Quest for Denturism

1.1 Development and formal education:
By the time dentistry classes were introduced into university studies, a more formal separation was created between those who, for the greater part, extracted teeth (dentist/dental surgeon) and those who specialized in the construction and fitting of dentures (dental technician/denturist). Throughout the 19th and early 20th century, Dental Technicians continued to work in the mouth, while Dentists mounted an increasingly strong lobby to influence regulations related to the delivery of dental health care services. They succeeded to persuade legislators to limit work in the mouth to themselves. When Dental Technicians working in laboratories, were asked for their opinions, their sub-contracting dependence on the Dentist largely shaped their responses. Technicians who had continued to work with patients were not consulted, and legislation that continues until today, defines the scope of practice for the two professions.

1.2 Creating a monopoly:
As dentistry developed from the era of the tooth puller and the charlatan and became a learned profession, the right to make dentures were also added to their domain. This international phenomenon was established by customary practice and not by logical association. It was a well earning procedure and was soon monopolized, and any denture-maker who did not have the school training to qualify as a Dentist, prosecuted for a crime. The skills passed on from one denture-maker to another were suddenly not recognized anymore and deplorable health-scare tactics were used to discourage their practice under the false excuse of causing cancer to the mouth. The quest for clinical rights for Dental Technicians dates back to a time before Dentists or Dental Mechanicians were recognized by law and even before the first Dental School were established in South Africa.

Greater numbers and economic power of Dentists always made for an unequal contest to lobby for justice. Furthermore, Dental Technicians are solely dependent on Dentists for their income and as a result, few could afford to publicly state their objectives without facing a boycott by their clients that would result in a closedown of their laboratory. The option of earning income solely from what was then suddenly deemed to be illegal practice, was never a popular prospect amongst decent hard-working Dental Technicians. By monopolizing the provision of dentures for themselves, Dentists made the practice of Denturism a felony and as a result the provider of dentures by a non-dentist, was unjustly turned into a law-breaking criminal.

Instead of making Prosthetic Dentistry another speciality field, technical work was separated from the clinical procedures. Dentists conducted only clinical procedures as a go-between. As the manufacturing process has always been time consuming, it became profitable to hire "back room boys", who worked under deplorable circumstances, as the vulcanising process was most unpleasant. They were underpaid, with no security or paid vacations. Dental Technicians were used as scapegoats for whatever went wrong during the clinical process. For many decades Dental Technicians had been abused as cheap labour. The great depression and the 2nd World War created a harsh economic environment. The SADA proposed a deal with the Dental Mechanicians (name for dental workers by combining mechanic and technician) to guarantee them a charter, in trade for giving up the right to serve the public directly. The deal were to guarantee a pension fund, a fixed tariff of fees and minimum wages to employees. Organised Dentistry already breached this charter before it could be implemented, when they obstructed the introduction of a Pension Fund for Dental Mechanicians in 1951.

1.3 Attempts to reintroduce the original denture-maker:
In 1943 an international dental magazine published the plea by an esteemed South African dental specialist for the establishment of a specialist category of clinical denture technician. His views then, still encapsulate today, what Denturism essentially is. Since the 1950’s Denturism re-emerged as a gradually globalizing prosthetic speciality, developing as a natural career path from Dental Technology. Going back to its original discipline, by joining the technical and clinical procedures, to supply dentures directly to the denture wearer!

In 1945 the Minister of Health and Demobilization chose to ignore the Prosthetic Dentist’s Bill that was proposed by the Dental Mechanicians of South Africa. Despite the exposure of underhand tactics, the Dental Mechanicians Act, promoted and steamrollered by the Dental Association, was implemented. The sole monopoly for Dentists to sell dentures made by someone-else, was created, purely to assure a higher income for the dental profession in order to lure more dental students into the profession and by doing so, create the workforce that would serve the public oral health interest. That was the motivation used in Parliament, as justification for creating the monopoly for Dentists. The Dental Association, who spearheaded the Dentist’s Mechanicians Bill (the possessive form) through Parliament, used reprehensible cancer scare tactics and numerous false statements to secure support for an unjustifiable delusion.

