A cure for teething problems

Dentist training has not kept pace with the improvement in people's teeth. Aubrey Sheiham argues for radical change. Dental caries have decreased dramatically in most industrialised countries in the past two decades, as has periodontal disease.

Dental care has played but a minor role in these improvements. A few simple measures such as using fluoridated toothpaste or changing diet habits have shown that caries are preventable, while improving oral cleanliness and cutting down smoking can cut the rate of periodontal diseases.

The sharp fall in the prevalence of these two major dental diseases calls for a radical revision of the dental curriculum. But there are other reasons for change. These include: public expectations and demands; changing concepts of health and disease; health promotion; the politics of professionalism; competition from other dental and health workers; new techniques and materials; demography, such as the greying of the population; and changes in welfare/health services organisation.

No other profession has seen such a profound change in its work in such a short time. Nevertheless, dental education has remained virtually unchanged and there has been remarkably little discussion of future trends.

Dentists require different skills and many trained in the conventional manner are now ill suited for the challenges of today. They are overtrained for low-technology work and undertrained for the more advanced procedures.

A committee of inquiry into unnecessary dental treatment concluded that clinging to the outdated approaches and techniques creates a further problem. That is idiosyncratic decision-making and inappropriate treatment, often not based on scientific evidence.

A greater commitment to prevention, improved diagnosis and a more selective approach to treatment will mean fewer fillings. When required, restorations of high quality should continue. If dentists do less restorative work they will have more time for communication and prevention.

Dental education should reflect dentists' new role in diagnosing oral and dental diseases, treatment planning, providing high quality complex dental care, administration of a dental team who will carry out the majority of investigations, simple procedures and oral health education.

The dentist will influence the behaviour of patients and food and drink manufacturers and advise patients about risks to dental health and investigate and control the risks. In the expanded role dentists will use their intellectual and therapeutic skills and not become burnt-out doing repetitive unfulfilling simple procedures.

Dental educators have not taken advantage of the marked improvement in dental health to change dental education. Most changes have been minor. Training is still dominated by the large departments of conservative/restorative and prosthetic dentistry which are reluctant to reduce teaching time and staff to reallocate resources to departments of oral diagnosis, treatment planning and general dental practice and dental public health. Only a few schools are teaching clinical decision-making or evidence-based dentistry. Managed dental care teaching is being introduced.

The most encouraging changes have been the expansion of teaching sociology, psychology and communication skills and dental public health. This followed changes in medical education and the lengthening of dental courses to five years.

Dental practice placement schemes have given dental students important insights into dental practice and helped to bridge the gap between dental school and practice. Oral medicine has become an increasingly important discipline. Health care will increasingly involve shared record systems with doctors, pharmacists and other primary care professionals.

Telemedicine, being tried in Northern Ireland to assist dental practitioners to diagnose oral conditions, is likely to become standard practice.

Other much-needed changes are a marked reduction in training to do simple techniques, more emphasis on evidence-based dentistry, clinical decision-making and treatment planning.

Dental undergraduate training must be closely coordinated with vocational and continuing education. Therefore it is essential to expand training in general dental practice. Students should gain more skills in the advanced techniques they will do in practice as well as skills in communication.

Reducing the numbers of dentists will allow them to use their skills more appropriately to carry out complex procedures and to supervise a primary oral health team. The rapid improvement in dental health should allow a dental practitioner to attend to many more patients.

There is an oversupply of dentists. That is why three dental schools have closed in the United Kingdom and student numbers have dropped by 10 per cent to 800 a year. With fewer caries the World Health Organisation estimates that half the current numbers of dentists would be needed by the year 2000 if dentists used no auxiliaries.

The Nuffield Foundation report on training auxiliaries calls for a further reduction in dental student intakes arguing that each dentist should have a team with two auxiliaries who can do 65 per cent of dentists' current tasks. Spare capacity in dental schools can be filled by dentists requiring retraining and dental auxiliaries.

Both Sir David Mason and Margaret Seward, the past and current presidents of the General Dental Council, have expressed concern about the reluctance to change curricula. The GDC, the higher education funding councils and the Department of Health should lobby to get dental schools to change their curriculum and the types and numbers of students.

Aubrey Sheiham is professor of dental public health at University College London medical school.