The Five Pillars: Why Beyond?

Someone asked why dental hygienists and dental therapists have relatively complex procedures, such as paediatric tooth extractions, in their job descriptions. The scope creep hype has every health specialist on edge. Evidence points to dentists as one of the professions that should be least worried about being scope creeped. 

To start at the beginning, the reason behind the establishment of "para-dental" specialties like dental therapy and hygiene must be examined. Dentistry has always been vastly understaffed. The United States of America has a dentist-patient ratio of about 1 dentist to roughly 1500 to 1600 patients (and the ideal ratio is around this value). That being said, data also shows that rural areas of the United States have a greater burden, with 1 dentist serving over 3000 patients. Considering that only about 45 to 69 percent of Americans ever go to the dentist, with only about 50 percent of the population meeting the biennial dental visit recommendation, the prognosis is scary for an imaginary nation of idealized, dental health-conscious patients. 

In 1906, in the United States of America, Dr. Fones trained his cousin and assistant, Irene Newman to clean and polish teeth. Irene was later licensed by the U.S after the program showed great success with Dr. Fones and Irene Newman training increasing numbers of people, stalling dental decay in children, and thought to have played a large role in the reduced mortality rates recorded in Bridgeport, Connecticut during the 1918 Influenza virus pandemic. Ms. Irene Newman was the first dental hygienist. Dental Therapy, on the other hand, was established in 1920. Rejection rates of young men and women enlisting in the New Zealand army for the World War I effort were high, and a primary cause was rampant dental disease. The dentist-to-patient ratio was a staggering 100 to 1.2 million patients. Dental therapist training started at this point. With shorter training times and lower admission standards as opposed to dental schooling, dental therapists, formerly known as dental nurses, treated children up to the age of 12, with care beyond age 12 handled by trained dentists. As of the 1970s, permanent tooth loss had been nearly eliminated (pre-fluoridation of water supply lines) with over 95% of school children enrolled in the dental care program.

The idea was simply to reduce the burden. Evolution in knowledge regarding dental diseases shows that a large part of the dental disease burden is preventable by education of the populace and certain minor procedures, such as scaling and polishing or routine extraction of impacted teeth. These minor procedures and community education are the job roles prescribed for dental therapists and dental hygienists. In Nigeria, the worry would have been regarding the scope creep of dentists into the job roles of hygienists and therapists, except that patients rarely present at the early stages when therapists and hygienists can be helpful. The question may arise as to whether these wartime jury-rigging structures are still needed. Dentists can perform with ease the work of either profession. Dentist immigrants seeking employment in the UK are authorized to work without additional education (after individual assessment by the General Dental Council) as dental therapists pending their exams. The only pathway previously available for foreign-trained dentists awaiting ORE certification was to work as a dental nurse.

Yet, in parts of Africa, the need for dental education and early-stage intervention is too great. Africa presents one of the largest burdens worldwide for dental diseases, with quite a few of these diseases occurring due to untrained interventions. Noma, or cancrum Oris, a necrotizing disease of the Orofacial region is still being managed in Northern Nigeria and other parts of sub-Saharan Africa. This disease occurs when dental disease progressively worsens to a point where certain bacteria begin to slowly digest tissues of the oral cavity, starting from the gums and periodontium, through the connective tissues and bones, to the skin. It is life-threatening and affects children very commonly, leaving them disfigured for life in the best-case scenarios. This disease would be otherwise impossible to find in a system of care where dental diseases could be intercepted earlier. Ebinyo, also known as canine extirpation or infantile oral mutilation, is a practice that persists in many countries in Eastern Africa and is spreading with African immigrants to the United States, Australia, and other similar countries. The practice involves the use of objects such as bicycle spokes, nails, and hot knives to gouge out unerupted canines. It is usually done by traditional healers in these countries to treat fevers and diarrhea.

This is an excerpt of a paper published in the year 2000 regarding Ebinyo: "The history in all 3 of the children indicated that traditional healers in Somalia had treated them when they were infants for the prevention or treatment of diarrhea. Patient 1's gums were cut into and the lower cuspids(the pointed teeth lateral to the 4 incisors) were extracted to prevent diarrhea. Patient 2 had a hot nail pressed into his gums in the area of the lower cuspids as treatment of an episode of gastroenteritis. The mother of both of these children also had an absence of her permanent lower cuspids. Patient 3's mother reported that when he was between 4 and 6 months of age, a traditional healer made cuts in the area of the child's lower cuspids and removed gum tissue to prevent diarrhea. A Panorex film revealed the absence of the right lower cuspid and the presence of a radiopaque mass, consistent with odontoma in that site. A deformed and impacted left lower cuspid with associated radiopaque structures was identified in the left mandible. An exploration was done and a biopsy specimen was taken of these structures. Biopsy findings were consistent with an odontoma (a benign tumor) in the mandible at the expected site of the deformed permanent cuspid tooth bud on the right side. On the left side, an impacted and deformed permanent cuspid developed. Oral surgeons speculated that the odontoma formed as a result of the disruption of the dental tissues resulting from the traditional treatment. Both mothers reported that this was a common procedure in some regions of Somalia."

The greatest concerns regarding scope creep should not be within the clinic walls but without. Teeth whitening procedures at spas with all the training of a short online course by non-certified professionals, extraction of teeth by unsanitary and unhygienic means, increased rates of tooth loss from every Tom, Dick, and Tolu choosing to wait out the chronic jaw pain that worsens after waking up. If the future of Africa has anything to do with Africa's dental health, things are not looking good. The WHO reported a 3.3 dentists per 100,000 patients ratio between the years 2014 and 2019, and a 257 million disease cases increase over the last 30 years between 2023 and 1993. If anything, dentists may be slowly going extinct, as dental hygienist and therapist ratios to dentist ratios are slowly increasing in wide swathes. 

For all the in-house concerns among doctors, dentists are disproportionately affected. Still, the five pillars are holding up a humble bungalow that currently accommodates many mammoths. If the state of things will improve at all, drastic changes to patient care mechanics must be made. The five pillars and beyond, are in no danger of melding into indistinct portions. The danger is found in the possibility of melting away the patient populace into the soup of antibiotic-resistant bacteria and quackery that the world around us is becoming. The structures of dentistry, must stand strong in this period.

Fun fact

Dental hygienists were actually required to be females for over forty years after the establishment. The first male dental hygienist, Jack Orio, graduated from the 2-year dental hygiene course in 1965.

Salami Wisdom