1.4 The Consequences of an unjustified Monopoly:
70 years later, there can be little doubt that this experiment had been a failure from the start. It immediately put many Dental Technicians out of work and forced the profession of Dental Technicians into a subservient role. It was also responsible for unwarranted friction and mistrust between Dentists and Dental Technicians ever since. Parliament called on Dental Technicians to make this sacrifice in the interest of public health. One can justly ask what affect this monopoly had on the oral health of the public at large. Many views expressed, have indicated unacceptable standards and quality of public oral health. The white woman of SA older than 65, who have had access to the best dental services in the country, have an unacceptably high level of Edentulism, almost twice as high as the males of the same group, due to their dutiful regular visits to the Dentist. The creation of financial incentives in the private sector have detracted from the ultimate goal of health for all, and instead have created freedom for practitioners to abuse and mismanage their patient’s health and medical schemes. The good reputation of dentistry has been tarnished by the fraudulent practices commonly and arrogantly referred to as creative billing, padding of accounts, and tarriffmanship. Access to basic oral health services has been woefully inadequate and unaffordable to the majority of the population. Some private Dentists delegate their clinical responsibilities as a go-between in the provision of dentures, to unregistered dental assistants who had no formal training. This practice frustrates dental technicians, who have to absorb the cost of preventable wasted materials and time, resulting from increased levels of remakes. In short, the experiment has failed, and the continued existence of the monopoly needs to be challenged.

1.5 Attempts to restore common sense:
In 1989 the Preliminary Report on Denturism was tabled with the Competitions Board. At the time the response from the Competitions Board seemed promising as there were well-established free market principles entrenched in the local economy. However, when Mr Nelson Mandela was released from his incarceration, and he spoke of the transformation to a socialistic economy, all free market ambitions were put on hold.

As a result of a motivational report called “Denturism, A New Profession” to the Director-General of the then Department of National Health and Population Development in 1992, the Denturism Committee was instituted by the SA Dental Technicians Council (SADTC), in terms of the Dental Technicians Act, and all stakeholders invited to participate in the workshops. The majority of the stakeholders co-opted to serve on the committee were enthusiastic and positive about Denturism. However a dispute was declared by the DASA representative on the validity of empirical evidence of denture needs and related data. The Committee recommended to the SADTC to wait for the findings of Dr Hartshorne’s research on the topic in the Western Cape, (before a final decision to implement the new category be made) as it was going to provide all the outstanding information. By 1995 Dr Hartshorne left the University for private-practice and no commitment could be given if his research results would be completed. A new study group of dental technicians then took it upon themselves to research and draft a document to assist decision-makers with relevant information to consider the introduction of a new oral health care category of Denturist.

1.6 Political intervention:
In 1994 the results of the National Oral Health Survey conducted in 1988-89 was published. The statistical data indicated and the summary concluded that the possibility of introducing Denturism could no longer be ignored. In 1997 the Dental Technicians Act was amended and a definition for a Clinical Dental Technologist (Denturist) added on the initiative of the Oral Health adviser of the Minister of Health. Although the principal decision is correct, the definition was not an agreed measure. Unfortunately, due to specialist stakeholders not being consulted, the formulation did not keep tread with global trends and practices, and a fundamentally flawed definition and unrealistically limited scope of practice resulted. The suggested Scope of Practice was outdated and did not take international benchmarks into account. The provision that the category had to be registered by another Regulator (the HPCSA) where the monopoly holder is already regulated and under jurisdiction of another Act, proved to be an undefeatable obstacle. 

