The Dental Auxiliary: A Historical Perspective
Dr John Welshman
In the United Kingdom, a number of linked factors have together recently directed attention to the potential of skill mix in dentistry. They include the fact that oral health in general has improved enormously compared to 20 years ago, although of course marked geographical and class differentials remain. There is more concern about access to oral health care, as it has become increasingly difficult for many people to find a National Health Service dentist. And there is a greater recognition that much of the work currently done by dentists is for fairly standard items of service. It is now suggested that much of this work might be delegated to dental auxiliaries, leaving the dentist to perform a role as leader of the dental team. The role of ancillaries is recognised in their now being called the Professionals Complementary to Dentistry.
There are signs that policy-makers in the United Kingdom are more receptive to the idea of an enhanced role for the Professionals Complementary to Dentistry. Apart from the report of the Court Committee (1976) and the Royal Commission on the NHS (1979), other important reports have included the Bloomfield Report (1992), the Nuffield report on Education and Training (1993), and the Report of the Dental Auxiliaries Review Group (1998) (1). At the British Dental Association annual conference in April 1998, for example, Alan Milburn, Minister for Health, stated that the stated aims of the Government were to reduce inequalities in oral health status, improve access, offer a more integrated health service to local communities, provide services of the highest quality, and ensure that all the members of the dental team made a full contribution. He indicated he would consider how far the General Dental Council’s report Professionals Complementary to Dentistry, could help the government fulfil its stated aims. (2)
Similarly the recent document Modernising NHS Dentistry, published in September 2000, has indicated there are plans to register other types of auxiliaries with the General Dental Council; widen the role of dental therapists and hygienists; and create new classes of clinical dental technicians and orthodontic assistants.
At the same time, until recently there has been no scientific investigation of the reliability of the many studies that have been carried out to compare the work of dentists and dental auxiliaries. This is currently the subject of a systematic review that has been funded under the NHS R&D Programme in Primary Dental Care, and carried out by colleagues at the Universities of Oxford and York, and at the Eastman Dental Institute, London. This paper does not consider that systematic review, which is currently nearing completion. Rather it looks at another neglected aspect of this question, which is the history of dental auxiliaries. Thus this paper seeks to provide a historical survey of the history of the dental auxiliary, focusing in particular on the New Zealand dental nurse, and on several studies that were carried out in New Zealand in the 1950s.
The Professionals Complementary to Dentistry
The professionals complementary to dentistry currently comprise a number of different groups, each with their own history and areas of expertise. One distinct group is that of dental surgery assistants, whose working life is typically short, not often more than four to five years. Dental hygienists comprise a second group, usually seen as doing the cleaning, polishing , and scaling of teeth. The American Dental Hygienists Association was set up in 1923, and the British Dental Hygienists Association in 1949. A third group is that of the dental therapists, who in the United Kingdom are allowed to fill teeth and extract deciduous teeth - most work only on children. Their number is small - for example, in 1993 there were 371.
Dental technicians typically make veneers, inlays, crowns, bridges, and orthodontic appliances. In 1993, it was estimated that there were 7,900 dental technicians in the United Kingdom. Some work illegally as denturists, that is, they carry out all the clinical and technical stages in the construction of dentures. Maxillofacial technicians tend to work in hospitals along with clinicians; their work includes splint therapy, prosthetic rehabilitation, implantology, and pre-operative planning. Finally there are the orthodontic auxiliaries, although these do not currently form part of the orthodontic team in the United Kingdom. (3) There are also marked differences in their names and functions in different countries, and in that extent that they have been complementary to the services typically provided by dentists.
Oral Health : The United Kingdom Context
Several studies, notably the Court Report on the Child Health Services (1976), and the report of the Royal Commission on the NHS (1979) have provided revealing insights into oral health status in the United Kingdom. They also have important implications for the way that the history of dentistry has been approached and written.
The Court Report, for example, noted that the 1968 adult dental health survey found that over 15 per cent of those between the ages of 15 and 34 in the North had lost all their teeth - 37 per cent of the adult population was edentulous. It noted that in New Zealand, where children were treated by dental nurses, the effect had been impressively demonstrated. The Report argued that dental care had largely been directed to adult treatment, and that ‘the emphasis should move away from adult dentistry and repair, to children’s dentistry and prevention’. It made important recommendations that dental ancillaries, such as hygienists and those trained at the school in New Cross, London, could make an important contribution to child dental health.(4)
The chapter on dentistry was one of the most interesting in the report of the Royal Commission on the NHS. It noted that there had been no general review of NHS dental services in the previous 20 years, and found that the dental health of the nation was ‘poor’. Toothlessness had fallen since the 1968 adult dental health survey. By 1978, edentulousness at all ages in England had fallen from 37 per cent to 29 per cent, and in Scotland had fallen from 44 per cent to 39 per cent. However the Royal Commission also noted important regional and intra-regional variations in dental resources. For example, the dentist: population ratio was 1:2494 in South West Thames, but 1:5445 in the Northern region. The proportion of people with no natural teeth showed striking regional and class differentials - being generally higher among social classes I, II, and III, and in Scotland and Wales. As with the Court Report, the Royal Commission noted the potential contribution of auxiliary staff, recommending that flexibility in meeting demands could be achieved through their increased use.(5)
The 2 reports made a number of other points, including the fact that water fluoridation had not been introduced in most areas, that the emphasis had been on treatment rather than prevention, and that changes in diet and in the use of fluoride toothpaste had ultimately been of more importance than the provision of dental care. However for dental historians they have a wider significance. For too long the history of dentistry has been concerned with the history of the professionals rather than the patients, with the supply of services rather than need, and with a focus on perceived successes rather than failures.
