indirect indicators about the sustainability of dental therapy in rural areas. Conclusions: The available data indicates that dental therapist/hygienists have suitable skills and could constitute a valuable asset to meet the dental demands in remote-rural areas. However, the evidence base is limited and of a poor quality. There is a need to put in place ‘well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce’.

INTRODUCTION

Providing accessible primary dental care is a challenge for those planning the delivery of dental services. The difficulties in meeting the demands for dental care in remote-rural areas have motivated the World Health Organisation (WHO) (e.g. the Primary Health Care Approach, WHO)¹, Governments (e.g. the ‘Dental Action Plan’, Scottish Executive)² and the dental profession (e.g. Dental Auxiliary Review: Dental Auxiliary Review Group)³ to examine workforce strategies to increase the availability, affordability and accessibility of primary dental care for those residing in remote-rural areas⁴.

Developing dental therapists/hygienists (DTHs) as an integral part of dental care provision in such remote-rural localities has for some time been considered as a sustainable solution to the challenges of reaching remote-rural patients:

For many, because of the scarcity of dentists in some rural and underserved areas, dentists alone cannot meet that need. It is now time to expand the dental care workforce and explore alternative models for providing oral health care, especially for the most vulnerable children and families⁵.

Evidence from a secondary analysis of dental treatment data in the UK and the recent review by Nash et al.⁵ suggested that DTHs treating adults and working independently could cover one-third of the treatment provided during dental visits⁶. This would allow dentists to concentrate on complex clinical procedures and so increase the throughput and the number of patients treated5., 6., 7.. This effect, however, is known to be reduced by the tendency for DTHs to be employed as hygienists⁸ and/or their clinical work being restricted to paediatric dentistry7., 9.. In the UK there remains a general unease within the dental profession about the use of DTHs in remote-rural areas4., 7., 10.. This is specifically related to concerns about supervision for types of dental treatment considered to be beyond the clinical skills of DTHs in remote-rural areas⁸.

The question remains what type of practice configuration would be appropriate for the employment of DTHs in remote-rural areas? Croucher & Ackerman¹¹ proposed the setting up of mobile dental units in remote-rural areas with dentists available to support DTHs, while, more recently, Sun & Harris¹² examined six models of DTHs–dentists working based upon employment status and remuneration system. The models ranged from one dentist to two DTHs (smallest practice) to 10 dentists working with one DTH (largest practice). For one of the practices that employed three dentists and two DTHs, all NHS dental treatment was conducted by the DTHs. Despite this important work, conducted in urban areas in the north west of England, the question, posed by Nash et al.⁵ remained unanswered – ‘What type of DTH–dentist model should be proposed to increase accessibility, acceptability and provide cost-effective dental care for individuals residing in remote-rural areas?’

The structured review, presented here, was commissioned by a remote-rural health board in order to assist them to make informed and strategic decisions with regard to workforce planning and the role of DTHs within primary care in remote-rural areas. The underlying premise being that DTHs, working with other members of the dental team, in a fixed dental surgery, could be considered as a suitable option to address dental workforce issues associated with a lack of readily available dental services for people in remote-rural or poor socioeconomic areas13., 14..

The overall aim was to examine the place of DTHs working in primary dental care in remote-rural areas in order to inform best practice with regard to workforce planning. To achieve this aim a systematic approach was used to inspect the available evidence on the effectiveness, efficiency, sustainability, acceptability and costs of DTHs working in primary dental care in remote-rural areas.

METHODOLOGY

Search strategy

Relevant primary and secondary literature was identified by searching five online electronic databases (Medline, Embase, HMIC, CinAHL, PsycINFO via either the EBSCO Host or OVID platforms.

Search terms included subject headings and key words relevant to dental surgery, oral health, dental therapists, hygienists or auxiliaries. This search string was combined, using the Boolean operator ‘AND’, with subject headings and key words relevant to remote-rural populations and services (Table 1). Publications were limited to those in the English language. No other limits or filters were applied. Publications found by this search strategy were scrutinised independently by two members of the study team, and a decision made as to whether or not publications should be included or excluded was made according to the criteria reported in Table 2.

Table 1.

