About Denturism

Health Care Realities in South Africa
           About South Africa
                Rainbow People
                Language & Religion
                Economy
                Political Reform
             Recreation & Sport
                Conservation
           About General Health
           Disabilities and Geriatrics
            About Oral Health
           About Denture needs
The Essence of Denturism
Public safety and oral health
           Non-invasive procedure
           Popularity with the public
           Dentistry's anti-competitive harassment
           Petty monopolism or public concern?
Political Importance of Serving the Poor and the Elderly
Unfounded perception of Professional encroachment
        Dentist's deficient training in Prosthetics
          Specialists or Quacks?
          Acceptance of legislated practice
          Serving the needs
          Humanitarian Outreach Program
Oral Pathology in Context
           The incidence of Oral Pathology in denture wearers
           Importance of early detection of Oral Cancer
           The myth of Oral Cancer caused by Dentures
           Educating the Public in Oral Disease Prevention
EU recognition of Denturist qualification
Dentists’ Monopoly
           Legal Monopoly entrenched to supply dentures
           Concession to introduce Denturism
Restraint on selling dentures and the solution
         Summary  of Restraint
           Nature of the Restraint
           Effects of the Restraint  
           Rationale offered for the Restraint
           International Experience
           Fundamental Analysis  
           Proposed Solution
           Proposed Preliminary Recommendations to ensure viable practice
           Effects of the Proposed Solution
Effect of Competition on the Cost of Dentures

 

About South Africa

South Africa is located at the southern tip of the African continent and is surrounded by ocean on three sides; the Atlantic Ocean on the west coast sweeping around south to meet the Indian Ocean on the east coast. In the north, South Africa shares its border with the countries of Namibia, Botswana, Zimbabwe, Mozambique and Swaziland. The mountain Kingdom of Lesotho is geographically enclosed within South Africa. The country is divided into nine provinces, with local municipal structures overseen by provincial governments. 

  

Rainbow People
South Africa is a nation of over 47-million people of diverse cultures, languages and beliefs. South Africa has a culturally diverse origin, one nation made up of many peoples. With 11 different official languages, a multiplicity of traditions and skin tones ranging from ebony to sun burnt pink, we are, as Archbishop Desmond Tutu once put it, the rainbow nation of Africa. While about three-quarters of South Africa's population is black African, this category is neither culturally nor linguistically homogenous. The white population is estimated at 10%, the coloured population 8.8% and the Indian/Asian population at 2.5%. 

Language & Religion
South Africa is a multilingual country. Besides the 11 officially recognized languages, scores of others - African, European, Asian and more - are spoken here, as the country lies at the crossroads of southern Africa. English is generally understood across the country, being the language of business, politics and the media - but only the fifth most spoken home language. isiZulu is the mother tongue of 23% of South Africa's population, followed by isiXhosa at 17%, Afrikaans at 14%, Sepedi at 9%, and English and Setswana each at 8%. In terms of religious affiliation, about two-thirds of South Africans are Christian, mainly Protestant. They belong to a variety of churches, including charismatic, traditional, and some that combine Christian and traditional African beliefs. Many non-Christians espouse these traditional beliefs. Other less significant religions are Judaism, Islam and Hinduism.

Economy
South Africa's economy is the largest in Africa, with strong mining and mineral processing sectors. South Africa is a middle-income, emerging market with an abundant supply of natural resources; well-developed financial, legal, communications, energy, and transport sectors; a stock exchange that ranks among the 10 largest in the world; and a modern infrastructure supporting an efficient distribution of goods to major urban centres throughout the region. The country's primary exports are fruit, wine, tobacco, sugarcane and corn. South Africa's per capita GDP, corrected for purchasing power parity, positions the country as one of the 50 wealthiest in the world. South Africa's wealth is distributed inequitably and the country is characterized as a land of contrasts. A strong economy and well-developed infra-structure had been established over many decades, but growth has not been strong enough to lower South Africa's high unemployment rate, and daunting economic problems remain from the Dutch and British Colonial era followed by the apartheid policy (separate development for different races) of the previous Government - especially poverty and lack of economic empowerment among the disadvantaged groups.

Political Reform
South Africa held its first truly democratic elections in 1994, following many decades of internal and international pressure to end its apartheid policies and usher in black majority rule. A new government was formed under the African National Congress (ANC) and Nelson Mandela became the first new President. The new government set about to dismantle all existing systems, including policies and structures of apartheid and partnered the formulation of a new Constitution based on equality and freedom. Despite some social and economic progress in the first few years of the new government, efforts to improve the health and living standards of South Africa's population have been hindered by severe poverty, crime & corruption, unemployment, HIV/AIDS and a perceived racial obsession of the Government that often interferes with an inherent spirit of reconciliation. A major new report titled A Nation in the Making  paints a picture of dynamic change in South African society, with rapid social mobility and large improvements in both living conditions and race relations. But it stresses that economic divisions within the country remain set along the racial fault-lines created by apartheid. South Africa's black middle class has grown by an astounding 30% in just over a year, and now wields an annual collective spending power of R180-billion, a new study finds. And according to the researchers, business has yet to tap the full potential of SA's most important, and dynamic, market segment. According to the latest South African edition of the World Values Survey, 96% of South Africans are now proud of their country, with white South Africans closing the patriotism gap with their black compatriots.

