By Professor Julie Satur
The Development of the Profession
Dental therapists operate in a primary care role, carrying out low to medium technology oral health care and health promotion, referring patients to dentists (or other health care providers) for services which are beyond their skills. Their skills include examination, diagnosis and treatment planning, radiology, preparation of cavities and their restoration with amalgam, cements and plastic filling materials, pulp therapies and extractions of deciduous teeth, clinical preventive services such as prophylaxis and scaling, fissure sealants and fluoride therapies, diet counselling and oral health education and promotion. Up until July 2000, dental therapists in most states of Australia were limited to public sector employment with School Dental Services providing care to children and adolescents under the ‘general supervision of a dentist1’ and with the assistance of a dental nurse....
In practice, a dentist will attend, for example, a Victorian dental therapist’s clinic weekly or fortnightly for half a day to attend to referral patients, mostly comprising orthodontic referrals, higher complexity restorations such as fractured incisors or endodontia and permanent extractions. In some of the less populous areas, these visits are less frequent, for example in the Northern Territory, dental therapists may work in isolated communities visited quite infrequently by a dentist but would have access to a dentist for consultation by telephone (Weir 2002). The relationship between a dental therapist and a dentist is a collaborative and referral relationship where both form part of a team providing optimal oral health care. The overwhelming majority of dental care for children in Australia is provided by dental therapists (Dooland, 1992).
Only in Western Australia have dental therapists been permitted to practice in the private sector where, since 1973 they have been providing services under the prescription of dentist to patients of all ages. Since the dental legislation reviews, conducted under the auspices of the National Competition Policy in 1998-2004, Victoria, Tasmania, South Australia, Queensland and the Northern Territory have passed legislation removing the restrictions on employment of dental therapists. New South Wales has been the only state to retain the public sector restrictions and the Australian Capital Territory is yet to complete its review. In most states dental therapists now work in private general dental practices, pediatric and orthodontic specialty practices, preschool and community health programs and hospital clinics although the majority still work in school dental programs as they always have. The origin of dental therapy has been variously attributed to both Great Britain and New Zealand in the early years of the 20th century. The following section describes the early years of dental therapy’s development in New Zealand and its progression to Australia (Satur 2003).
1 This was a regulatory requirement; dental legislation in most states required that dental therapists work in a relationship with a dentist variously described as ‘under direction/ prescription/supervision/control of a dentist’.
The Development of Dental Therapy
In 1913, the then President of the New Zealand Dental Association, Dr Norman K Cox proposed a system of school clinics operated by the state and staffed by ‘oral hygienists’ to address the dental needs of children between the ages of 6 and 14 years. At the time the idea was considered too unorthodox but in 1920, at a special meeting of the New Zealand Dental Association, 16 members voted for the adoption of school dental nurses with 7 opposed to the proposal....
School dental nurses were to provide diagnostic and restorative services to children ‘…in a rigidly structured set of methods and procedures which spare her the anxiety of making choices”. Leslie (1971) reports that organised opposition was considerable on the grounds that the employment of dental nurses posed: ‘ …a menace to the public, (a) menace to the (dental) profession and an injustice to those seeking to enter the ranks of the (dental) profession by recognized avenues…’(Leslie 1971).
Despite the opposition, the New Zealand School Dental Nurse was born, trained initially in a school in Wellington run by the health department. After the second world war training schools were also established in Auckland and Christchurch producing by 1990, around 900 dental therapists and a 95% participation rate by New Zealand’s school children (Tane 2002, Hannah 1998). Dental therapists in New Zealand work in mobile units and clinics attached to schools, providing diagnostic, preventive and treatment services and referring treatment beyond their skills to local dentists. Supervision was provided at a rate of around 1dentist to 50 therapists with the purpose of ensuring therapists did not work beyond their skills and updated their practices (Leslie 1971).
This model of service delivery demonstrated considerable success and was the target of inquiry by many other countries around the world. In Great Britain, during the first world war, ‘dental dressers’ were used to carry out examinations and treatment for children in parts of England. Their role however, was eliminated by the Dentists Act of 1921 because of hostility to the role on the part of the dentist profession. They were later re-introduced, on the strength of the New Zealand scheme, as dental therapists when the high dental needs of children were ‘rediscovered’ in the 1960s 2, carrying out similar services but under the prescription of a dentist who carried out the examination and care plan (Larkin 1980, Nuffield 1993). School dental services based on dental therapists were also established in other countries including Canada, South Africa, the Netherlands (temporarily), Fiji, Hong Kong, Malaysia and the Philippines and in 2000, 28 countries around the world utilised dental therapists (FDI 2001). In some of those countries, including New Zealand and Canada, dental therapists also provide their services to adults (ref).