Search terms used in the search architecture

Search architecture
1	dental therap* or dental auxiliary* or dental hygienist* or dental assistant* or dental technician* or allied dental personnel or dental ancillary or oral health therapist
2	MH Dental Hygienists OR MH Dental Auxiliaries+ OR MH Dental Assistants OR MH Dental Technicians OR DE Dental Health OR DE Dental Education OR DE Dental Surgery OR DE Dental Treatment OR DE Oral Health
3	1 OR 2
4	Remote n2 rural
5	MH Rural Health Services OR MH Rural Population OR MH Rural Health OR MH Rural Areas OR MH Rural Health Centres OR MH Rural Health Personnel OR MH Medically Underserved Area
6	4 OR 5
7	3 AND 6
8	Limit to English language

Table 2.

Inclusion and exclusion criteria

	Criteria
Include if publication	Is likely to include data pertinent to dental therapists
	Is likely to report data that is pertinent to remote or rural populations (see definition further below)
	Reports empirical data whether quantitative (e.g. randomised controlled trial, survey, cohort, case-control, interrupted time series) or qualitative (e.g. in-depth interview, focus group, ethnography)
	Reports primary or secondary derived data
	Is published in the English language
Exclude if publication	Does not include a sufficient focus on dental therapists
	Is not primarily focused on remote or rural areas
	Is not empirical

Those publications assessed as meeting all inclusion criteria were retrieved in full. The full-text copies of all retrieved papers were independently examined by MT-H and SMcG. All publications included in the review were then categorised based on methodology. Data were extracted regarding: the methods used, the primary study aims and key findings specifically related to the review research questions.

Contacting experts

As well as searching for published literature, we also contacted key international experts working in the field (Table 3). We asked the experts if they were aware of any recently completed or on-going studies in the area.

Table 3.

International experts contacted

Expert	Position	Institution
Professor Fiona Blinkhorn	Deputy Head of School of Dental Therapy	The University of Newcastle, Australia
Professor Elizabeth Davenport	Professor of Dental Education	University of London, England
Dr Louis Fiset	Affiliate Associate Professor Curriculum Director for DENTEX, a 2-year training programme for Alaska Natives to provide dental care for fellow villagers in the most remote regions of the Alaska	University of Washington, USA
Dr Andrew Hall	Senior Lecturer in Restorative Dentistry. Special responsibility for training dental therapists/hygienists in Scotland	University of Dundee, Scotland
Professor Eino Honkala	Professor in Dental Public Health	Kuwait University, Kuwait
Professor Peter Milgrom	Professor of Dental Public Health Sciences and Pediatric Dentistry. Director of the Northwest Centre to Reduce Oral Health Disparities at the University of Washington	University of Washington, USA
Professor David Nash	William R. Willard Professor of Dental Education	University of Kentucky, USA

Assessing methodological quality

The studies included were assessed for methodological quality according to individual elements of quality rather than a summary scale approach. For the assessment of quantitative studies, the use of such summary scales is not supported by empirical evidence¹⁵ and is actively discouraged¹⁶. The methodological components we assessed for any surveys included were: sampling strategy, response rate, use of validated instruments and appropriate statistical testing.

Assessing the methodological quality of qualitative studies using composite scales has also been hotly debated and contested¹⁷. For any qualitative studies included, we therefore performed a global assessment of study quality, dichotomised according to whether it appears to be strong or weak. Strong studies are likely to include triangulation of data, respondent validation, clear exposition of methods of data collection and analysis, and reflexivity.

Operational definitions

Definition of remote-rural areas

This review was commissioned to assist a National Health Service (NHS) Health Board to make informed and strategic decisions with regard to workforce planning and the role of DTHs, within primary care in remote-rural areas.

Remote-rural geography raises challenges for the equitable distribution of health services in terms of providing dental treatment services, particularly in relation to physical distances to dental surgeries and clinics. Definitions of ‘remote’ and ‘rural’ populations can vary considerably from those based on the density of a population to classifications based on the time it can take to travel to centralised or key services¹⁸.

The Scottish Executive have provided a widely used definition based upon the fact that more than 169,000 people in Scotland (3%) live more than 2 hours from a major population centre (defined as over 30,000 people) and 4% of the Scottish population live more than 90 minutes from a major population centre¹⁹. At the outset, it is necessary to provide a clear and distinct definition of ‘remote-rural’. The Scottish Executive definition differentiates between ‘accessible rural’ areas and ‘remote-rural’ areas. Accessible rural areas are:

those with a drive time of 30 minutes or less to the nearest settlement with a population of greater than 10,000

and remote-rural areas are:

those with a drive time of greater than 30 minutes to the nearest settlement with a population of greater than 10,000¹⁹.