Recreation & Sport 
With weather patterns being conducive to an outdoor lifestyle, appreciation of our natural resources and outdoor adventures remains an important approach to leisure time in South Africa. Being a very large and extraordinarily varied country, there is almost unlimited opportunities for adventure activities of all sorts. You will be spoilt for choice when looking for activities and leisure pursuits, from diving and shark cage diving to hiking, mountain climbing and abseiling, ostrich-riding, elephant-back safaris, fishing, surfing, hang gliding, hot-air ballooning, bungee jumping, whale watching ... the list is endless. Staying fit and healthy through participation in sport activities is a typical lifestyle, although many from the poorer sectors of society sometimes do not readily have access to organized sport.  With South Africa proudly becoming Rugby World Champions for a second time recently and having hosted The Rugby World Cup, Cricket World Cup, World Cup of Motor sport, Women's World Cup of Golf, Swimming World Cup, African Cup of Nations and being in the middle of organization to host the 2010 FIFA World Cup for Soccer, it is fair to say that South Africans are sport crazy. Over many decades the country have produced various national heroes with international status in Soccer, Rugby, Cricket, Athletics, Golf, Boxing, Tennis, Swimming, Motor sport, Power-boating, and many other sporting disciplines.

Conservation
Cities have grown, much land has been given over to farming, and thanks to the foresight of conservationists past and present, South Africa remains blessed with abundant wildlife. Best known are the mammals, and the most famous of these are the Big Five: elephant, lion, rhino, leopard and buffalo. Not that giraffe, hippo, kudu, wildebeest and zebra, or whale are small. The third of the famous big cats is particularly fascinating. The cheetah is the speed champ, capable of dashes of almost 100 kilometers an hour. Incredible diversity in over 200 indigenous mammal species, bird life and lesser known wildlife ... ranging from tiny antelope such as the suni to ferocious reptiles like the crocodile are contained in natural habitat in conservation areas. With 20 National Parks (including two of the world's most famous wildlife reserves, the Kruger Park & Kgalagadi Transfrontier Park) & numerous private game reserves, your trip to South Africa would be incomplete without experiencing a South African wildlife safari. Within our borders there are 7 UNESCO World Heritage sites and South Africa has been rated as having the third-highest level of biodiversity in the world, and the only country to contain an entire floral kingdom. The Cape Peninsula National Park has more plant species within its 22 000 hectares than the whole British Isles and New Zealand together.

• Human Development Report 2006, DFAT, UNDP
• The World Factbook 2007 compiled by the CIA <www.cia.gov/library/publications/index.html>
• < www.southafrica.info>

 

About General Health 

Population: 47.2 million
Urban population: 58.8%
Life expectancy: 49 years
Literacy rate:  82.4%
Unemployment rate:  26%
Population below poverty line: 50%
Infant mortality rate (per 1,000 births): 54
Number of doctors (per 100,000 people): 77

The state of health in South Africa has suffered some major set backs in recent years. Life expectancy at birth has dropped from 53.7 years in 1970-75 to just 49 years in 2006. Infant mortality rates have increased from 45 per 1,000 births in 1998 to 54 per 1,000 births in 2006. The burden of the health crisis is borne largely by the poor and rural population. Factors contributing to the current health situation include poverty, poor sanitation and water supply, inadequate housing and inaccessibility of health services. The most common communicable diseases in South Africa are tuberculosis, malaria, measles, cholera and HIV/AIDS. Around 18.6% of the adult population (aged 15-49 years) is affected by HIV/AIDS and new infections are increasing at an alarming rate. Since the first democratic elections in 1994, the South African Government has restructured the health system to improve equity and access to primary health care.

Previously, under apartheid, each public health facility was allocated to a particular racial group with more services directed toward the white population. These services were also concentrated in the secondary and tertiary levels, such as hospital and specialist care. The current public health system is district-based, with a greater emphasis on primary health care. There are now more than 3,500 health care clinics in South Africa which offer basic services free of charge, such as child immunization, maternity care, counseling, family planning, oral health, disease prevention, accident and emergency services and health promotion.

80% of South Africans rely on the public health system, which is under-resourced and suffering from a severe shortage of medical personnel. Poor working conditions and low pay are driving many doctors, dentists and nurses to leave the public health system for private practice or to work overseas. Although the private health sector is growing rapidly, services are generally out of reach for the vast majority of the population who don't have medical insurance. Only 16% of the population have group scheme cover. Approximately 60% of spending on health care is in the private sector, which is accessed by less than 20% of the population.

• Sources: Human Development Report 2006, Population Reference Bureau, South African Equity Gauge, UNDP

 

Disabilities and Geriatrics

Government introduced free health services for people with disabilities in July 2003. Beneficiaries include people with permanent, moderate or severe disabilities, as well as those who have been diagnosed with chronic irreversible psychiatric disabilities. Frail older people and long-term institutionalised state-subsidized patients also qualify for these free services. Beneficiaries receive all in- and outpatient hospital services free of charge. Specialist medical interventions for the prevention, cure, correction or rehabilitation of a disability are provided, subject to motivation from the treating specialist and to approval by a committee appointed by the Minister of Health.