2 In 1957, under instructions from the Privy Council, ‘…the British Dental Association was forced to witness the resurrection of an occupation which it had previously eliminated…’ Larkin 1980
The Development of Dental Therapy in Australia
As early as 1919, a Melbourne dentist advocated a state dental service which would primarily have educational and other preventive functions. He drew on the concept of the British system of ‘dental dressers’ for a new Victorian ‘oral hygienist’ who would provide much of the care under the supervision of a dentist (Robertson 1989). In 1923, in order to make recommendations to the Victorian Cabinet for the extension of dental treatment for children, the Acting Director of Education for the State of Victoria wrote to the Principal Dental Officer for New Zealand’s School Dental Service expressing interest in the scheme to train young women as dental assistants for work in schools. Clearly, concern for child oral health was significant, but the threat of the development of another layer of practitioner, when the university educated dentists were ‘…fending off the demands (for registration and practice) by recorded men, twilighters and (dental) mechanics…’ was too great for the establishing Victorian dentist profession (Robertson 1989)....
The need to improve the dental health of children remained of great concern and a ‘factfinding mission’ was established to look into the New Zealand Scheme in 946 (Robertson 1989, Gardner 1992). But it was not until the 1950s and 60s that the National Health and Medical Research Council’s (NHMRC) Dental Health Committee made recommendation that any instrumentality responsible for the dental care of Australian children ‘…should now give consideration to the utilization of dental auxiliary personnel in the form of the school dental nurse...’ (NHMRC 1965). The NHMRC noted the success of such schemes in other countries and in particular, the 98% participation rate and social acceptance attached to the New Zealand Scheme and also, the reluctance of the dental profession to support the concept of operative dental auxiliaries in Australia. It made recommendations that demanded systematic and regularised non-university training3 , the complementary (rather than substitute) nature of dental auxiliary practice, the need to define the range of skills they could practice and the need for direction and control of their services by a registered dentist. It stressed the need for administration by a dentist of such services and for each state to train sufficient auxiliaries for their own needs to engender allegiance in its staff and to reduce the demands for reciprocity and the risks of competitive salaries and other ‘undesirable developments’. Courses of training should be as short as possible in order to maintain the cost- effectiveness of the auxiliary while ensuring competence. It also suggested that such school dental nurses should be female and have their employment restricted to the government service (NHMRC 1965).
As a consequence, Tasmania and South Australia established dental therapy schools to train dental therapists for their state’s dental programs in 1966 and 1967 respectively (Dunning 1972, Gussy 2001). When the Whitlam government offered conditional block grants to expand the School Dental Scheme in 1973 to encourage the development of auxiliary based school dental programs, all of the other states took up the extra funding with NSW, Qld, WA establishing schools in 1974 and Victoria in 1976. Many states also provided bursary schemes for young Australian women to train in New Zealand and return to work in Australia in the establishment years. All Australian courses required the completion of secondary school (university entrance level) prior to admission and in 1979 were graduating a combined total of around 280, all female students (Commonwealth Department of Health, 1979).
Western Australia, which began training dental therapists in 1971, was unique in using the tertiary sector for training and allowing their dental therapists to work in private and public practice, and today is the only state allowing them to provide treatment under prescription, to adults. Their school dental service however operates like those of the other states with dental therapists providing examinations (radiography, diagnosis and treatment planning) and dental treatment including fillings, extraction of deciduous teeth, local anaesthesia, preventive services and health promotion to school aged children under the off-site general supervision of a dentist.
3 The NHMRC (1965) noted several times in its report that auxiliary personnel should be trained in an appropriate government instrumentality- ‘…that this is not a matter for the University Dental schools’.
Dental Therapists Practicing in Australia Today
The National Registration and Accreditation Scheme requires that information about every registered health practitioner in Australia is published on a single national register of practitioners. For the first time, it is possible to produce accurate reports on the number of practitioners registered in each profession in Australia...