Dental auxiliary

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DENTAL AUXILIARIESPRESENTED BY: Dr. Esha Bali

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CONTENTS• Introduction• Definition• Degree of Supervision

• Classification of auxiliaries• Functions of auxiliaries

• Function and Training• Non - operating auxiliaries

– Dental surgery assistant– Dental secretary/ receptionist– Dental laboratory technician– Dental health educator

• Operating auxiliaries– School dental nurse (New Zealand type)– Dental therapist– Dental hygienist – Expanded function dental auxiliaries

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• Newer types of auxiliaries– Dental licentiate– Dental aides– Community dental health coordinator– Oral preventive assistant– Advanced dental hygiene practitioner

• Evolutionary process of dental health services• Development of Dental Profession

• Benefits of auxiliaries• Impact on Indian scenario• Conclusion• References

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INTRODUCTION

• The vision of the dental team is one of various people in dentistry with different – Roles– Functions– Period of training all working together to treat

patients. • Health care systems depend not only upon

infrastructure and resources, but also on the availability of skilled human resources.

(Parkash H. Dental Workforce Issues: A Global Concern. Journal of Dental Education 2006,70;11, 22-26)

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• Dental auxiliary is generic term for all persons who assist the dentists in training patients.

• Repetition without shift of attention makes for speed and accuracy.

• Reason for division of labor also lies in the different levels of knowledge attainable within one field by persons of differing aptitude and opportunity for training.

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WHO Definition (1958)• Auxiliary is a technical worker in a certain field with less

than full professional training. • A dental auxiliary can be defined as ‘A person who is

given responsibilities by a dentist so that he or she can help the dentists render dental care, but who is not himself or herself qualified with a dental degree’.

-Slack (1960)• The duties undertaken by dental ancillaries range from

simple tasks such as sorting instruments to relatively complex procedures which form part of the treatment of patients.

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• In U.K the corresponding generic term is used called “Dental Ancillary”

• The word auxiliary means being helpful, subsidiary; whereas ancillary means subservient, subordinate.

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DEGREES OF SUPERVISION • Auxiliaries of all types operate under varying

degrees of supervision by dentists• In 1975, American Dental Association (ADA)

defined four degrees of supervision of auxiliaries as :– General supervision– Direct supervision– Indirect supervision– Personal supervision

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1. General supervision: – The dentist has authorized the procedures and they are

being carried out in accordance with the diagnosis and treatment plan completed by the dentists.

– The dentist is not required to be in the dental office when the procedures are being performed by the allied dental personnel,

but has personally diagnosed the condition to be treated,

has personally authorized the procedures, and will evaluate the performance of the allied dental

personnel.

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2. Indirect supervision: – The dentist is in dental office, authorizes the procedure and remains in

the dental office while the procedures are being performed by the auxiliary.

– The dentist is in the dental office, has personally diagnosed the condition to be treated, authorizes the procedures and remains in the dental office while the procedures are being performed by the allied dental personnel, and will evaluate the performance of the allied dental personnel.

3. Direct supervision: – The dentist is in the dental office, personally diagnosis the condition to

be treated, personally authorizes the procedure, all before dismissal of the patient, and evaluates the performance of the dental auxiliary.

4. Personal supervision: – The dentist is personally operating on a patient and authorizes the

auxiliary to aid treatment by concurrently performing supportive procedure.

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CLASSIFICATION OF DENTAL AUXILIARIES:

• Dental auxiliaries may be classified according To the training they have received, The task they are expected to undertake, and The legal restrictions placed upon them.

• While different titles have been given to groups of auxiliaries classified in this way, terminology is not consistent from one country to another.

• Therefore, unless standard definitions are provided of what constitutes a dentist, a dental therapist, or any other dental health worker, national and international statistics cannot be comparable and meaningful.

• Standardization of definitions of health worker has been initiated by the International Labour Organization and by the conference conducted by the

World Health Organisation in New Delhi in 1967

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WHO CLASSIFICATION

NON OPERATING AUXILIARIES a) CLINICAL - a person who assists the dentist in his clinical work but

does not carry out any independent procedures in the oral cavity. b) LABORATORY - a person who assist the professional (dentist) by

carrying out certain technical laboratory procedures.

OPERATING AUXILIARIES • This is a person who not being a professional is permitted to carry out

certain treatment procedures in the mouth under the direction and supervision of a professional.

• This classification is particularly useful in that it draws a distinction between operating and non – operating auxiliaries.

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REVISED CLASSIFICATION Slack GL, Burt BA (1981)

NON OPERATING AUXILIARIES• Dental surgery assistant• Dental secretary/ receptionist• Dental laboratory technician• Dental health educator OPERATING AUXILIARIES• School dental nurse (New Zealand type)• Dental therapist• Dental hygienist • Expanded function dental auxiliaries NEW TYPES OF DENTAL MANPOWER• Dental licentiate • Dental aides • Community dental health coordinator • Oral preventive assistant • Advanced dental hygiene practitioner

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FUNCTIONS OF DENTAL AUXILIARIES

Office & chair side assistance Assisting in radiographic exposure Taking impressions for study casts Removing sutures & dressing Applying topical anesthetics Performing preliminary oral examination Performing oral prophylaxis Providing health education Applying anti cariogenic agent Placing & removing rubber dams Placing & removing matrices Placing & removing temporary restorations Placing, carving & finishing amalgam restorations

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DENTIST

• A dentist is a person licensed to practice dentistry under the law of the appropriate state, province, territory or nation.