The above definition¹⁹ of ‘remote-rural’ will be adopted as a means of guiding content of the structured review.

Definition of the research questions

What is the available evidence the effectiveness, efficiency, sustainability, acceptability and costs of DTHs working in primary dental care in remote-rural areas?

Research question 1. Effectiveness of DTHs in remote-rural practice

Evidence was deemed to provide information about effectiveness if it provided answers to the question of whether DTHs are the right profession for a specified task or intervention.

Research question 2. Efficiency of DTHs in remote-rural practice

Evidence on efficiency demonstrated the presence or absence of DTHs’ ability to do a task or intervention well.

Research question 3. Acceptability of DTHs in remote-rural practice

Evidence on acceptability comprised of patient and professional views on DTHs conducting clinical work.

Research question 4. Sustainability of DTHs in remote-rural practice

Evidence on sustainability included workforce demands and job satisfaction.

Research question 5. Affordability of DHTs in remote-rural practice

Any information on resources and costs involved with the DTH role were labelled as cost.

RESULTS

Overview of included studies

The search strategy yielded 1,175 publications. Following screening, 19 publications reporting 21 studies (17 surveys and four qualitative studies) were initially included (Figure 1). On closer scrutiny, however, 14 studies10., 20., 21., 22., 23., 24., 25., 26., 27., 28., 29., 30., 31., 32., 13 surveys10., 20., 21., 22., 23., 24., 25., 27., 28., 29., 30., 31., 32. and one qualitative study²⁶ did not specifically focus on remote or rural settings. While it was possible that any of these 14 studies10., 20., 21., 22., 23., 24., 25., 26., 27., 28., 29., 30., 31. could have included study participants from remote or rural settings, no data pertaining to rural settings were provided and therefore no conclusion about rural areas could be drawn. This meant that only seven studies32., 33., 34., 35., 36., 37., four surveys32., 33., 34., 35. and three qualitative studies32., 36., 37. met all the inclusion criteria.

Figure 1.

Number of publications and studies screened and included in the review.

Of the seven studies included, two were reports of the same study participants but presented slightly different aspects of the data33., 34.. All of the seven32., 33., 34., 35., 36., 37. included studies reported within the last 7 years (Table 4). Three of the studies were conducted in Australia33., 34., 35. two in the UK (both studies reported in the same paper)³² and one in New Zealand³⁷. The remaining study³⁶ included study participants from the UK, Belgium, Greece, Finland, Canada and New Zealand. Of the four questionnaire surveys, three included studies on dental therapists33., 34., 35., and one focused on the views of dentists studies³². The participants in the three qualitative studies represented a range of key stakeholders, including dental therapists, their managers, dental nurses, vocational trainees and dentists.

Table 4.

Methodological quality of the included surveys

Study type	Methodological elements
Survey	Sampling strategy indicates likelihood of generalisability	Response rate classified as good if response rate over 60%	Use of validated instruments	Appropriate statistical testing
Hornby et al.32	Yes	70%: good	No	N/A
Kruger & Tennant33	Yes	53%: poor	No	N/A
Kruger & Tennant34	Yes	53%: poor	No	N/A
Satur et al.35	Yes	61%: good	Yes	Yes

Methodological quality

The methodological quality of the surveys varied, particularly with regard to their response rates (Table 5). Only one study³⁵ was assessed as satisfactory in terms of the four methodological elements assessed. Two studies32., 35. achieved satisfactory response rates and two33., 34. did not. The four surveys adopted a sampling strategy that maximised the generalisability of their findings to the wider population they were attempting to represent. All three of the qualitative studies32., 36., 37. were assessed as potentially weak methodologies.

Table 5.

Details of the seven included studies

Study (first author)	Year	Country of study	Study type	Participants mixed dental professionals/dental therapists/dentists/public	Setting	Reports data pertinent to
						Effectiveness	Efficiency	Acceptability	Sustainability	Cost
Hornby32	2006	UK	Survey	Dentists (n = 336) Senior dentists (n = 151) Dentists (n = 185)	Two English counties	Yes	–	Yes	Yes	–
Kruger33	2004	Australia	Survey	Mixed (n = 90) Dentists (n = 70) Dental therapists (n = 16) Dental hygienists (n = 4)	Remote-rural Western Australia	–	–	–	Yes	–
Kruger34	2005	Australia	Survey			–	–	–	Yes	–
Satur35	2009	Australia	Survey	Dental therapists (n = 59)	Victoria, Australia	Yes	–	–	–	–
Hornby32	2006	UK	Qualitative	Mixed semistructured interviews (n = 40) Dentists (n = 25) Vocational trainees (n = 3) Dental therapists (n = 3) Dental hygienists (n = 3) Dental nurses (n = 3) Practice managers (n = 3) One focus group of PCT reps (n = 5)	Two English counties	–	–	–	–	–
Kravitz36	2007	UK; Belgium Greece Finland Canada New Zealand	Qualitative	Actual (n = not provided) Aimed for n = 4 key informants from each country	Six developed countries	Yes	–	Yes	–	–
Tane37	2009	New Zealand	Qualitative and quantitative	Semistructured interviews with managers of dental therapists and policy makers (n = 12) Questionnaires to various stakeholders (n = 399)	New Zealand-wide	Yes	–	–	–	–