All assistive devices for the prevention of complications, and cure or rehabilitation of a disability, are provided. These include orthotics and prosthetics, wheelchairs and walking aids, hearing aids, spectacles and intra-ocular lenses. The Department of Health is also responsible for maintaining and replacing these devices. By mid-2006, the department was assessing all public hospitals for accessibility to people with disabilities, strengthening policy on free healthcare for people with disabilities, and facilitating the implementation of the International Classification of Functioning, Disability and Health. By mid-2006, guidelines on the implementation of the National Rehabilitation Policy had been finalized, and the revision of the price list for orthotic prosthetic devices completed.

The Department of Health was also developing a strategy on orientation and mobility services for the blind. The Department aims to reduce avoidable blindness by increasing the cataract-surgery rate. The toothless (dentally disabled) elderly needs similar intervention that will have a major revitalizing effect on almost all aspects of their standard of life, nutritional health, oral health and general health. The spirit of the Older Persons Act  is certainly underpinned by the sense of compassion of denturists for providing rehabilitation services to the elderly and other edentulous people in need of having their dignity restored by dentures!  

In supporting the health needs of the elderly, the Department’s policy is to keep the elderly in the community with their families as long as possible. In partnership with the Department of Social Development, the Department of Health has implemented the integrated nutrition programme for vulnerable children alongside the luncheon clubs for the elderly, to allow for interaction between senior citizens and children. It was also involved in developing survey indicators for the WHO Study on Ageing. The study seeks to create a multi-country platform for data collection, which results in a reliable source of health information about adult populations aged 50 years and older.

• Source: www.info.gov.za/aboutsa/health.htm#chronic_diseases

About Oral Health

Data of Oral Health professionals in South Africa: 

Dentists: 4830 ( with 1800 practicing overseas, 300 in community service & those working as academics, leaves  2800 private dentists active)
Dental Specialists:  6 disciplines – total 409
Dental technicians:  1290 registered, believed to be ±1000 active
Dental Laboratory Assistants:  ±3000 estimated, to be registered from 2008
Oral Hygienists:  973
Dental Therapists: 457
Dental Assistants:  >1900 Registration in process

Most oral diseases are not life-threatening but affect almost every individual during his and her life time, resulting in pain and discomfort, expenditure on treatment, loss of school days, productivity and work hours, and some degree of social stigma. Oral conditions are important public health concerns because of their high prevalence, their severity, or public demand for services because of their impact on individuals and society. Oral disease levels appear to be increasing in major sectors of the South African population, especially the underserved, disadvantaged and urbanizing communities.  When contemplating the effects of edentulism on a person's quality of life, there can be no doubt that edentulism is indeed a form of disability

Basic health and social services are a human right and oral health is a significant component thereof. Individual oral health treatment options are not available to most people, with few oral health promotive and preventive activities. State dependent people should have access to basic oral health treatment services. Oral diseases are largely preventable and therefore oral health promotion and primary prevention are a top priority. Although national goals are be of some value it is recognized that communities and the circumstances in which they live are extremely diverse. 

• Source: Preamble to the National Oral Health Strategy, Dept of Health.

The Department of Health set aside R2 322 million in 2006/07 to ensure an efficient oral health service. The department’s policy on promoting oral health has shifted from curative, hospital and urban-based oral healthcare to integrating oral healthcare in the Road to Health Chart for babies, as part of the Healthy Lifestyles Campaign. In 2006/07, the department was expected to champion the regulations on fluoridating water supplies, in collaboration with stakeholders such as the Department of Water Affairs and Forestry, provincial and local government, the South African Association of Water Utilities and South African Local Government Association.

Since the development of dentistry in the nineteenth century, the productivity of the dental surgeon was stifled, as he was responsible for both the clinical and technical procedures of denture construction and delivery, as well as the clinical, surgical and educational responsibilities of controlling oral disease. The result was the introduction of auxiliaries to enable the dental surgeon to be more efficient in patient care. The first of these was the dental technician, who took over the responsibility of manufacturing all the custom made dental appliances for the dentist's patient on a contract basis. Following this dramatic increase in productivity due to the efficiency of dental technicians, the categories of dental assistant, oral hygienist and eventually dental therapist were to follow.

