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Dental Workforce

Introduction

Population growth, the retention of teeth and an ageing population are likely to lead to an increase in demand for dental services. India is experiencing lop-sided distribution of the dental workforce. The country is producing approx, 23,000 dentists per annum. The distribution of dentist to population requirement is uneven with more than 98% dentists available for urban areas. less than 2% dentists are available for 72% of rural population.

There remains a substantive demand for diagnostic, preventive, conservative treatments in India while lessening need for exodontia (a branch of dentistry that deals with the extraction of teeth). IDA has drafted a framework to develop, nurture and manage dental resource personnel. Towards this end, IDA conducted a `Strategic evaluation and future planning for dental personnel resource development & oral health planning' workshop on a national scale, under the aegis of the Ministry of Health and Family welfare. The singular objective was to develop a proper database of dental personnel resources available in the country to take care of oral health of the population.

Definition

DENTIST is a person registered to provide dental care.

Principles

All Indians should have access to modern, comprehensive oral health care. Indians must be largely self-sufficient with regard to the training of the dental workforce.

Maintaining and improving oral health relies to a large extent on access to equitable oral health care services which, in turn, is reliant on an adequate dental workforce. Governments should ensure an equitable funding framework to promote excellence in teaching, learning, scholarship and research in dentistry. The dental workforce training for allied dental personnel should be based on the requirements and demand of the community.

Policy

The future dental workforce should provide services that:

• are population based;
• are patient focused;
• lead to the coordinated, non-fragmented provision of oral health services;
• are preventively orientated;
• should ensure an adequate dental workforce in rural and remote areas; and
• are delivered efficiently and effectively.

The future dental workforce should comprise general and specialist dentists to provide treatment and to prescribe and supervise appropriate procedures to be undertaken by dental assistants, dental technicians and dental laboratory assistants. The training of dentist should be focussed on prevention rather than restorative dentistry and exodontia.

Dentists

Introduction

Dentists in India have a proud tradition of voluntarily supporting Dental Colleges and dental research. Dentists in India have a strong culture of cooperation by sharing experiences and knowledge. Dentists have a strong culture of philanthropy. A dentist is the only oral health practitioner entitled to use the title “dentist” and may also be known as a dental surgeon or dental practitioner, or by a specialist dentist title. Dentist training involves five years training at college. Therefore the Dental Council of India and governments have recognised dentists as the principal dental care provider.

Definitions

Dental Council of India is a Statutory Body incorporated under an Act of Parliament viz. The Dentists Act, 1948 (XVI of 1948) to regulate the Dental Education and the profession of Dentistry throughout India. A Dentist is an appropriately qualified dental care provider, registered by the Dental Council of India to practise dentistry. Dentistry is the science and art of preventing, diagnosing and treating diseases, injuries, developmental and acquired defects of the teeth, joints, oral cavity and associated structures within the context of general health.

Principles

Dentists are the most completely and highly trained dental care provider to the delivery of dental treatment. All Indian should have access to modern, comprehensive oral health care. Dentists perform invasive and irreversible procedures and should be registered. Universities should award PhD degrees when substantial component of original research is involved.

Policy

Education and training of dentists must be to degree level in a programme conducted by a college and accredited by the Indian Dental Council (IDC). The title of such a qualification should be a Bachelor of Dental Surgery.

Selection for entrance into such a programme should not be based solely on academic performance and may include:

• communication skills;
• good character; and
• physiological suitability to be a health practitioner.

A one-year internship is given to enhance the knowledge and skills of the graduate. The dentist as team leader must be responsible for diagnosis, treatment planning, delivery of dental procedures and continuing evaluation of the oral health of the patient. The dentist is also responsible for the support, direction and supervision of dental assistants working directly with them. Dentists providing dental care within clinical practice must maintain an appropriate level of professional indemnity cover. Dentists should conduct themselves in accordance with the Indian Dental Association’s Principles of Ethical Dental Practice. Dentists have an ethical obligation to engage in continuing professional development throughout their practising careers.

Specialisation in Dentistry

Introduction

The recognition of specialities and specialist dentists serves to identify to the public and to the dental and individual practitioners who have special competence in a specified area of dental practice.

Definitions

Specialisation is the exclusive practice of a recognised speciality of dentistry by an appropriately qualified practitioner. Notwithstanding the delineation of a speciality, the area defined may be practised by registered dentists provided they possess the necessary skills, experience and expertise. A Specialist Dentist or Specialist is one who practises a recognised speciality, possesses a higher qualification relevant to this area of dentistry and has fulfilled any other statutory requirements within territory of practice and has been so registered. In the absence of appropriate credentials, limitation of practice does not confer specialist status; nor does possession of a higher qualification and limitation of practice to an area of dentistry not formally recognised as a speciality. The Dental Council OF India is a body responsible for evaluating and approving courses leading to formal dental qualifications and assessing overseas qualified dental care providers.