Overview of the available empirical evidence

Regarding the research questions, four studies: two surveys32., 35. and two qualitative studies36., 37. provided data pertinent to understanding the effectiveness of DTHs. Only two studies32., 35. provided data pertinent to the acceptability of DTHs, and three studies32., 33., 34. provided data directed at understanding their sustainability. None of the studies included provided data relevant to understanding the acceptability or cost issues of DTHs.

Research question 1. Effectiveness of DTHs in remote-rural practice

Four studies32., 35., 36., 37. provided information about the effectiveness of dental therapists in remote-rural areas. Overall, the studies demonstrate that health services are interested in the ways that dental therapists can influence dental care provision in these areas. Areas with a shortage of dentists, for example, are exploring the use of other dental professionals to meet existing treatment needs.

One study³⁷, provides anecdotal evidence suggesting that 90 years ago, dental therapists in New Zealand had the ability to work independently in remote-rural areas, at least with paediatric patients. The weight of evidence for the effectiveness of dental therapy in remote-rural areas focuses on the demand for and working practices of DTHs.

A workforce modelling exercise carried out in North Staffordshire, England, for example, showed that under certain conditions, hygienists and/or dental therapists could provide aspects of the care previously delivered by dentists³². These conditions include: a shortage of dentists, a suitable case mix and clarity of roles of the dental professionals involved. These workforce models further suggest that dental therapists could make up 15% of the required workforce. This percentage rises to 46% for those with a dual dental therapy/hygienist qualification. The fact that DTHs together could make up almost half of the required dental workforce in remote-rural areas notable, as an increasing number of training institutions provide a dual qualification in dental therapy and dental hygiene. Satur et al.³⁵ reported that 13.6% of dental therapists in their study also held a dental hygienist qualification.

Satur et al.³⁵ also identified differences in working practices between dental therapists in rural and urban settings. Dental therapists in rural areas significantly more often interpreted radiographs, administered local anaesthetics and carried out pulpotomies than urban therapists, and were significantly more likely to work with patients over the age of 25 years (P < 0.05). Dental therapists in remote-rural practice provided significantly less dental health education, dietary counselling (P < 0.01), fluoride application, bleaching, tooth whitening and use of nitrous oxide (P < 0.05) than colleagues in urban locations. The survey further showed that regardless of reported work location or practice type, most dental therapists regularly practiced dental health education (76.3%), dietary counselling (74.6%), prophylaxis (69.5%) and scaling (67.8%). Working practices were further affected by consequences of changes to the local legislation, which had removed some limits to dental therapists’ employment and allowed them to work as private practitioners. The survey of dental therapists in rural areas showed that they spend 4% of their working days in orthodontic practice, 30% in public health-care settings and 23% in private practice. They also had 43% of their working days available for further dental therapy-related work³⁵.

Research question 2. Efficiency of DTHs in remote-rural practice

The studies included provided no empirical evidence about the efficiency of dental therapists in terms of quality or scope of care provided.

Research question 3. Acceptability of DTHs in remote-rural practice

Evidence on acceptability comprised patient and professional views on DTHs conducting clinical work. Only two studies provided empirical evidence on the acceptability of dental therapists among dentists32., 36.. No evidence was found with respect to patient views on dental therapists.

The available evidence mirrors evidence about dentists’ views of dental therapists in general7., 10.. Dentists’ views of dental therapists in remote-rural areas range from apathy, fear of competition, and concerns about the quality of care to general support³⁶. Dentists accepted the need for action to address access to care and unmet need but felt that they did not know enough about dental therapists’ training or skill range. The weight of dentists’ concerns appears to be about the allocation of responsibility for and supervision of therapists’ clinical and patient work.