For many decades there has been a fashionable trend amongst newly qualified dentists from South Africa to go and work overseas to gain experience. Many never returns, resulting in a loss to the country, in terms of money spent in subsidized training, funded by the taxpayer. In the UK alone, there were 1753 South African dentists working in October 2002. Large numbers of SA trained dentists are also registered in Canada, Australia and New Zealand. There are currently 696 Oral Hygienists and 271 with expanded function (total 967) registered with the HPCSA. The proposals of the National Human Resources for Health Plan of the Department of Health are to increase the production of Oral Hygienists from 70 to 150 annually by 2009. There are currently 457 registered Dental Therapists deployed in South Africa. The current proposal of the National Human Resources for Health Plan of the Department of Health is to increase the production of Dental Therapists from 25 to 600 annually by 2009. The cost of training a dental therapist is half of that of a dentist. The cost of employing a dental therapist is half of that of a dentist. The workload in the public sector involves primarily the delivery of the basic minimum package of dental care as prescribed by the Minister of Health, which encapsulates the dental therapy profession wholly and specifically. The South African Dental Association (SADA) has called for the closure of the profession of dental therapists and to end the training of this category. In the private sector Dental Therapists are facing blatant professional discrimination and anticompetitive fund allocation by Medical Schemes, and exclusion from consultation and representation in the dental programs and structures that are dominated by dentists for the professional advancement of dentists only. Unilateral decision-making of Dentists on behalf of other Oral Health groups has been the trademark of dental services in South Africa. Various workshops have been held by the Department of Health to plan the future of the Oral Health Professions, invariably excluding some of the important stakeholders from the workshops.

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 any more and deplorable health-scare tactics were used to discourage their practice under the false excuse of causing cancer to the mouth. The process of legislation and establishment of vested rights for dentists were a long out-drawn struggle over many decades. 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. Organized dentistry refuses to get involved in a transparent debate about this monopoly or the need for Denturism.

In South Africa Dentistry has become an elitist business, attracting to it's ranks generally those with a focus to make big money and only serving those with medical insurance and the means to pay the balance from private funds (sometimes even with indifference for the oral health of the patient). The Society have no problem with Capitalism or professional people making a FAIR profit, provided monopolistic services does not exclude the majority of the population from access to basic services. Private dental practice serves less than 20% of the total population (some will argue less than 6% visits dentists regularly). Despite lip-service to beautifully phrased policy statements as the National Oral Health Strategy, the State do not provide much dental care due of a need to focus most of the Health budget on life-threatening diseases and basic health promotion. There is some basic oral health promotion work being done, and to some degree tooth extraction and pain relief at district clinics and very limited provision of dentures through the training institutions (dental students facilitate 2-3 dentures per student during their training ). At least 80% of South Africans rely on the public health system, with virtually no budget at all specifically allocated for the provision of dentures.

      WHERE MUST POOR PEOPLE GET DENTURES ?     

See also Public Safety and Oral Health 

About Denture needs

The following distribution of Edentulism (toothlessness) and Availability of dentures in different racial population groups were reported in 1988-89 by the National Oral Health Survey of the Department of Health:

Edentulism
Population Group	% Edentulism	Total Number
Rural Blacks Urban Blacks Coloureds Indians Whites Total	3 7 37 6 19 11	171 506   221 620   611 974     32 852   564 244 1 602 196

Distribution of denture wearers
Population Group	% of Edentulous Population	% of Total Population	Total Number
Rural Blacks Urban Blacks Coloureds Indians Whites Total	47,6 27,7 67,9 72,9 94,8 69,8	1 2 25 2 18 8	81 690    61 465   415 386    23 955   535 458 1 117 946

In 1988 the Coloured citizens of South Africa were 37% toothless, compared to 6% of the Indian and 19% of the White populace. Traditionally, the black population, generally regarded as the most underprivileged group, used to have excellent teeth retention with an edentulous rate of only 3% in Rural areas and 7% of the Urban Black community under the age of 65. This tendency is changing rapidly due to diet-changes, life-style and trauma. The correlation between “westernisation” and deterioration in oral health through caries attack has often been documented internationally. The Inuit Eskimos, New Zealand Maoris, Australian Aboriginals, the South Pacific Polynesians and the Tahitians are all good examples. Caries as a childhood disease with profound implications in adulthood is a worldwide problem. In stark contrast the black population in South Africa had excellent teeth retention and relatively little denture needs at the time. The average rate of edentulism for the total population was measured at 11%.

It is a recognized fact that the rehabilitation of toothlessness is not only a health care problem, because needs and demands for dentures are influenced by values and believes, as well as social, demographic and economic background of an individual or society (even cultural background in some circumstances, as mentioned above). The affordability of the denture-service to the patient is very important because a large number of denture wearers are indigent elderly or retired and has very limited or no funds. When comparing the tendencies of denture wearers between different population groups, it is clear that amongst non-black groups a fair amount had dentures: Coloureds 67%, Indians 72% and whites 94%. Less than half the edentulous rural Black community and only 27% of the edentulous Urban Blacks had dentures. At that point in South African history the most likely reasons for this tendency would have been the lack of access to and unavailability of dental services to black patients, as well as economic factors such as insufficient earning capacity to contribute to Medical Schemes and an inability to pay dental bills privately. Almost 500 000 people without any teeth did not have dentures and much of the 1.12 million denture wearers were in need of replacement dentures for various reasons or they were dissatisfied with their current dentures for various reasons, as they do indeed need to be replaced every 5-8 years due to resorbtion of underlying bone tissue. See also Poverty

The World Health Organization's Division of Non-communicable Diseases & Oral Health reported that 60% of the world's population of age 65-74 were edentulous. Studies in South Africa have shown that 74% of the non-institutionalized Coloureds older than 55 are edentulous. The institutionalized White population older than 65 was recorded to be 88% edentulous. Furthermore, in the western world, the large group of people born after World War II called the Baby Boomers, have become Middle-aged Boomers and are going to be Geriatric Boomers by 2010. Those older than 65 are living longer and this group is getting bigger as their % of the total population have increased from 10-11% in most Western countries in 1985 estimated to reach 17-18 % by 2025. In South Africa, the same trends have been reported. These figures do not only have profound effects on denture needs, but also on continuous replacement dentures as well. Imagine a static workforce having to look after the burgeoning number of pensioners? At the current inflation rates, how are their medical bills going to be financed and who is going to supply their dentures?