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• These laws ensure that to become licensed, a prospective dentist must satisfy certain qualifications such as:– Completion of an approved period of professional education

in an approved institution.– Demonstration of competence – Evidence of satisfactory personal qualities.

• Legally entitled to treat patients independently, to prescribe certain drugs and to employ and supervise auxiliary personnel.

• Dentists must be both licensed and registered.

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DEVELOPMENT OF THE DENTAL PROFESSION

• Dental diseases have always afflicted human health.• The first written evidence on dentistry is by Pierre Fauchard in

1728.• Even the well known dentist G.V. Black had possessed a formal

education of dentistry in just 20 months.• Baltimore college of dental surgery (1840) was the first dental

college in world. Later known as University of Maryland. • First journal of dentistry was ‘The American Journal of Dental

Sciences’.• The first Organization was named ‘The American Society of

Dental Surgeons’.• The first census was in 1850 in the US which showed a dentist:

population ratio of 1:8000 (compare it with 1900 having a ratio of 1:2562 and in 1980 it was 1:1348).

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DENTAL PROFESSION IN INDIA

• Dr. Rafiuddin Ahmed started the first dental college in Calcutta in 1920.

• At the time of independence, there were only 2 government institutions, – Lahore and Bombay, and there were 19 private

institutions such as – Nair dental college (Bombay) and The Calcutta college.

• Presently, there are about 240 dental colleges in India.

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• The World Health Organisation recommends a 1: 7500 dentist to population ratio whereas the dentist to population ratio in India is as low as 1:22500.

(World Health Organization: Recent advances in oral health. In Technical Report Series-826. World Health Organization; 1992:1-37.)

• In 2004, India had one dentist for 10,000 persons in urban areas and about 2.5 lakh persons in rural areas.

(India Ministry of Health and Family Welfare and Dental Council of India. Status of dental colleges for admission to BDS course. At:http://mohfw.nic.in/Adental.html.)

• Almost three-fourths of the total number of dentists were clustered in urban areas, which house only one-fourth of the country's population.

(Tandon S: Challenges to the Oral Health Workforce in India. J Dent Education 2004, 68:29-33.)

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Non – Operating Auxiliary.

• Dental surgery assistant • Dental secretary / receptionist • Dental laboratory technician • Dental health educator

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DENTAL SURGERY ASSISTANT

• Dental assistants are an invaluable part of the dental care team.– Enhancing the efficiency of the dentist in the

delivery of oral health care and – Increasingly influencing the productivity of the

dental office through • Sound management• Effective communication skills, and • Promotion of patient education.

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HISTORY OF DENTAL ASSISSTANT: • The introduction of anaesthesia in dentistry after

1850 is one of the reasons for dentists requiring the presence of an dental assistant and to act as a helperone for female patient.

• In 1885, Dr. Edmund Kells of New Orleans hired the first woman dental assistant to replace his male "helper".

• He has generally been credited as the founder of the dental assisting profession.

• This aptly-named "lady in attendance" made it acceptable for a respectable woman to seek dental treatment without her husband or a maiden aunt present in the office.

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• Dr. Kells then realized that the "lady in attendance" could be helpful in office duties, as well as in facilitating dental health care delivery for women.

• By 1890, he routinely employed women as both chair side and secretarial assistants. Although subsequent years brought many women into the dental practice for treatment, the employment of women as dental assistants was still not widely accepted by many dentists.

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• It was thought that "the female's very form and structure unfits her for the duties of dentistry" and "women's inferiority and lack of mechanicability" caused her to be relegated to the background of dental health care delivery. Many years passed before dentists realized the true worth of and potential scope of practice of the "lady in attendance”.

• In 1921, Juliette A. Southard organized dental assistants into the Educational and Efficiency Society.

• This organization later became the American Dental Assistants Association (ADAA).

• A curriculum committee was organized in 1930 to develop courses and to provide training in writing educational guidelines for dental assistants.

• By 1943, the ADAA had determined that sound preparation was key to successful dental assisting practice.

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• A high school diploma had to be earned before membership could be granted in this organization.

• In 1944, the Certification Committee was established to promote standards and to craft a certification examination for dental assistants.

• The Certifying Board of the ADAA was formed in 1948 to credential dental assistants who passed the examination.

• This board, now known as the Dental Assisting National Board (DANB), joined the National Commission for Health Certifying Agencies in 1979.

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DUTIES ASSIGNED TO DENTAL ASSISTANTS

• The expert committee on auxiliary dental personnel of the World Health Organisation lists following duties; – Reception of patient.– Preparation of the patient for any treatment he or she may need.– Preparation and provision of all necessary facilities, such as mouthwashes,

napkins.– Sterilization care and preparation of instruments.– Preparation and mixing of restorative materials including tooth filling and

impression materials.– Care of patients after treatment until he or she leaves, including clearing away of

instrument and preparation of instruments for reuse. – Preparation of the surgery for the next patient.– Presentation of documents to the surgeon for his completion and filling of this.– Assistance with extra work and processing and mounting of x-rays.– Instruction of the patient, where necessary, in the correct use of the toothbrush.– Aftercare of persons who have had general anaesthesia.