Principles

Specialisation serves to stimulate organisation, education and research in a particular area of dentistry. The establishment of a dental speciality must address a clear health need and public demand. The acquisition of specialist status and the use of the designated title of the speciality should be strictly regulated. Only fully qualified and registered dentists will be eligible for training as specialists. A specialist's primary purpose must be to render a service to patients and the community which requires knowledge and skill beyond those which could normally be expected in the relevant area of dental practice. Specialisation should not in any way curtail the right of the general dental practitioner to practise any discipline of the profession.

Only specialist dentists, as recognised by the Dental Council of India can refer to themselves as specialists. The public must not be misled about a practitioner’s specialist status.

Policy Recognition of Dental Specialties

To be recognised as a dental speciality, any proposed speciality should meet the following criteria. It should:

• Have a clear need and demand of a substantial portion of the population.
• Be important to the health of individual patients.
• Be an area of dentistry in which general practitioners may have need to refer patients for provision of expert services in a particular area of dentistry.
• Require special knowledge and skills, superior to undergraduate dental education and training, in order to perform procedures of an advanced, difficult, or unusual nature.
• Be definable in order to prescribe the scope of the speciality.
• Be one in which there is a formal course accredited by the dental education accrediting authority to qualify practitioners appropriately.
• Be recognised by the Indian Dental Association (IDA).

Requirements for Specialisation

A person seeking recognition as a specialist in a chosen area shall have:

• Successfully completed an acceptable undergraduate course in dentistry.
• Attained the legal status to practise dentistry.
• Completed a mandatory period in the general practice of dentistry in private practice, hospital or other institutional practice, a public health service or the Armed Services.
• Completed a course of graduate education accredited by the dental education accrediting authority leading to an acceptable higher qualification relevant to the area of specialisation.

Education Requirements

The minimum period of postgraduate education, including training/experience for any speciality, should be four years full time, but longer clinical training may be deemed to be appropriate for some specialities. The title for such a qualification should be Master of Dental Science. Only those courses of specialist education which have been accredited by the Indian Dental Council should be recognised as acceptable qualifications for specialisation. Completion of research, no matter how advanced or valuable, should not be considered as sufficient grounds for registration in any speciality.

Registration

Specialist status shall be subject to registration conferred through statutory powers vested in the Council. Dental Acts should prescribe:

• areas of dental specialisation;
• requirements for registration as a specialist dentist; and
• that only recognised specialist dentists may use specialist titles.

Currently Recognised Dental Specialties

The dental specialties and specialised dentists recognised by the IDA shall be designated and defined as follows:

Dento-maxillofacial Radiology

That part of dental practice which deals with diagnostic imaging procedures applicable to the hard and soft tissues of the oral and maxillofacial region and to other structures which are relevant for the proper assessment of oral conditions.

A Specialist in dento-maxillofacial radiology shall have the title of Dento-maxillofacial Radiologist.

Endodontics

That part of dental practice which deals with the morphology, physiology, and pathology of the human tooth and in particular, the dental pulp, root and peri-radicular tissues. It includes the biology of the normal pulp, crown, root and peri-radicular tissues and the aetiology, prevention, diagnosis and treatment of diseases and injuries that affect these tissues.

A Specialist in endodontics shall have the title of Endodontist.

Forensic Dentistry

That part of dental practice which deals with the examination and evaluation of dental evidence, which may then be presented in the interests of justice. It includes identification of unknown human remains, identification of unknown deceased individuals following mass disasters, examination and assessment of bite mark injuries, child abuse injuries and facial injuries following assault or trauma, age assessment of both living and deceased persons and civil cases involving malpractice and fraud allegations.

A Specialist in forensic dentistry shall have the title of Forensic Dentist.

Oral and Maxillofacial Surgery

That part of dental practice which deals with the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects of the human jaws and associated structures.

A Specialist in oral and maxillofacial surgery shall have the title of Oral and Maxillofacial Surgeon.

Oral Surgery

That part of dental practice which deals with the diagnosis, surgical and adjunctive treatment of diseases and injuries limited to the dento- alveolar complex.

A Specialist in oral surgery shall have the title of Oral Surgeon.

Oral Medicine

That part of dental practice which deals with the clinical diagnosis, assessment and principally non-surgical, pharmacological management of anatomical variants, pathological conditions, diseases and pain of the dental, oral and adjacent anatomical structures and the dental/oral manifestations and complications of systemic diseases, pathology and conditions and their treatment.