The circa 1.6 million edentulous population will continue to need complete denture services, to a large extent accounting for 65+ year olds, as demand for dentures is strongly correlated with age. People are now living longer than previous generations; and due to an extended life cycle pattern amongst the elderly, the claimed projected decline in edentulism will be more than offset by the increase in replacement dentures of the adult population older than 55 years. A substantial segment of the population will continue to become partially and fully edentulous due to neglect and a lack of financial resources to access basic dental services to have their natural teeth attended to. 

Even if the demand for full dentures falls as people retain more of their natural teeth for longer, there will continue to be a demand for partial dentures, some of which comes from cases of tooth loss arising from trauma, sports injuries and accidents. The black population in particular previously had excellent teeth, but this tendency is deteriorating rapidly with diet changes. A large portion of denture wearers in South Africa count amongst pensioners and the poor, of whom many do not have access to Medical Schemes and already mostly falls outside the market that can afford the services of privately practicing dentists. In the absence of a specialist category of Denturist , the indigent denture wearing public are left to the mercy of unscrupulous "quacks " where they are subjected to:

·       Cross-infection of Hepatitis B, tuberculosis and other communicable diseases (possibly even HIV/AIDS ), due to unhygienic practices;

·       The quality of dentures is often unsuitable due to limited technical knowledge resulting in design and/or manufacturing flaws;

·        The materials are normally stolen; and

·        These fly-by-night characters are unaccountable for recourse after the dentures have been delivered. 

·        As untrained operators, the potential for serious consequences resulting from non-diagnosis of malignancy presenting in the mouth and the delays in crucial treatment can have devastating results.

The public needs more efficient and cost-effective services that are in line with international practice and Free Market principles. Human Resource Development in Oral Health Care have been suppressed much too long in South Africa. The question the denture wearers of South Africa needs answered is why are we not following the international trend, moving forward together, in a spirit of mutual respect, to champion the only real cause worth tackling, that of the oral health and well being of our communities? That goal can best be achieved by all categories doing their very best in their own expert capacities and by removing outdated and unjustified restrictions and monopolies!  In some countries it is becoming normal to see Dentists, Denturists, Hygienists, Therapists and other OHHR and Specialists in group practices to serve all the various dental needs of their communities. Cooperation and referrals between dentists and denturists is becoming routine. Those who refers their patients to the other profession also benefits by receiving more patients on referral from them. 

In South Africa Oral Hygienists may also benefit from expanding their services as independent service providers and the public oral health (hygiene) may benefit from such an arrangement as a result of these educational services being more accessible and subject to market forces. For more information about this topic see also Dental Care Providers

In the final analyses the dental consumer must have the freedom of choice to make informed decisions by him/herself without interference of monopolistic manipulation of the market! They must be empowered to get access to better affordable rehabilitation and oral health education.

• Source:1988-89 National Oral Health Survey of the Department of Health

•  Information in this About Oral Health profile have been compiled from information already reflected elsewhere on this website

When one reflects on the history of Medicine, medical doctors were given full authority; they handled everything. As they realized they couldn’t do it all themselves, support professions developed. Likewise, Dentists and Government need to understand how professional offshoots could benefit Dentistry and more importantly - the dental consumer[1]. The suggestion by a prominent South African Dental Specialist that the provision of dentures should not necessarily play any part in the practice of Dentistry is one that has been met with hostility from the Dental Association. That it does play a part is the result of custom and not of logical association. As Dentistry transformed from the era of the tooth puller and charlatan, to an educated profession, the right to make dentures was clung to, jealously guarded[2]. Global trends in dental legislation were to try to monopolize denture delivery for dentists. This trend is being challenged and reversed as Denturism is already legally recognized in 34 states & countries and slowly spreading around the Globe. Essentially the introduction of this additional category of denture provider is not about dentists having to give up any rights, but simply about introducing an additional choice of service provider to the dental consumer.

60 years ago denture work was without doubt the most lucrative part of dentistry, and reasons were therefore found why it should not be practiced outside the ranks of the profession. However, on Medical grounds, there is nothing to support the claim. After the patient have lost all their natural teeth, the dentist takes the impression and bite, measurement procedures calling for no greater skill or precision than is required for the actual making of the denture. The finished restoration is placed in the patient’s mouth and such minor adjustments that are required are carried out. Here again the procedure is one of mechanical or technical nature and does not call for surgical skill[3].