The New Zealand School Dental Nurse
The early history of the New Zealand School Dental Nurse has been extensively covered in earlier work, and need not be repeated here. (6) But briefly, from 1921, and under the supervision of Sir Thomas Hunter, much of the responsibility for the dental health of schoolchildren in New Zealand had been given over to school dental nurses. Her functions included oral examinations, cavity preparations and restorations (with copper amalgam, silver amalgam, and silicate cement), and pulp capping. She could also extract deciduous teeth, was responsible for oral health education, and could refer children to dentists.
In some ways, the evolution of the New Zealand School Dental Nurse can simply be seen as a response to that country’s distinctive geography and demographic patterns. In 1950, the population of New Zealand was 1.8m, with a high proportion of young people - in 1946, for example, the child population had been 590,000. The biggest cities were Wellington, Auckland, Christchurch, and Dunedin, but none was particularly large by European standards, since the largest had a maximum population of 300,000. The bulk of the population lived in small townships of 2-3,000 people, and in rural communities. Moreover some areas of the South Island were uninhabited.
A comparative history of the histories of health care in New Zealand and the United Kingdom would be extremely interesting. There are signs of increasing interest in the history of health care in New Zealand. (7) Moreover there is evidence that public health doctors who migrated from New Zealand to Great Britain, and who worked in public health in Britain in the 1940s, were shocked by what they found there. (8) However a true comparative history remains to be written. Our interest here is in the studies of the New Zealand School Dental Nurse carried out in the 1950s. There were many minor studies. But the most important were arguably those by Allen Gruebbel on behalf of the American Dental Association (1951), by the United Kingdom’s Ministry of Health (1950), and by John Fulton on behalf of the World Health Organisation (1951).
The Gruebbel study was in general highly critical of the New Zealand School Dental Service, arguing that equipment was inadequate and the quality of treatment poor. School dental nurses were supplied with only 2 types of silicate cement, Gruebbel alleged, they used copper amalgam fillings, and they were reliant on portable dental chairs and foot engines. He claimed that the dental health of army recruits in New Zealand was no better in 1939-45 than in 1914-18, since 58 per cent had a denture of some kind. Gruebbel wrote ‘a school dental nurse is not a dentist, she is a technician trained in the mechanical art of filling, cleaning and extracting teeth’. But much of Gruebbel’s criticism was not of the New Zealand School Dental Service per se, but of state intervention and health care in a socialist system. It was therefore highly influenced by the distinctive political culture of the United States - ‘excessive social legislation is destructive to individual effort and initiative’. (9)
The study by John Fulton on behalf of the World Health Organisation was carried out between February and April 1950. Fulton reported that 4,072 schoolchildren aged 7-14 were given a dental examination. The prevalence of dental caries in New Zealand was high. Nevertheless a high proportion of these children had been treated. In 1949, an average of 715 children per nurse had been cared for in the school dental clinics at an average cost per child of £1 8s 11d. Fulton argued that ‘New Zealand’s public dental programme has gained a large measure of success in controlling the effects of dental caries in schoolchildren’. (10)
A team from the United Kingdom’s Ministry of Health visited New Zealand in February and March 1950, travelling by air, road, and steamer. The sending of the team was prompted by the imminent collapse of the School Dental Service, and its report was in many ways more positive. School dental clinics in New Zealand were simple wooden structures, consisting of a lobby, a surgery, and a small recovery room. The team found that the clinical standard of the final year students at the Training School and school dental clinics in Wellington was high. It concluded that ‘we are of the unanimous opinion that the training of the New Zealand school dental nurse has resulted in a high standard of technical efficiency...the dental nurse system in New Zealand meets an urgent need’. (11)
One member of the team, A. T. Wynne, amplified these findings in an article published the following year in the British Dental Journal. Wynne repeated that his overriding impression of the work of the school dental nurses was their ‘really astonishing determination to save teeth’. Wynne was critical of the Gruebbel report, claiming that much of what he said was not criticism of the school nurses. Overall Wynne argued that ‘the essential fact remains that the mouth of the average New Zealand child is maintained in a healthy condition, with a minimal loss of teeth, by the work of the dental nurses’. However he noted that the use of dental nurses in the United Kingdom would have to be supplementary to the existing system - some work might be delegated to dental nurses but they could not replace dentists. (12)
At the same time, it is important to note that more recent studies have noted that a much higher proportion of New Zealanders wear full dentures than comparable groups in other countries with similar levels of dental disease. (13) Whether this is related in any way to the New Zealand School Dental Service is unclear. More significant is that the New Zealand model was taken on board in Australia, in remote parts of Canada, and in the Netherlands. The New Zealand School Dental Nurse was an important influence on the emergence of systems of oral health care, particularly in South East Asia, where a number of countries adopted the New Zealand model.