A Specialist in oral medicine shall have the title of Oral Physician.

Oral Pathology

That part of dental practice which deals with diseases of the teeth, jaws, oral soft tissues and associated structures, studies their causes, pathogenesis and effects, and by use of clinical, radiographic, microscopic and other laboratory procedures establishes differential diagnoses and provides forensic evaluations. A Specialist in oral pathology shall have the title of Oral Pathologist.

Orthodontics

That part of dental practice which deals with the study and supervision of the growth and development of the dentition and its related anatomical structures, including preventive and corrective procedures of dentofacial irregularities requiring the re-positioning of teeth, jaws, and/or soft tissues by functional or mechanical means.

A Specialist in orthodontics shall have the title of Orthodontist.

Paediatric Dentistry (Paedodontics)

That part of dental practice which deals with the prevention and the treatment of dental diseases and abnormalities in children and their associated developmental and behavioural problems.

A Specialist in paediatric dentistry shall have the title of Paediatric Dentist or Paedodontist.

Periodontics

That part of dental practice which deals with the prevention, recognition, diagnosis and treatment of the diseases and disorders of the investing and supporting tissues of natural teeth or their substitutes.

A Specialist in Periodontics shall have the title of Periodontist.

Prosthodontics

That part of dental practice which deals with the restoration and maintenance of oral health, function and appearance by coronal alteration or reconstruction of natural teeth, or the replacement of missing teeth and contiguous oral and maxillofacial tissues with substitutes.

A specialist in prosthodontics shall have the title of Prosthodontist.

Public Health Dentistry

That part of dental practice which deals with the community as the patient rather than the individual, being concerned with oral health education of the public, applied dental research and administration of dental care programmes including prevention and control of oral diseases on a community basis.

A Specialist in Public Health Dentistry shall have the title of Public Health Dentist.

Special Needs Dentistry

That part of dental practice which deals with patients where intellectual disability, medical, physical or psychiatric conditions require special methods or techniques to prevent or treat oral health problems, or where such conditions necessitate special dental treatment plans.

A Specialist in Special Needs Dentistry shall have the title of Special Needs Dentist.

Obligations of Specialist Dentists

In treating a referred patient, a specialist dentist shall:

• keep the referring practitioner informed of progress;
• attempt to seek consent of the referring practitioner before making a further referral;
• not perform services which are outside his/her specialty without the consent of the referring practitioner; and
• after completion of treatment, direct the patient back to the referring practitioner.

A specialist dentist shall guide and educate other dentists and allied dental personnel to higher levels of competence within their scope of practice.

Higher Education Funding For the Dental Workforce

Introduction

Population growth, the retention of teeth, and an ageing population are likely to lead to an increase in demand for dental services. India is experiencing a dental workforce maldistribution. The regional, rural and remote areas are generally under-supplied with dental providers. Hence, developing and maintaining a sustainable dental workforce is a fundamental issue.

Higher education funding to dental schools is insufficient and staffing levels are inadequate. Dentists assist in overcoming this funding shortfall by providing voluntary unpaid clinical supervision, with the situation arising where some dental schools must rely heavily on this donated service.

Healthy Mouths, Healthy Lives: India’s National Oral Health Programme has determined that dental ‘services, including prevention and health promotion, should be accessible to all who need them, across all cultures, language groups, communities of place and interest, abilities and socio- economic groups, with recognition and respect for individual needs and views.’

The higher education sector via dental college and IDA provides all education and training for dentists.

Principles

Maintaining and improving oral health relies to a large extent on access to equitable oral health care services which, in turn, is reliant on an adequate dental workforce. India must be largely self sufficient with regard to the training of the dental workforce. In order to maintain an adequate and sustainable dental workforce, it is critical that the Government fund dental schools to ensure they remain viable to promote excellence in teaching, learning, scholarship and research in dentistry. Government funding should be at levels such that viability of dental schools is not reliant on fee- paying students. Fostering an interest in rural, remote and public sector practice is a responsibility of dental schools. Incentives to encourage rural, remote and public sector practice will improve the distribution of India’s dental workforce.

Policy

It is imperative that the establishment of new dental schools or the expansion of dental school training numbers is based upon demonstrable need. The government must adequately fund the dental colleges to ensure viability and appropriate staffing levels. The funding level for dental training should be determined separately from other courses, recognising the uniquely high costs of dental training and the high retention rates in dental courses. The establishment of new dental schools is resource intensive and costly. Wherever possible, Governments should take advantage of economies of scale and existing infrastructure by expanding places at established dental schools.