Internationally the emphasis in dentistry has shifted to crown & bridgework and implants to treat the partially edentulous population[4]. As a result there has been a trend in dental schools to reduce and in some instances even eliminate removable prosthetic coursework from their curriculum. The highly trained dentist of the future, who must be qualified to advise on all matters of health in any way connected with the oral tissues, should not waste his/her valuable time and commercialize him/herself by the manufacture and sale of dentures[5]. The fragmentation of the denture delivery system through a go-between is counter-productive and interferes with the communication between the consumer and the manufacturer . Dentists are expertly trained in the combat of oral disease and general oral health care! Dental technicians who have the manual dexterity and technical skills and are already professional in making dentures, should do this work. They already receive tuition in anatomy & physiology. They only need a modified course of instruction in the clinical procedures of denture delivery and in oral pathology recognition, so that they can refer when necessary. Internationally Denturist-students spend much more time on technical and clinical education than dental students in removable prosthetics[6]. A course devoted to specializing in denture prosthodontics must lead to a superior clinician in the denturist than in the dentist[7]. Naturally this new proposed health care category for South Africa should be controlled and registered by the appropriate authority.

It makes operational sense to add clinical/biological skills to the work of dental technicians with regards to the de-fragmentation of the process of providing dentures and have one-and-the-same person doing both the clinical and technical procedures involved and for that purpose deal directly with the person for whom the denture is being made. Most people would still need a dentist, for care of their natural teeth. Delegation of the process of denture manufacture (including the simple clinical procedures involved) away from a multi-disciplined dentist to an expert with more specialized duties must inevitably produce efficiency or service gains not only for the dentist and the denture-maker, but especially for the denture wearer. The provision of dentures by CDTs will free the hands of dentists to use their time and specialized skills more effectively towards the prevention and treatment of oral disease and the promotion of oral health.

The most efficient and economical provision of dentures globally is by Denturists. By nature of their training and education, such denturists are specialized in discipline-specific removable prosthetic work. They are specially trained to do both the clinical and manufacturing procedures in providing dentures directly to the consumer and see a much higher amount of denture patients on a daily basis than dentists! Internationally, Denturism is becoming the service of choice for the wealthy as well as the poor[8]. 

See Making Dentures to view the procedures involved and a graphic illustration of the difference between the customary (often clumsy) procedures and the proposed more efficient specialization.

---

[1] Paul Levasseur DD, President of the International Federation of Denturists 2003
[2] Mr. CL Frizzel HD DRCS (Edin) LDS (Birm): A Plea For A Special Dental Course. The Dental Magazine and Oral Topics, Vol 60, April 1943
[3] DF Malherbe, LA Steyn, C Du Plessis, Z Fatagodien. Clinical Dental Technology: A Quest For Equity In Oral Health Care by The Society for   Clinical Dental Technology, 1998 Ó. Motivational Report to the SADTC, Minister of Health and the Department of Health.
[4] Duffy Malherbe.  Provision Of Removable Prosthetics By Denturists – What Is The Controversy? International Dentistry South Africa, Laboratory World. Vol 8 No 1. Jan 2006
[5] Mr. CL Frizzel HD DRCS (Edin) LDS (Birm): A Plea For A Special Dental Course. The Dental Magazine and Oral Topics, Vol 60, April 1943  
[6] Dr Kenneth Kais DDS, Head of Bates Technical College, Tacoma, Washington. Member of the Education Committee of the National Denturist Association, USA. E-mail to The Society-2007-06-25
[7] Professor Cyril Thomas. Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. E-mail to The Society-Tue 03/07/2007
[8] Gerry Hanson Globalization of Denturism Presentation by the CEO of the International Federation of Denturism to the National Denturist Association (US, May 2005) and the Australian Dental Prosthetists Association (Sydney, August 2005).

Australia has had licensed Denturists (dental Prosthetists) for more than 50 years and are deployed extensively throughout all Australian states. In the field of removable dentures Denturists have four to six times the Training of Dentists. Denturist professional indemnity insurance is the lowest of any health profession because they do their job so well that complaints are minimal compared to Dentists [9].

 

Denturism is so popular in the eyes of the consumer that in the State of Oregon (1976) it was voted in by the public on the State general ballot by the largest margin that state has ever known – 78% for legislated denturism and only 22% against [9].  After almost 30 years of denturist practice in that same State, the public was asked to reflect on their confidence of denturists for the introduction of partial dentures to the domain of denturists. In 2004 Oregon citizens voted in this new ballot and again showing public confidence in denturist practice by another landslide victory [10]. In Maine denturist practice has been legislated since 1977 without one single denture complaint filed against a denturist. In Arizona, the denturist issue was so desirable to the public that US Congressman Bruce Babbitt, the governor of Arizona at the time (1982), single-handedly wrote and successfully introduced that State’s denturist legislation. In Montana (1984), even though organized dentistry had spent over half a million dollars to propagate a dirty and slanderous campaign to prevent any competition to their monopoly, the Denturist Public Act was successfully implemented [11]. The same success was repeated in the States of Idaho (1982) and Washington (1994). Denturism is so practical and safe to the public that the Federal Trade Commission (FTC), after conducting a five-year study, sent all State Governments a letter of recommended rulemaking: encouraging each state to institute the profession [12]. The FTC also made statements of recommendation to the denturist profession’s outstanding track record in Canada. Denturists have been legally regulated throughout all of Canada for 30 years. Denturists in countries throughout the world have proudly earned special commendations for their safe, ethical, and thorough public denture care delivery system [13].  Reports indicate that denturists practicing in Tasmania for more than 50 years and other states of Australia for at least 30 years have had no detrimental effect on the oral health of patients [14].  Similar research conducted in Canada and Finland supports these findings [15] [16]. Various prominent international politicians and experts in this field have given their blessings to the safe and agreeable practice of denturists [16]. These letters are available for scrutiny.  See also Acceptance of legislated practice