1.7 Conflicting Reports:
In 1998 The Society for Clinical Dental Technology was inaugurated and their report: “Clinical Dental Technology: A Quest for Equity in Oral Health Care” was tabled, requesting an open debate with all stakeholders. Copies of the report were sent to the Minister of Health and to all members of the Dental Technicians Council (SADTC), who held two workshops to gather opinions and information from the stakeholders. During the ensuing workshops the SADA delegations quoted from Dr Hartshorne’s report, although his findings was only made available when a report was published in the South African Dental Journal of September 2001. He was awarded with a PhD by Stellenbosch University for his philosophy to upgrade untrained quacks to supply dentures, rather than supporting Dental Technicians to undergo clinical training to become Denturists. Both reports were considered as subjective by their opposition, leaving decision-makers without trustworthy data, which is not made suspicious. A transparent debate including all stakeholders was perceived as the only route to defuse the controversy. The SADA has however, always declined from committing to a debate.

Advocate Lekitima, shortly after his appointment as Registrar of the SADTC towards the end of 2002, provided the Office of the Minister of Health once again with a complete set of documents that included another copy of the 1989 CDT Report. To date no response has been received from the Minister’s office on this report. 

1.8 More Manipulation:
Apparently a Committee of the Health Professions Council of South Africa (HPCSA) initially approved the implementation of Clinical Dental Technology (CDT) in 2000. Another Committee of that Council then recommended that further research is needed in view of the community service that Dentists were going to do in future. On the strength of such an ignorant irrational gesture the issue of Denturism was rejected and the goal posts moved again, as a stalling tactic. Dental Boards have their peer's best interest in mind rather than the interests of consumers. Dentists are appointed in all decision-making positions that relates to public oral health care. These appointments have placed the dental profession in an ideal position from where they have successfully exploited any competition by resisting encroachment on their monopoly. This type of abuse of this position of trust has successfully frustrated Oral Health Human Resource Development in many countries of the world. However, Denturism is steadily becoming a global profession due to public demand.

1.9 Minister’s directive undermined by own Department:
The Minister of Health, as recently as 17 October 2002, expressed concern that CDT have not been implemented, despite having been promulgated through legislation in 1997, and that a need exists for such a service. The fact that opportunistic “quacks”, who are untrained and unregulated, are providing an abundant denture service, poses a threat of transmittable diseases due to unhygienic practices. Her concern was not so much about the affordable fee, rather than the availability of a safe quality denture service to the public.

On 14-15 August 2003 an Oral Health Human Resources Workshop were organized by the Department of Health to plan future Oral Health Services, from which some of the critical stakeholders were omitted. Dental Technicians and The Society for CDT were not invited. A Task Team was instituted to “find clarification” and to “come up with recommendations” on some points about two controversial issues, namely Dental Therapy and Clinical Dental Technology. The Society for CDT were shocked to hear that this Oral Health Human Resources Task Team consisting of mainly Dentists, recommended that the implementation of CDT be scrapped, as they considered such a category as unnecessary, based on scamp misinformation. Despite ensuing correspondence for more than a year with the Chairperson of that Task Team, no rational answers or comprehensible justification for the decision could be extracted. Copies of the correspondence were faxed to the SADTC and to the Minister of Health.

1.10 Exclusion of stakeholders:
A Health Professions Council of South Africa (HPCSA) workshop had been organized for 22 April 2005 by the Medical and Dental Professions Board for preliminary discussions on:

  • A proposed laddered approach to the education and training of Oral Health professionals in SA, and
  • Establishing an Oral Health Professional Board