Where a new dental school is proposed, it must be demonstrable that it will have appropriate infrastructure, patient pool and staffing available to support students and have an appropriate student mix that may assist in addressing the long term workforce needs. The distribution of any additional dental undergraduate places should take into account the demography and oral disease prevalence needs of the community. It is important to develop strategies to improve the geographic distribution of dentists. Undergraduate education models should foster an interest in rural and remote dentistry and also equip dental graduates to face the challenges of rural and remote dentistry.

Undergraduate education models should provide dental school students with strong early exposure to rural and remote dentistry. The dental schools should maximise the potential for rural rotations during undergraduate study as one strategy to address the geographic distribution of dentists between urban and rural locations. Existing dental colleges should establish rural/remote clinics. Increasing the number of dedicated university places supported by scholarships for Indigenous students and students from rural and remote backgrounds; Graduate incentive programmes offering supported employment pathway into rural and remote areas.

Benefits of Defined Health Professions

Introduction

All health professions have history and culture, and often represent a discipline of health science with a defined body of knowledge. The explosion of knowledge within each health field has led, by necessity, to an increased variety of practitioners and increasingly specialised healthcare providers. Defined health professions offer patients a basis for trust in the competence, knowledge, safety and professionalism of practitioners. Dentists in India have a proud tradition of voluntarily supporting Dental Colleges and dental research. Dentists in India have a strong culture of cooperation by sharing experiences and knowledge. Dentists have a strong culture of philanthropy.

Principles

Optimal patient outcomes should determine the make up of health professions. Patients need health providers with clearly defined and readily understood roles and titles to assist them in choosing the correct provider. Health practitioners belonging to a defined profession and associated disciplines benefit the public as this leads to higher standards of care via:

• adherence to a code of ethical conduct based on a shared commitment to always give priority to the existential needs and interests of the public they serve above their own;
• a collegiate environment that encourages sharing of knowledge for the benefit of patients;
• ongoing information and support from profession-based member organisations to their members;
• support and mentoring of students and new health providers by their colleagues;
• providing relevant continuing professional development activities;
• better focused and supported research;
• specific indemnity arrangements with patient safety and quality of care feedback loops; and
• encouragement of volunteer service in India and overseas.

A patient-centred approach to health care requires that all health practitioners establish sound referral and communication measures to ensure the overall welfare of the patient remains the key focus.

Policy

Clearly defined health professions must remain to ensure:

• optimal health outcomes;
• the advancement of the art and science of each field; and
• patients are provided with a basis for trusting the competence and ethical integrity of practitioners.

The different health professions should work together to:

• ensure a better understanding of each others’ knowledge and skills;
• adopt a cooperative and interdisciplinary approach to treating patients where appropriate; and
• promote consistent health messages.

The Role OF Non Dental Practitioners In Oral Health

Introduction

Increasing evidence supports the links between oral health and overall general health. The risks of cardiovascular disease, aspiration pneumonia, premature and low birth weight in neonates, nutritional deficiencies and cerebrovascular accident are higher in people with poor oral health. Some medical conditions may be exacerbated by poor oral health or have deleterious effects upon oral health. Some medications and treatments can have a detrimental effect on oral health.

Increasing tooth retention with age means greater numbers of the elderly requiring assistance with the ongoing oral health care. Generally, old care facility staff are not trained to improve the oral hygiene of residents nor able to recognise dental disease. There is a need to develop further the capacity of the health workforce to meet the needs of older people, including oral health. Patients with dental emergencies and injuries often present to healthcare practitioners other than dentists. Dentistry is different to most of other health care in that the vast majority of dental services are procedural and provided by small dental clinics in the private sector, separate from other health facilities.

Definitions

Non-Dental Practitioners are health care providers other than those who are registered by a Dental Council. Screening is the intentional observation of patients to recognise potential deviations from normal health.

Principles

A wide range of healthcare providers influence the diet and lifestyle choices made by people of all ages and thereby contribute to their oral health. Non-dental practitioners who have been educated about oral health and oral diseases can attend to patients’ oral hygiene and screen for dental problems and so facilitate early intervention by dentists. The outcome of treatment for dental injuries is often dependent on early and correct treatment. Non-dental practitioners should be cognisant of the potential for oral health consequences in the care of their patients.

Policy

All healthcare and aged care facilities should have protocols for timely referral to dentists of patients with oral diseases and injuries.

Education and training courses for some non-dental practitioners should include a dental component enabling them to understand the oral health consequences of their care and to provide oral health promotion and dental screening. Education and training courses for emergency practitioners should include a dental component enabling them to provide dental first-aid.

Health care practitioners should work together to:

• ensure a better understanding of each others’ knowledge and skills;
• adopt a cooperative and interdisciplinary approach to treating patients where appropriate; and
• promote consistent health messages.