 

Dentists are well aware that denturists are qualified to serve the public without harm. Several states and the Federal Trade Commission have researched and found this to be true and have published recommendations to recognize this profession. It seems obvious that dentists, who continue to impede denturists' efforts to have denturism recognized, hence regulated, do greater harm. Dentistry's argument that only dentists can provide denture service is unsubstantiated. Denturists are educated to recognize abnormalities and refer them to the proper medical or dental specialist. Dentists do not diagnose oral cancer or any other lesion; oral pathologists do, and any health care professional can refer to them. In many areas, there is a respectful professional relationship with reciprocal referrals of patients between dentists and denturists. However, these denturists are often harassed by established dentistry. Denturists provide a personalized service to patients, fabricating a custom appliance in direct co-operation with the consumer. Dentists do not make dentures; they often don’t even have the basic equipment to polish a denture after an adjustment was done. In most cases they have auxiliary personnel see the patient for an impression, then send that impression to a laboratory that may even be in another country, for denture fabrication. They buy dentures and resell them with a substantial mark-up. That is the exclusive business they want to maintain. Educated denturists practice under regulated license in six US states, all of Canada, the United Kingdom, Denmark, Finland, Switzerland, the Netherlands, all of Australia, Newfoundland, Poland, Spain, Tasmania, New Zealand and other countries. Allowing the regulated and educated practice of this profession has increased access to dental care without creating any problems relating to public safety [17].

 

Countless studies have been conducted into the need for denturism at both State and Federal level in the US, Canada, Australia and many other countries elsewhere. All reliable studies have repeatedly shown the denturist profession to be, not only safe, but to be a necessary asset to the public. Denture wearers claim that due to their expertise in denture provision, denturists understand and communicate better with them than dentists do and as a result receive higher quality services and better denture satisfaction. Due to the compassionate policies of Denturist Associations, denturists are typically encouraged to, and have been known to, refund the money of patients who are not satisfied – something the dental profession is not willing to do! [18] This is a worldwide phenomenon.

 

In their opposition to denturists becoming competition to a small section of the market they serve, dentistry have spent much energy in devising tactics to fool the public and legislators by inventing non-substantiated health scares. Some wild claims relate to denturists spreading AIDS, cancer and other forms of oral pathology to their patients and even that denturists will inject patients with radioactive isotopes [19]. All dentistry’s negative claims were fabricated in an effort to protect it’s monopoly and to date have not been able to produce one fiber of empirical evidence to substantiate such claims. All their claims have been proven to be invalid by Health Ministers, Oral Pathologists, the American Cancer Society, the U. S. Surgeon General’s office, State Legislative studies, the Federal Trade Commission, and by Senior Citizen and Consumer Survey Reports [20]. See also The myth of Oral Cancer caused by dentures  also on this website.  

 

   " Of all the forms of inequality, injustice in health care is the most shocking and inhumane ."  - Martin Luther King, Jr.  

In September 2000, all 191 Member States of the United Nations recognized the "collective responsibility to uphold the principles of human dignity, equality and equity at a global level". A set of eight Millennium Development Goals (MDGs) was adopted by world leaders. The goals are to be met by 2015. The focus evolves around poverty, child and maternal health, education, gender equality, environment, HIV/Aids, and global partnership. Annual reviews of world progress towards the MDGs have shown that while there have been encouraging signs of reduced poverty in parts of Asia, there is further deterioration particularly in Sub-Saharan Africa.

The people of South Africa have gradually been liberated and a new sense of nationalism has been manifested by the principles of Masakhane (united action), Ubuntu (group-support fellowship), Faranani (partnership with all our people), Letsema (new patriotism), Batho Pele (people first), Vuk’uzenzele and simple old-fashioned decency and goodwill that is still in abundance.

On the 6th of Feb 2004, when we celebrated ten years of freedom and democracy, President Thabo Mbeki in his State of the Nation Address, spoke about the challenge to create a caring egalitarian (liberated, unrestricted and free) society. He said that we have to eradicate poverty, improve the quality of life of all our people, …with special reference to people with disabilities, children and the elderly  and the implementation of programs to release all our people from the social conditions that spell loss of human dignity[3].

In the Debate that followed, the Minister of Health, Dr Manto Tshabalala-Msimang responded by repeating the need to take action to affirm the rights of the poor and the vulnerable. She stated that:

“equity in the distribution of resources remains a critical factor in achieving the “health care for all” mandate, as a huge imbalance remains in resources between the private and public sectors, on the one hand, and between urban and rural areas on the other. These measures determine who lives and who dies; who suffers permanent harm and who is restored to good health. The tragedy is that the poorest among us, who are the most in need of good public health care, all too often have the weakest services ”[4].