• (Auxiliary Dental Personnel. World health Organization. Technical report series. No. 163)

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TRAINING OF DENTAL ASSISTANT• Is done to assist the dentist by providing an extra pair of hands to enable him to

work more effectively and speedily.– Length of training

• Is directly related to the degree of development of the area.• In developed areas where

– The dentist have been trained in efficient use of chair side assistants.– Areas where there is an adequate number of suitable recruits.

• The candidates are expected to have had a secondary education and a formal course of training of one year’s duration is required. – Curriculum

• The formal course should include :– The importance of ethical behavior– Principles and methods of sterilization– Preparation of filling and impression materials– Care and maintenance of instruments and light equipments– First aid– Basic knowledge of dental nomenclature– The use and compilation of appropriate documents and records.


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• There is still great variability in the utilization of dental assistance from office to office and from country to country.

• Some dental assistant are in fact merely receptionists with a added duty of sterilising instruments and replacing them in a cabinet.

• Other dental assistant relived of receptionist duties stay constantly on chair side, called as chair side dental assistant or dental surgery assistant

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• Four Handed Dentistry is given to the art of seating both the dentist and dental assistant in such a way that both are within easy reach of the patient’s mouth.

• Perform additional tasks such as retraction or aspiration.

• The dentist can thus keep his hands and eyes in the field of operation and work with less fatigue and greater efficiency.

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• RESULTS TO BE EXPECTED WITH THE HELP OF DENTAL ASSISTANT

1. More dental-care services can be provided through use of a trained assistant because she conserves the dentist's time by performing the numerous tasks incident to routine dental treatment, which the dentist would otherwise have to perform himself.

2. Quality of services is also improved because the dentist is under less physical and mental strain.

3. Better control of the patient is possible through the influence of an assistant.4. The necessary armamentarium is as near as the dentist's hand. He can work

from the seated position during the entire treatment procedure, and be less fatigued.

5. Provision of more services results in greater patient turn-over, which brings greater income.

6. The resultant increase in the number of patients treated, reduces the incidence of caries through early detection and treatment, and makes available to the dentist more time for providing preventive treatment.

7. Also, the appointment periods are shorter, resulting in less pain and discomfort to the patient.

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DENTAL SECRETARY / RECEPTIONIST:

• This is a person who assists the dentist with his secretarial work and patient reception duties.

• DENTAL LABORATORY TECHNICIAN • The dental technician, whose main function is the fabrication

of appliances, should work according to the prescriptions and under the supervision of the fully qualified dentist.

• Dental laboratory technology is both a science and an art. Since each dental patient's needs are different, the duties of a dental laboratory technician are comprehensive and varied.

• Although dental technicians seldom work directly with patients, except under the direction of a licensed dentist, they are valuable members of the dental care team.

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History of dental laboratory technician • In the past the dentist himself undertook on his own

laboratory work. Later due to increased burden of patient, dentists started teaching laboratory work to technician and later retaining him as employer in office.

• Under these conditions the quality of training varied with the ability of the dentists.

• In many countries, like India and US, course for dental laboratory technician is for 2 years while in some country, like United Kingdom it is for 3 to 5 years on part time basis.

• Dental laboratory technician may be employed by – dentists in private or public health practices; they may be – self employed and accept work from dentists in the area or – may be employed by commercial laboratory established by other

dental technicians

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• Functions of the dental technician would include:– The casting of models from impressions of patients’ mouths.– The construction of appliances based on these models from the

dentists prescription.– The treatment of metals and of plastic materials used in construction

of these appliances.– The construction of splints used in faciomaxilliary surgery.– The construction of orthodontic appliances to the dentist prescription.– The keeping of dental stores.

• The expert committee emphasize the dental technician should not take impressions of the mouth and that he should not have contacts with patients.


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Training of the dental technician

• Candidates for training should have a standard of basic education sufficient to support their technical study.

• This basic education should include secondary education.• Training period of the dental

technician• The World Health Organisation Expert Committee considers 3

years of training, desirable. • This should not be less than two years and if possible should

probably be extended over a period of three years.• The course should be followed by a period of practical work in

a laboratory before the trainee receives license.

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• Curriculum• Formal training should include theoretical education and

practical training.• Following elements should be included in the curriculum:

Instructions in basic principal of chemistry and physics that relate to the needs of dental laboratory technicians.

Instruction in the use and care of tools, implements and equipment that are important to the dental laboratory technician.

Instruction in those elementary principals of the biological sciences that will enable dental laboratory technician to understand his functions as an auxiliary to the dentist.

Instruction to those techniques that are used in fabrication of Full dentures. Partial dentures. Ceramics. Porcelain work. Crown and bridge work. Orthodontic appliances. Any other appliances needed by the appliances.

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Instruction and responsibility of dental laboratory technician as a member of the dental health team including information about ethics

Extensive information about dental materials and experience in use of materials in fabricating appliances.

Information about the role that the dentist plays in providing dental health care, so that dental laboratory technician may in turn understand the relation of his responsibility to that of the dentist.

• In countries where it is not at first possible to institute courses of formal nature in institutions, it is recognized that dental laboratory technicians may be trained through the medium of apprenticeships, although this admittedly is not efficient as formal educational programs.

• When apprenticeship methods are used, they should be conducted only by fully qualified dental laboratory technician.