The date for the workshop had to be postponed twice. Predictably invitation to this workshop was not inclusive of all stakeholders, but a representative from The Society for Clinical Dental Technology, were due to represent Dental Technology at this workshop. The intention and mission of attending this workshop was to get Denturism back on the Agenda. When the Agenda for this workshop was circulated it included minutes of various other meetings and it became clear that this was no preliminary discussion. A 37-page feature document was drafted in 1993 and although it may have gone through various stages of development remained an attachment to many documents and frequently referred to. Clearly it had a great influence on the decision making process. After studying this document one could not help to draw the conclusion that this whole debate has reached an advanced stage and moving towards conclusion and implementation. Oral health professionals not registered with the HPCSA and various other interest groups have been excluded from this process. As a result, our representative withdrew from the workshop to prevent his involvement being construed later as providing consultation legitimacy. The withdrawal letter, addressed to the Chairperson of the workshop, explaining the reasons for withdrawing, was also copied to the SADTC, the DENTASA and the three Universities of Technology that train oral health human resources. As a result of the reaction from these stakeholders in response to the letter, the workshop was cancelled and the matter referred back to the HPCSA. 

1.11 Attempt to repeal the enabling legislation:
During November of 2005 a letter by the SADA to the Minister of Health was leaked to the dentaltech forum, an Internet discussion group where Dental Technicians from South Africa and abroad air their views. The Society for Clinical Dental Technology responded in a letter to the Minister of Health to most of the distorted misrepresentation in the SADA’s letter and responded specifically to the appeal to have the enabling legislation for Clinical Dental Technology in the Dental Technicians Amendment Act of 1997 repealed. This letter from The Society was copied to all the stakeholders in Oral Health Care. The response from the SADA listed what we perceive as the whole range of 17 stock-rhetoric excuses against the implementation of Denturism. The Society responded to the counter-arguments point-by-point after we consulted with our colleagues abroad. The letter addressed to the SADA was copied to the Minister of Health, various Directorates in the Department of Health, the HPCSA, the SADTC, the training institutions, all the oral health profession’s Associations and indeed to all stakeholders in oral health care, The SADA’s response was simply that their failure to respond should not be seen as acceptance of the contents of our letter and that they reserve the right to raise their concerns in the appropriate forum.

Many more chapters of the same strategic one-sided manipulation ensued. Numerous reports and applications to the Department of Health to look into the matter of implementation of the category of Denturist was frustrated. In the absence of a forum to share our view and in an effort to present our cause, The Society for CDT published motivational articles in virtually every edition of the Southern African Dental Technology Journal (SADTJ) since its inception in 2009 and also in numerous international Denturist Journals, seemingly to no avail.

1.12 Application for a Register for CDT:
After engaging the Acting Chief Director: Public Entities Governance at the Department of Health, Ms M Mushwana and the Director of Oral Health at the Department of Health, Dr FJ Smit for guidance, a South African Denturist (qualified in New Zealand) requested the HPCSA during October 2013, to open a Register for CDTs as prescribed by the Dental Technicians Amendment Act. His request was supported by letters from Retirement Facilities in need of mobile denture services. The blunt response posted the same day, was that the profession does not exist yet in South Africa. On 14 October 2013 the Society for CDT sent a 4-page general motivation for the establishment of a new Oral Health Care category of Clinical Dental Technologist (Denturist) to the SADTC in support of the request for a Register, also to facilitate overseas qualified denturists wishing to practice here and also to facilitate the creation of Regulations for the training of future practitioners. Both referrals, the SADTC and the DENTASA were also copied in all the correspondence. This led to the matter being referred to the Dental Chairperson at the HPCSA, who responded 12 months later that there are no Denturists deployed in any State Health facility, nor any training institution and therefore he does not support the request.

1.13 The SADTC taking responsibility:
At a workshop/dinner of the SADTC on 20th June 2014, with invited guests from all stakeholders, the issue of CDT was investigated afresh, when 3 position papers were presented by Denturist Advocators. The former President of the SADA, Dr D Vermeulen, publicly admitted that their Association considered Denturism as a treat to their members and that they always had the cooperation from Dr FJ Smit, Director of Oral Health at the Department of Health, who have always assured that the issue of Denturism was obstructed by using his office to prevent it from getting onto any Agenda of policymakers. He was informed that unlike Professional Associations that only serve the interests of its members, the SADTC is a statutory body, who have a duty to serve the interests of the public. The SADTC is in a process of rewriting the Dental Technicians Act and endeavours to incorporate the regulation of Denturism into the proposed format.