Changes in legislation concerning dental therapists, in particular, have triggered concerns among dentists in different countries32., 36.. In England, for example, dental therapists’ ability to work in the general dental service has allowed for greater flexibility in service provision but also raised concerns among dentists who feel that the responsibility for treatment needs to remain with dentists³².

Research question 4. Sustainability of DTHs in remote-rural practice

The available empirical evidence contained only indirect indicators about the sustainability of dental therapy in rural areas. Workforce demands, work patterns and dental therapists’ level of job satisfaction were selected as suitable indirect indicators of sustainability.

One reason for the lack of direct evidence about sustainability is the lack of available relevant clinical as well as human resource data³². This dearth of information may result from the fact that dental therapy information is often held by local practices and is not yet aggregated across health services. This lack of data is the main reason why only circumstantial evidence is available on the presumed high rates of staff turnover among dental therapists. This circumstantial evidence is based on comparison with other dental professions, the high percentage of female therapists, high proportion of part-time work arrangements and a reported two out of three dental therapists not having worked continuously in dental therapy since their qualification32., 35..

Empirical evidence was available on work patterns of dental therapists in rural areas, including a comparison with their colleagues in urban settings. Dental therapists in rural areas tend to be almost exclusively female, aged between 30 and 40 years and have, on average, two children³³. Just over half of the dental therapists were working full-time and 45% were working part-time. Full-time therapists worked on average 38.25 (SD 1.06) hours per week and part-time therapists worked 23.63 (SD 14.5) hours per week. Dental therapists in rural areas also worked fewer days (2.9 vs. 3.8 days) compared with their urban counterparts (Satur et al. ³⁵). Full-time therapists treated an average of 248 (SD 78.4) patients per month whereas part-time therapists treated an average of 128 (SD 92.6) patients per month. For comparison, full-time dentists in the same study³³ saw a mean of 260 (SD 95.7) patients per month and part-time dentists saw a mean of 160 (SD 90) patients per month. Very few of the dental therapists (5%) had leave cover or locums.

Fifty-five per cent of dental therapists had worked in a rural area before their current rural jobs, 25% had come from urban areas and 20% were new graduates³³. One-third of dental therapists responding to a Western Australian survey were not working as therapists anymore. Anecdotally, reasons for leaving the profession included child rearing, household duties, a preference not to work or a change of career³³. Those dental therapists still working in the profession had spent an average of 6.21 years (SD 7.04) at their current workplace³³.

Another Western Australian study investigated major influences on dental therapists’ coming to work in rural areas, remaining in rural areas and leaving rural areas³⁴. Ninety per cent of dental therapists, all female, mentioned ‘lifestyle’ as the main influence to start work in a rural area, 65% mentioned their partners’ work, 25% listed job availability and family proximity and 20% were originally from a rural area. Fifteen per cent of dental therapists indicated financial or income reasons.

The main reasons for staying in a rural area were professional development, courses or training (45%), financial incentives (30%), employment of spouse (15%) and improved accommodation (15%). The main reasons given for leaving rural areas related to children’s education (35%), better employment opportunities, including financial reasons (35%), and to follow their partner (30%)³⁴.

Research question 5. Cost of DTHs in remote-rural practice

No empirical evidence was available on the costs or opportunity costs of dental therapists in remote-rural areas.

Responses from experts

Several of the experts contacted provided useful and informative information regarding a number of initiatives and projects. Recently, a 2-year study evaluating the clinical performance and community acceptance of the original group of dental therapists practicing in rural (remote, bush) Alaska was published by the W. K. Kellogg Foundation³⁸. The investigators found that the dental health aid therapists (DHATs) were performing safe, competent and appropriate care for Alaska natives. The DHATs were well accepted in their communities as both providers of dental health care and role models.

Discussion in a recent publication focused on workforce development in addressing access to care in the USA³⁹. Safety concerns are the primary reasons stated by organised dentistry in opposition to DHATs coming to the 48 continental states. In view of this, ongoing discussions concerning supervision are felt to be essential to allay apprehensions. A special issue of the Journal of Public Health Dentistry referred to above calls upon the reader to consider several pertinent matters in developing educational programmes for dental therapists.

Professor David Nash provided information regarding ongoing studies in his 2012 review of the literature, which has identified literature relating to the practice of dental therapists in all contexts throughout the world. The project, which was funded by the W. K. Kellogg Foundation, began 1 July 2011 and provided a comprehensive bibliography in the published report in April 2012⁵.