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DENTURIST • Denturist is a tem applied to those dental laboratory

technicians who are permitted to fabricate denture directly for patient without dentist’s prescription

• Dental services were included in the health plan of one of the first systems of health insurance in the world, a system introduced in 1883 in Germany.

• Because of shortage of dental personnel, legislation was passed in 1914 in German Imperial Diet permitting dental laboratory technician to work directly with the public in supplying complete denture.

• But later quality of work declined; hence in March 1952 Federal Republic of Germany enacted legislation confining the practice of dentistry to fully trained and qualified dentists.

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• During same time due to shortage of trained dental technician in Canada, many technicians from Germany moved to Canada and they began working directly with the public.

• They organised a denturist society across Canada and began a legislative battle to gain professional recognition and legal status.

• Denturists in the United States, encouraged by the successes in Canada, began to organize similar efforts in the various state legislations to legalize denturism.

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• First denturist type legislation was filled in Illinois in 1955. In the period 1977-1980, denturism became legal in Maine, Arizona, Oregon and Colorado.

• The arguments over denturism have generated great controversy in many countries where denturism legislation has been introduced.

• DENTURISM has been defined by the American Dental Association as "the unqualified and illegal practice of dentistry".

• (Waterman GE; Effective use of dental assistant; public health report; Vol. 67, No. 4, April 1952; 390-394.)

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• A "denturist," according to the ADA, is "a person who is educationally unqualified and not licensed for the necessary protection of the public, to practice dentistry in any form on the public".

• On the other hand, the National Denturists Association, the organization of U.S. dental laboratory technicians seeking to be licensed independently, describes a denturist as "a highly skilled laboratory technician who has devoted his lifetime to the making of full and partial dentures".

• The divergence in these two definitions reflects the controversy surrounding the concept of denturism and its practice.

• (Flanders RA; The denturism initiative; Public health reports; Sept-Oct 1981; Vol 96, No 5; 410-417.)

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• Denturists are now practising in many developed as well as underdeveloped countries.

• Reason behind denturism in developed countries like United States, – low cost of denture to needy people who are old, – no provision for denture in Medicare; – people think dentists are middle person for giving

denture.

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DENTAL HEALTH EDUCATOR • In few countries duties of some dental surgery assistants

have been extended to allow them to carry out certain preventive procedures.

• In Sweden, two additional weeks of training are given after which the auxiliaries are allowed to conduct fluoride mouth rinsing programmes to groups of children.

• In the United Kingdom, a small group of dental health education officers (who may not be first trained as dental surgery assistant) are employed as number of local authorities and practices to educate in matter of prevention

• In Finland personnel with greatest oral health education (OHE) work load are dental assistant and dental hygienists.

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• They teach modern theories of health education, emphasizing on the factors that strengthen self confidence and the power of the patient to decide for her/himself, rather than merely presenting him/her with information.

• The possibilities and interest of patient are considered to be of primary importance.

• The most important mean of promoting oral health were the model of the parents, encouraging and strengthening self confidence and removing dental anxiety.

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OPERATING AUXILIARY.

• School dental nurse• Dental therapist • Dental hygienist • Expanded function dental ancillaries

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THE NEW ZEALAND SCHOOL DENTAL NURSE

• The New Zealand school dental nurse plan was introduced in 1921• During World War I (1914-1918) extensive dental disease were observed in

army recruits and dentists were in short supply. • Hence in 1921 first training school for dental nurse was opened in

wellington, New Zealand. • This school came into being at the urge of Sir Thomas Hunter, a founder of

the New Zealand dental association and a pioneer in the establishment of a dental school in New Zealand.

• Hunter knew of the success of the dental hygienist in United States and saw in these women means of correcting the deplorable defects he saw in the teeth of New Zealand children.

• In 1923, 29 dental nurses were graduated from the wellington school • The dental nurse is employed only by the government. • The dental service offered to children begins at the age of two and one-half

years. • When child reaches the age of thirteen he is discharged from the services of

dental nurse.

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Functions of School Dental Nurse

• General • Maintaining a specific group of approximately 500 children

in sound dental health and free from dental defects by examining and treating them at six monthly intervals.

• Teaching the principles of oral hygiene, using modern teaching and publicity methods, and gaining the interest and cooperation of the children and their parents in this matter.

• Specific• Examining patients and charting the dental condition• Performing prophylaxis.• Placing fillings in both permanent and deciduous dentition.• Extracting teeth under local anesthesia.• Making topical application of preventive medicaments.

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• Recognizing malocclusion and lesions whose treatment is beyond her scope, and referring them to a dentist.• Carrying out routine examination and treatment of the

children in her group.• Giving special attention to teaching the principles of oral

hygiene and prevention of dental disease not only to individual children but also to school classes, teachers, women’s organization, parent – teacher association and similar bodies.

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• Training of nurse The object of training should be to produce personnel who are capable of

maintaining specific groups of preschool and school children in a state of sound dental health by means of treatment in a restricted field given at regular and frequent intervals (normally every six months) and by instructions in the principles of oral hygiene.

School dental nurse work under the direction and control of dental surgeons.

• Training period of nurses A minimum of two calendar years

• Curriculum of nurses Special instructions in the principle of teaching and public speaking, visual

education, and the preparation of models and posters for health education.

The encouragement to develop confidence and initiative in this field of work

Instruction in the history of dentistry, the history and ethics of nursing, and the role of various organizations that are concerned with the promotion of child health.