CONCLUDING RATIONALE FROM HISTORIC OVERVIEW:

2.1 Self-serving Monopolists opposes Development of Emerging categories:
Organized Dentistry single-mindedly labelled Denturism as the illegal practice of Dentistry. Sadly, the problem lies in the antiquated definition of Dentistry, which has not been updated in modern times. In the early 1900's Dentistry monopolized the provision of dentures, as part of their domain in many parts of the world, and jealously guarded against any competition. It used to be the most lucrative part of dentistry and "reasons" were therefore created, to justify the monopoly. As an example, in some states of the USA, were Denturism is not legislated yet (due to the ADA's strategic opposition) neither the Canadian Denturist qualification (considered widely as the international benchmark qualification) nor any of the American training programmes is recognized. The selling of a denture by such a non-dentist (regardless of Denturist qualification and proven prosthetic expertise exceeding those of Dentists) is declared a felony and regarded in the same severity as someone deliberately misleading the public for example, doing surgery without any medical education. The independent deployment of Denturists, Dental Therapists and Oral Hygienists have been an ongoing struggle in the USA and many other locations. Internationally, a pattern has emerged of almost all forms of Oral Health Human Resource development being opposed and stonewalled by Organised Dentistry, unless it can be manipulated to provide financial gain Dentists.

Due to the ongoing economic depression, part of the patient pool usually served by mostly privately practicing Dentists, can no longer afford the cost of the conventional services. They are prevented from access to alternative service providers, because Organized Dentistry are opposed to the licensing and training of such categories. It is long overdue for Policy makers to dismiss the self-serving agenda of Organised Dentistry, to make adjustments for the international trends and local demands in these modern times and to normalise the dental market. Such measures would include the introduction of free-market principles, the deployment of Denturists and independent expanded function for Oral Hygienists and Dental Therapists, in order to serve the basic oral health needs of society as a multi-disciplined Oral Health Team of experts.

2.2 Deliberate Obstruction of patient’s choices:
For the past 70-80 years, a pattern emerged globally, where the chain of denture supply is shortened and allows direct interaction with the manufacturer, providing a more proficient service at a better affordable fee. The question the people of South Africa needs answered is why have we not following the international trend to implement this category as was already done in 40 other states and countries? Why does the initiative not progress further than the 1997 enabling legislation that provided for an outdated definition of this category, despite the tireless efforts of the Society for CDT to engage with policy makers? Clearly, strategic opposition by the monopoly-holder, have prevented decision-makers and Oral Health Planners to consider input from any stakeholder which do not serve the vested interests of the Dental Association (SADA) and their agents within the Department of Health, who have repeatedly manipulated the topic of Denturism from the Agenda.

2.3 Appeal to serve the patient:
It is time to stop this abuse of one profession over others! In terms of the principles contained in the National Health Act and the Health Charter, the time to replace Dentist-centred dentistry with Patient-centred dentistry is long overdue. There can be no doubt and the SADTC are in overwhelming agreement that we do need Denturists as a new oral health care category in South Africa. It is in the public interest, because it offers only great advantages! Globally Denturism has come of age. Patients must be free to select the type of oral health service that best meet their needs in terms of personal healthcare, dignity, wellbeing and affordability.

Political restraints prohibiting people the opportunity to choose Denturists’ services are sadly misdirected, because large numbers of the old and the poor have unmet oral prosthetic needs. Denturism Journals often reflect on the outreach character and dedication of individual Denturists all over the world, who provide altruistic services daily. Countless Welfare Societies actively serving denture needs around the world, are keen to partner with Denturists to serve these vulnerable categories in need of denture care. All people deserve the freedom to choose a Denturist, because …

Denturists Change Lives – One Smile at a Time!