DISCUSSION

The provision of dental care in remote-rural areas is persistently facing challenges with respect to: (1) recruiting and retaining dental staff, (2) offering easy access to patients, and (3) coping with the treatment demand. Strengthening the presence and role of DTHs has been proposed as a strategy to address each of these challenges. Empirical evidence about the effectiveness, acceptability and sustainability of DTHs in remote-rural areas has the potential to inform workforce planning and training strategies³⁵. Ideally, therefore, any decisions on the deployment of DTHs should be informed by a sound body of evidence⁹.

This is the first structured review to focus specifically upon issues pertinent to dental therapy in remote-rural settings. The findings suggest that, while the available evidence is recent and set in a wide variety of international settings, it remains limited in terms of both quantity and quality. One of the main findings of this review relates to the absence of any empirical evidence on the efficiency, costs or cost-effectiveness of deploying DTHs in remote-rural areas. The search identified no empirical studies investigating the clinical performance of dental therapists or providing health economics data on the use of dental therapists in remote-rural areas. As a result, there appears to be no published evidence supporting or challenging any clinical role of DTHs in these areas.

Even where data are presented regarding questions about the effectiveness, acceptability and sustainability of DTHs in remote-rural areas, the depth and breadth of findings is insubstantial. A small number of studies provided insights into the effectiveness of rural dental therapists. Based on workforce modelling exercises, there is a demand for the skills DTHs bring to the remote-rural dental team. This demand is considerably increased for dually qualified dental therapists and hygienists who could purportedly manage almost half of the treatment and care demands facing remote-rural dental teams. Of interest in this context is the finding that the working practices of rural and urban DTHs differ considerably, with remote-rural DTHs providing less health education and more invasive treatments.

The skill mix of DTHs is linked to a further main finding of the review. Dentists appear to be largely unaware of dental therapists’ range and level of skills. This is expressed in widespread concerns among dentists about the level of supervision DTHs need and the types of patients they can see. Concerns triggered by this lack of awareness are exacerbated by changes in legislation concerning DTHs. While the evidence base on this matter is restricted to two studies, these concerns are also prominent in the wider literature on dental therapy7., 10.. Dentists’ concerns about dental therapy are likely to play a role in the actual uptake and acceptance of DTHs in remote-rural dental care provision.

Questions concerning the sustainability and job satisfaction of DTHs will be a further key factor in the development of a remote-rural DTH workforce. Unfortunately, little empirical evidence for the sustainability of remote-rural dental therapy/hygiene is available. Nevertheless, the existing evidence provides valuable insights into parameters affecting sustainability in this respect. Almost all dental therapists are female, in their 30s and have children. Almost half of them work part-time and for fewer hours than their urban counterparts. These characteristics not only play a role in DTHs remaining in remote-rural areas but are also the reasons for DTHs heading towards more urban areas. Overall, it appears that remote-rural areas with a high quality of life combined with good educational possibilities for DTHs and their children help to retain this and other professions. Rural areas that cannot provide a satisfying quality of life tend to lose staff. With these factors in mind Kruger & Tennant³⁴, suggested a series of strategies to recruit and retain dental therapists in remote-rural areas. These include a broad and integrated strategy, including exposing dental therapy students to rural experience during their training, promoting the remote-rural lifestyle, attracting more students from remote-rural backgrounds, financial incentives and ongoing professional support and development.

Of particular note was an absence in the literature concerning the most appropriate work skills mix in terms of the DTHs to dentist ratio to enable and secure the maintenance of sustainable and cost-effective use of DTHs in remote-rural localities. The question still remains – ‘What is the most efficient, effective and sustainable model of DHTs–dentists within remote-rural primary dental care?’

CONCLUSIONS

There is a lack of high-quality evidence available to inform decision-making about the future of dental therapy in remote-rural areas. For example the best and most effective model for DTHs within remote-rural primary dental care remains unknown. The little evidence that is available indicates that DTHs could be a valuable contribution to meeting the dental demands in remote-rural areas. However, the sustainability and acceptability of a remote-rural dental therapy workforce appears to depend on dentists being better informed about clinical and human resource aspects related to DTHs and DTHs being satisfied with their work as well as their overall lifestyle. Therefore to quote Richards⁴⁰: ‘There is an overwhelming need for well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce.’

Acknowledgements

We acknowledge the funding from NHS Highland, award number 121.804689.

Competing interests

None declared.