Instruction in the use, care and repair of instruments and equipment.

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• Work of dental nurse is supervised by the senior dental officer. One supervising dental officer is allocated to 50 nurses, so nurses function with high degree of independence.

• Percentage of utilization of children’s dentals service is almost 98% of the primary and intermediate school population and 64% of preschool children.

• After many years of steady growth, staffing saturation, reduction in need of restorative treatment due to widespread of fluoridation; the school dental nurse program in New Zealand is now in the process of organisational adjustment

• (Puder EE. THE NEW ZEALAND DENTAL NURSE. American Journal of Public Health.1970 (60); 7:1259)

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• The education of the dental nurse is an intensive two-year post-high school course, during which time she is salaried by government.

• Upon graduation, her status changes from student dental nurse to school dental nurse and she then serves her country in this capacity.

• There are no dental nurses engaged in any area of service other than the School Dental Service.


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SCHOOL DENTAL NURSE PROGRAMS IN OTHER COUNTRIES

• The New Zealand school dental nurse plan has attracted tremendous attention in dental circle all over the world. Many countries has adopted same concept or modified according to local environment.

• New Zealand program is expanded well into Southeast Asia under support of world Health Organisation and Colombo Plan, which includes many countries such as Ceylon, Malaya, North Borno, Thailand, Indonesia, Hong Kong, New Guinea, Ghana, Australia and England.

• Canada imported New Zealand Dental Nurse model since 1971, trained at the community college level.

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• The Dental Nurse name was retained in Manitoba, and in Saskatchewan and other federal regions, – the term Dental Therapist or Saskatchewan dental nurse was used. – Both were trained to provide emergency, preventive and restorative

care to children, but Dental therapists held expanded clinical regimen, also providing emergency care to adults.

• In United Kingdom, the first operating auxiliaries based in the New Zealand school dental nurse model were graduated in 1962.

• They are generally known as ‘New Cross’ auxiliaries because the one training school in located in the New Cross area of south London.


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DENTAL THERAPIST

• These ancillaries, earlier called dental dressers, were employed in the school dental service in parts of Great Britain.

• Their training and employment were opposed by the dental profession and the scheme was abandoned in 1925.

• The scheme was again introduced in 1960 in response to a shortage of dental manpower in the dental services and dental therapists have always been employed almost entirely within these existing services and cannot be employed in the general dental services.

• Dental therapists were formally established as a class of auxiliary dental worker by regulations made in 1963.

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• Dental therapist is more conserved term than dental nurse as they work under direct supervision dentists .

• Level of job satisfaction in dental therapist in developed countries is more than underdeveloped countries because system of remuneration, the characteristics of the working environment, and the type of service in which an individual works all exert an influence upon the individual experience and their working life.

• Dental therapists in Canadian armed forces are permitted to organize and conduct dental inspections and to categorize patterns into priority order.

• To meet the emerging crisis in the workforce, in 1995 an American Dental Association task force recommended a significant expansion of the dental team.

• They considered New Zealand school dental nurse and Canada’s dental therapist model.

• In 2001 few Alaskan students were sent to New Zealand for training. After returning back they were recruited to Community Health Aide (CHA) program as paediatric oral health therapists.

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• Person who is permitted to carry out certain specified preventive and treatment procedures on the prescription of a dentist including the preparation of cavities and restoration of teeth.

• They are like school dental nurse but their role is quite different, they are not permitted to diagnose and plan dental care. They are permitted to work based on the written treatment plan by the dentist.

• The training of therapists is for a period of 2 years including the clinical training.

• They can perform all functions as a school dental nurse, but are not allowed to perform endodontic procedures and interpretation of x-rays.

• In some countries, school dental nurse and dental therapists are allowed to perform only preventive work.

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• DENTAL HYGIENIST

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Dental Hygienist

Dr.Alfred Civilion Fones

Concept in early 20th century

In 1913 Fones Clinic in Bridge port.Worlds first Oral Hygiene School

1917 Irene newman receive first dental hygiene license

FATHER OF DENTAL HYGIENIST

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DUTIES ASSIGNED TO DENTAL HYGIENIST

Scaling and polishing teeth,

Applying fluorides, and other preventive

agents Educating patients to practice sound dental

habits

Diagnostic data collection

Desensitization of teeth after scaling

and polishingRadiographs

Bleaching of teeth

Occlusal splintsSealant placement

Preventive appointments.Photography

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• Dental hygienists are well-educated professionals.

• In late 1970’s, the American Dental Hygiene Association began to support alternative practice methods that would allow the dental hygienist to become the primary provider of preventive services in order to meet the health care needs of the public in accordance with state dental and dental hygiene practice act.

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• Three states of U.S (California,Coloardo and New mexico)

• CALIFORNIA RDHPA • 3years of clinical experience Successful completion of 150 hrs course

oral prophylaxis, root planing, applying pit and fissure sealants, charting and examination of soft tissue under supervision of dentist.

Bachelors degree or its equivalent

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• Colorado has no restrictions on hygiene practice and a dental hygienist may be an owner, but these practices must have an agreement with a dentist to provide direct supervision for local anaesthesia and general supervision for X-rays.