The Dental Auxiliary in the United Kingdom
The reports on the New Zealand School Dental Service were of course only the most recent step in the history of dental auxiliaries in the United kingdom. They had clearly been involved in dental care in the nineteenth century, when they had served as apprentices. Their use increased with the use of anaesthetics from 1850, when they acted as a chaperone for female patients. Towards the end of the nineteenth century, wives and daughters of dentists worked as receptionists and secretaries. (14) In the USA too, the potential of improved co-operation between dentists and dental assistants had been recognised as early as the 1920s. (15)
Until 1859, there had been no formal qualification for providers of dental treatment. Nevertheless from 1916 some dental auxiliaries (called ‘dental dressers’) were employed by Local Education Authorities (LEAs) in response to the shortage of qualified dentists and difficulties of employing them at the lower salaries than were paid in private practice. Derbyshire was one of the most important of these, along with Sheffield and Shropshire. In Derbyshire, 2 dressers worked with a dentist in small team, examining and treating the children under the care of the dentist. It was claimed this was cheaper and that there was an increase in productivity. These LEAs were encouraged by the 1921 Dentists Act which allowed ‘the performance of minor dental work under the personal supervision of a registered dentist, by a person who is not a dentist’ in the School Medical Service.
However dental dressers were effectively abolished in 1923, by the Ministry of Health using powers in the 1921 Dentists Act. The phrase ‘minor dental work’ was defined even more narrowly in 1932. (16) An experimental scheme to train dental hygienists at University College Hospital was dropped after opposition from the dental profession. Dentists also successfully opposed attempts to introduce auxiliary workers through the 1957 Dentists Act.
It was only in 1959, with the opening of a school at New Cross Hospital, that some progress was made. This trained some 60 therapists a year, who then went on to make a valuable contribution to the School Dental Service. However even then the work of dental therapists was still confined to the extraction of deciduous teeth, and it was a policy decision to locate the New Cross School away from existing dental schools. The use of dental therapists tended to be limited to the South East of England. Auxiliaries were introduced into Britain, but very much as a pale imitation of the New Zealand school dental scheme. (17) Their valuable contribution to the School Health Service notwithstanding, dental therapists were used in a pretty limited way in the United Kingdom.
The interesting question is why there was so much opposition to the employment of dental auxiliaries. Several reasons have been put forward. It has been suggested, for example, drawing on the sociological literature on professionalisation, that dentists had an occupational monopoly and were determined to restrict entry into the profession. Dental auxiliaries represented a serious threat to their income and status, and they were not willing to concede control of the patient to them. It was argued that ‘dental dressers’ would depress standards of care - they represented a form of inferior practice, and their elimination was seen to be socially progressive. (18) Access to care also seems to have been a much lower priority for policy-makers in this period.
The cyclical nature of these debates indicates the value of a historical approach to the history of dentistry. As in the 1950s, much of the interest in the potential of skill mix in dentistry has been prompted by concern about a manpower shortage. The increasing difficulty that may people face in finding a National Health Service dentist has led to anxiety about access to care, and it is clear that marked geographical and class variations persist. Now as then, other countries have provided a model for change, particularly in remote rural areas and developing countries where logistical problems coupled with a shortage of resources have forced the providers of care to innovate with both personnel and materials. Dentists remain concerned about delegating certain duties to the Professionals Complementary to Dentistry, until it has been scientifically proven that the later can perform as well as the former. Thus the Derbyshire ‘dental dressers’ and the New Zealand school nurses continue to have a relevance for contemporary policy-makers.
However although there are important continuities in this story, it is also clear that the policy context in the United Kingdom now is very different to that of fifty years ago. In the first place, the Government appears more committed to overcoming obstacles in access to oral health care, and has a genuine concern about inequalities in health. Second, the British Dental Association acknowledges the potential contribution of the wider dental team, and in any case has arguably a less direct influence on the policy process. Third, an improvement in the general oral health care status of the population means that much of the work of dentistry is now concerned with routine items of service. Finally the Professionals Complementary to Dentistry are themselves better organised than previously, and have a clearer sense of professional identity. It remains to be seen whether these factors will together ensure that skill mix in dentistry finally becomes a reality. The value of a social history of dentistry, however, is clear.
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