• New Mexico allows dental hygienists to engage in collaborative practice based on written agreement with one or more consulting dentists

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• ROLE OF DENTAL HYGIENIST AS DENTAL HYGIENE PUBLIC HEALTH

• Fales HM (1958) suggested three levels of competence within the groups of dental hygienist working in public health; – the certificate dental hygienist, – the dental hygienist with bachelor’s degree and – the dental hygienists with graduate training in public

health beyond the bachelor’s degree. • (Fales HM.The potential role of the dental hygienist in public health

programs. American Journal of Public Health Dentistry 1958(48);8:1054-7)

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• A certified dental hygienist has two years of technical training in dental hygiene

skills, state board license, and Is with or without experience.

• This classification of dental hygienist is primarily equipped to perform in the service area of the public health program.

• (Fales HM.The potential role of the dental hygienist in public health programs. American Journal of Public Health Dentistry 1958(48);8:1054-7)

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• Degree Dental Hygienist with Graduate Training in Public Health (M.P.H.)

• Dental hygienists in public health positions use a variety of skills in implementing community oral health programs that have positive effect on their communities.

• Most public health jobs require a combination of skills defined in multiple roles.

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Logue S, Geurink KV (2005) has enumerated following possible role that dental hygienist can play in public health.

SERVICE PROVIDERS / CLINICIAN • The public health dental hygienist provides clinical

services to a targeted population, including assessment of oral health conditions and preventive care. • Topical and systemic fluorides, dental sealants, and

fluoride varnishes are preventive therapies to be considered for clinical care in public health setting.

• (http://www.printsasia.co.uk/book/community-oral-health-practice-for-dental-hygienist-kathy-voigt-geurink-1416000968)

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HEALTH EDUCATOR / WELLNESS PROMOTOR

• The community dental health educator must reinforce the relationship of oral health to total health. • Public health dental hygienist can participate in

networking with other health professional such as dentists, physician, dental nurses and public health nutritionists.

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CONSULTANT / RESOURCE PERSON • A resource person or as consultant for dental

information and provide technical assistance at the local, state or federal level.

CONSUMER ADVOCATE / CHANGE AGENT • As a dental professional, the hygienists can be a leader

for the consumer and can be asked to be a vocal advocate for oral health.

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RESEARCHER• As a researcher, a dental hygienist uses scientific

methods and knowledge to identify and purse a specific area of interest. • Dental hygienists employed in the research arena work

in setting that vary from state health department to universities to private industry.

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TRAINING OF DENTAL HYGIENISTDual role an auxiliary to the dentist in private

practice or as a member of public health team• Training period– 2 to 4 years– It is thought that a minimum period of one calendar

year would be appropriate for countries willing to introduce this type of personnel into their health services.

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• Curriculum of Dental hygienist– Basic information on the structure and functions of

human body, with emphasis on oral cavity.– A special study of masticatory apparatus, including

its supporting structures and the macroscopic and microscopic aspects of teeth.

– Basic principles of chemistry and bacteriology to serve as a foundation for the understanding of the causation of dental caries, and a study of its prevention and control.

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Topical application of medicaments

Study of the main chemical substances

Dental health education methods and materials

Oral prophylaxis

Most common diseases of the oral cavity

Brushing technique

Instruction of the patient at the chair

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EXPANDED FUNCTIONS DENTAL AUXILIARIES (EFDA)

• The expanded-function dental auxiliary (EFDA) or expanded-duty dental auxiliary (EDDA) is a more recent development in operating auxiliaries in the United States and Canada.

• In EFDA is a dental assistant or a dental hygienist in some cases, who has received further training in duties related to the direct treatment of patients, though still working under the direct supervision of a dentist

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• Program - 1921 in response to a high incidence of dental disease and the inability of existing dental manpower to provide the needed services.

• In 1960, the American Dental Association advocated careful examination of the values of delegating to expanded functioning personnel those duties which were reversible (i.e., did not include the cutting of soft and hard tissues)

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• Coupled with then perceived dental manpower shortage, this statement led to a review of the educational requirements, productivity and quality of services by expanded duty personnel.

• The personnel could be trained to perform the desired services within considerably shorter periods of training than required for dental practitioners.

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• One such study was done in the Division of Dental Health of the Philadelphia Department of Public Health; they termed them as ‘Dental Technotherapists’.

• The first large scale service application of the expanded duty principle were made in Philadelphia.

They were called “Techno-Therapists”.

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Placement and removal of rubber dam.

Placement and removal of matrices and wedges

Insertion of calcium hydroxide and/or other liners and cement bases

Condensation and carving of amalgam restorations

Finishing and polishing of all restorations

Positioning, exposing, developing and mounting of x-rays

Place silicate and plastic restorations and

Contour stainless steel crowns for full coverage

Take full mouth and partial alginate impressions

The initial duties of the technotherapists consisted of the following:

(Soricelli DA; Implementation of the delivery of dental services by auxiliaries-the Philadelphia experience; AJPH, 1972, Vol.62, No. 8; 1077-1087.)

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• DUTIES UNDERTAKEN BY EXPANDED FUNCTION DENTAL AUXILIRY – Applying topical fluorides– Applying desensitizing agent– Applying pit and fissure sealants– Placing, carving and polishing amalgam restoration– Placing and finishing composite restoration– Placing and removing matrix band– Placing and removing rubber dam– Monitoring nitrous oxide use– Taking impression for study casts– Exposing and developing radiographs– Removing sutures– Removing and replacing ligature wires on orthodontic appliances.

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NEW TYPES OF DENTAL AUXILIARIES

Dental licentiate Dental aides Community dental health coordinator Oral preventive assistant Advanced dental hygiene practitioner

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• NEW TYPES OF DENTAL AUXILIARIES

Some countries have an acute dentist shortage and have no facilities for training dentists.

In 1958, the expert committee auxiliary dental personnel of the World Health Organisation suggest two new types of dental auxiliary for such situations;Dental licentiateDental aide

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• To address oral health care workforce concerns, several efforts are under way that would expand the workforce by incorporating new models of care as

• Community dental health co-ordinator• Oral preventive assistant• Advanced dental hygiene practitioner

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DENTAL LICENTIATE

• Dental licentiate is the semi independent operator trained for 2 years to perform.

• Duties undertaken by dental licentiate,– Oral prophylaxis.– Cavity preparation and filling of primary and

permanent teeth.– Extraction under local anaesthesia.– Draining of dental abscesses.– Treatment of most prevalent diseases of supporting

tissues of the teeth.– Early recognition of more serious dental conditions.

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DENTAL AIDE • They perform duties which include, elementary

first aid procedures for the relief of pain, including– Extraction of teeth under local anaesthesia,– Control of haemorrhage, and– Recognition of dental disease important enough to

justify transportation of the patent to a centre where proper dental care is available.

• The formal training extends from 4-6 months, followed by a period of field training under direct and constant supervision.

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COMMUNITY DENTAL HEALTH CO-ORDINATOR:

• To be recruited from within their own distinct communities, Community Dental Health Coordinators (CDHCs) will help the underserved within the community to navigate the health care delivery system, breaking down barriers to care and serving as patient advocates, facilitators and motivators.

• Work under a dentist’s supervision in health and community settings such as schools and senior citizen centres, Head Start programs and other public health settings.

• Trained to promote oral health and to provide the most basic preventive services

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• They will not diagnose disease, nor will they perform any irreversible procedures.

• Developed in two phases. Phase 1- development of an 18-month training

program has been completed. Phase 2- involves pilot training programs at three

sites: one Native American, one urban and one rural.

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ORAL PREVENTIVE ASSISTANT

Oral Preventive Assistant (OPA) workforce model is designed to foster an expanded preventive capability within the dental team by providing certain basic preventive services and freeing dentists and dental hygienists to concentrate on patients with more complex needs.

• OPAs will provide patients with oral health education and information —– Coronal polishing for all patients and – Scaling for patients with plaque-induced gingivitis -

contingent on state regulations.

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ADVANCED DENTAL HYGIENE PRACTITIONER • In November 2004, (ADHA) designed model with

intention to provide primary oral health care services to patients who are medically compromised, children, adolescents and geriatric populations. – They termed them as Advanced Dental Hygiene Practitioners

(ADHP). – The ADHPs would practice in a variety of settings such as rural

clinics and other institutions where they will provide basic oral health care to underserved and unserved populations.

• It is intended that the ADHP will be one of the comprehensive health care team members who will identify and make appropriate referrals for those in need of more comprehensive dental services

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• The scope of practice includes but is not limited to the following:– Health education, counselling, and health promotion; – Diagnosis, treatment, and referral of oral diseases and conditions within

a multidisciplinary care team; – Cavity preparation; – Pulpotomies; – Extractions; – Palliative therapy; – Atraumatic restorative therapy; – Pain management strategies; – Nutritional interventions; – Prescription writing for select medications; – Evaluation of health promotion and disease preven tion programs for

specific populations; – Case management; and – Consultation/collaboratation with other health professionals

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The Evolutionary Process Of Dental Health Services

• Type of personnel involved directly or indirectly in rendering dental services can be classified into three groups according to the level of their training– Professional personnel (qualified practitioners and

dental specialists)– Subsidiary, or sub-professional, personnel (auxiliary

personnel)– Non-professional (unqualified practitioner,

indigenous practitioner)

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• Five evolutionary stages are identified in the field of dental health care.

• Stage I - Undifferentiated occupation• Diseases of teeth are usually abandoned to their own

courses. Toothaches and infections are treated with folk medicines. With the development of public health physicians, nurses, priest and nuns working in isolated villages may have dental forceps and anesthetics to extract teeth in emergency cases.

• Stage II - Differentiated occupation• Some individuals are entirely devoted to practice of

dentistry (indigenous practitioners) without any type of formal training or qualifications. The necessary skills are required under an apprenticeship system.

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• Stage III - Initial professionalism• Formal training with a duration of one to two years are

organized by dental practitioners, who are united as a group or a guild• Before admission to the profession, candidates have to

meet requirements imposed by guild • The group of persons practicing dentistry takes on a

formal character and a dental profession comes into being.

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• Stage IV– Intermediate professionalism• Independent dental schools are established at the

university level• Dental courses are increased in length(3 – 6 Years)• The minimum requirement for admission is complete

secondary education.• Weaknesses in the law or in its enforcement may still

permit unqualified person to practice.• The utilization of certain types of auxiliary personnel

such as chair side assistance and laboratory technician, becomes firmly established.• Courses of training and regulation are established by the

profession for its auxiliary.

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• Stage V– Advanced professionalism• Dentistry acquires full recognition as a health

profession• Dental education becomes more balanced, with an

increasing emphasiz laid on the biological sciences.• Post graduate dental education is developed and the

number of dental specialities increases.• Dentistry becomes strongly organized and

institutionalized.• Dental practice by unqualified personnel disappears.

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BENEFITS OF AUXILIARIES• With rapid population growth and increasing

demand for dental care, more and more dentists are required. But this is an expensive process

• Hence training an auxiliary is more economical, less time consuming and fewer burdens to society

• Results in definite benefits to dentists, patients, auxiliaries and to whole community, financially, psychologically .

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I IMPACT ON INDIAN SCENARIO

• There exists a serious maldistribution of the dental professionals with nearly 75% dentists practicing in urban areas catering to 25% population.

• Unfortunately, only auxiliary personnel who exist in India are dental surgery assistant, laboratory technician, dental hygienists and ethically.

• They have to undergo a training of 2 years in institutions which have been recognized by Ministry of Health; Government of India and certificate course recognized by the Dental Council of India.

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• The most suitable types for Indian set-up will be school going dental nurse and EFDA

• They can play a major role not only in providing basic dental care but also in prevention of dental diseases both for children and general underprivileged population

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International Dental Journal, April, 2014. 10.1111/idj.12063Dental manpower planning in India: current scenario and future projections for the year 2020

Sudhakar Vundavalli

• The output of qualified dentists has increased substantially over last decade and at present there are over 117,825 dentists working in India. Although India has a dentist to population ratio of 1:10,271, the newly graduating dentists find it difficult to survive in the private sector.

• At present less than approximately 5% graduated dentists are working in the Government sector.

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• If the present situation continues there will be more than one lakh dentists over supply by the year 2020.

• Continuation of the current situation will lead to wastage of highly trained dental manpower and create a threat to the professional integrity of the dentists.

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Demographics & Current Scenario withRespect to Dentists, Dental Institutions

& Dental Practices in India. N. K Ahuja. Renu Parmar

Indian Journal of Dental Sciences.2011 ;2:3

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Utilization of dental care: An Indian outlook Gambhir RS, Brar P, Singh G, Sofat A, Kakar H.J Nat Sci Biol Med. 2013 Jul-Dec; 4(2): 292–297.

Various factors influencing utilization of dental services

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Vashisth S, Gupta N, Bansal M, Rao NC. Utilization of services rendered in dental outreach programs in rural areas of Haryana.

Contemp Clin Dent. 2012;3:164–6.

• A retrospective study was conducted to evaluate the type of patients, disease pattern, and services rendered in dental outreach programs in rural areas of Haryana, India.

• A total of 1371 individuals attended the outreach program seeking the treatment.

• Results - indicated that utilization of dental services was found to be more in females than in males.

• The utilization of dental services was found to be influenced by the socio-demographic characteristics of the population like age, education, occupation, etc.,

• Conclusion: That there was need to motivate people giving them information but paying attention to the individual reasons which restricted their behavior.

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Goel P, Singh K, Kaur A, Verma M. Oral healthcare for elderly: Identifying the needs and feasible strategies for

service provision. Indian J Dent Res. 2006;17:11–21

• A three-phase survey was conducted in Delhi in 2003 by Maulana Azad Dental College and Hospital and supported by the Government of India WHO Collaborative Program.

• Objective = To identify the oral health practices and patterns of utilization of dental services, to assess oral health status and treatment needs of the elderly population

• To test alternate strategies for controlling oral health problems among the elderly.

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• The rural areas of Delhi were included. Most of the subjects (80%) reported availability of dental services in their area, of which a major proportion was being provided by the private sector.

• One-fifth of the subjects - dental problems • 60% of these visited a dentist to avail dental care.• Reasons given by the subjects as barriers to

accessing oral health care were related to lack of priority for oral health (attitudes) and their dependent status (non-ambulatory/disabled elderly).

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CONCLUSION

• The practice of dentistry involves a personal relationship between the dentists, dental auxiliaries and the patients.

• Both dentist and auxiliary personnel try to emphasize health education, to correct misconceptions and to attack apathy about dental health.

• Because of their unique privileges granted to them, the members of the dental profession have the responsibility of providing a high standard of service to their patients and they should assume their duties freely and voluntarily.

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REFERENCES• Puder EE. The New Zealand Dental Nurse. AJPH. Vol 60 (7).

1970. 1259-63.• Tandon S. Challenges to oral health workforce in India.

Journal of Dental Education. Supplement 7. 2005. • Slack GL. • Jong AK. Community Dental Health.• Peter S. Essentials of Preventive and Community Dentistry• Hiremath SS. Textbook of Preventive and Community

Dentistry

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• Fales MH; The potential role of the dental hygienist in public health programs; AJPH; august 1958; Vol. 48, No. 8, 1054-1058

• Parkash H. Dental Workforce Issues: A Global Concern. Journal of Dental Education 2006,70;11, 22-16

• World Health Organization: Recent advances in oral health. In Technical Report Series-826. World Health Organization; 1992:1-37.

• India Ministry of Health and Family Welfare and Dental Council of India. Status of dental colleges for admission to BDS course. At: http://mohfw.nic.in/Adental.html.

• Auxiliary Dental Personnel. World health Organization. Technical report series. No. 163.

• Waterman GE; Effective use of dental assistant; public health report; Vol. 67, No. 4, April 1952; 390-394

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