The Minister elaborated on the advances made by her Department in providing free health care for children and pregnant woman, the extension of this free service to everybody at primary care level, and now disabled persons are included in this package, including hospital care. This is a contribution towards poverty alleviation. The Minister promised to step up health promotion programs, intensify the programs on non-communicable diseases and the eradication of the backlog in assistive devices such as wheelchairs, hearing- and walking aids[5].  

The aim of the Department of Social Development is to ensure the provision of comprehensive, integrated, sustainable and quality social-development services, and to create an enabling environment for sustainable development in partnership with those committed to building a caring society. It works in partnership with non-governmental organizations (NGOs), faith-based organizations (FBOs), the business sector, organized labor and other role-players in the spirit of Batho Pele (People First).

On 29 October 2006, Act No. 13, 2006  Older Persons Act, 2006 was assented by the President to deal with the plight of older persons by establishing a framework aimed at the empowerment and protection of older persons and at the promotion and maintenance of their status, rights, well-being, safety and security. The Preamble to the Act [6] recognizes that the Constitution establishes a society based on democratic values, social justice and fundamental human rights and seeks to improve the quality of life of all citizens in terms of the Bill of Rights as set out in the Constitution, everyone has inherent dignity and the right to have their dignity respected and protected; and whereas the State must create an enabling environment in which the rights in the Bill of Rights must be respected, protected and fulfilled; it is necessary to effect changes to existing laws relating to older persons in order to facilitate accessible, equitable and affordable services to older persons and to empower older persons to continue to live meaningfully and constructively in a society that recognizes them as important sources of knowledge, wisdom and expertise.

One doesn’t need special skills to diagnose that the elderly who has lost all their teeth (dentally disabled) needs a denture to rehabilitate the disabling effect to their speech, mastication and oral health functioning. The toothless elderly needs basic prosthetic services. This intervention will have a major revitalizing effect on almost all aspects of their standard of life, nutritional health, oral health and general health. The spirit of the Older Persons Act  is certainly underpinned by the sense of compassion that denturists have demonstrated for providing rehabilitation services to the elderly and other edentulous people in need of having their dignity restored by dentures! Due to their flexibility, Denturists are often the only denture service available for institutionalised or hospitalized geriatric patients. 

The Convention on the Rights of Persons with Disabilities of the United Nations underwrites i.a. the principles of dignity, freedom of choice, equality and non-discrimination, accessibility of services and access to justice, provision of health and rehabilitation services, and full and effective participation and inclusion in society of any person with disabilities[7]. These principles should indeed also apply to those with a teeth-impaired disability in South Africa.

The honorable Minister of Health, expressed concern on 17 October 2002 that Clinical Dental Technology have not been implemented, despite been promulgated through legislation in 1997, and that a need exists for such a service. The fact that “quacks ” are providing a denture service in abundance poses a threat of transmittable diseases due to unhygienic practices. Her concern is not so much about the price as the availability of a quality denture service to the public[8].

When the Minister of Health presented the Health Charter in August of 2005, she invited all health stakeholders to give their input towards more efficient health services that are patient centered and to find tailored solutions for specific needs. In response to that invitation, The Society were in the process to draft a memorandum to the Human Resources Cluster of the Department of Health in a quest to find a solution to the deadlock on the establishment of the category of Clinical Dental Technology (CDT), when the launch of the Strategic Framework for Human Resources for Health Plan in August 2005 came to our attention. All stakeholders were invited to make further recommendations to facilitate the process of finalizing this Plan for implementation[9].

The Society For Clinical Dental Technology submitted our Memorandum to the Department of Health as a general quest to implement the category and asked for an opportunity to make a presentation to the Human Resources Unit[10]. All the stakeholders in Dental Technology, including the SADTC, the DENTASA, and the Universities of Technology that train Dental Technicians, submitted supporting documents to our proposal[11]. 

20 months after The Society submitted our memorandum, after various dates have been postponed, we still had no opportunity to present our proposal towards improving the efficiency of denture delivery in South Africa. With the launch of this website we intend to inform whoever has access to the WorldWideWeb and our website, of our proposals. Who knows what partnerships may develop as a result? The spirit of the Older Persons Act  is certainly underpinned by the sense of compassion of denturists for providing rehabilitation services to the elderly and other edentulous people in need of having their dignity restored by dentures!  

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[1]Fred Hollows (1929-1993) was a passionate ophthalmologist and great humanitarian who became known for his work helping restore the eyesight of countless thousands of people in developing countries around the world. The Fred Hollows Foundation has worked in collaboration with local blindness prevention and other health organizations in more than 38 countries throughout Africa, Asia (South and South East), Australia and the Pacific. www.hollows.org
[2] President Nelson Mandela State Of The Nation Address, 24 May 1994.
[3] President Thabo Mbeki State Of The Nation Address, 6 February 2004.
[4] Dr Manto Tshabalala-Msimang, Minister of Health. Debate on the State Of The Nation Address, 10 February 2004.
[5] Dr Manto Tshabalala-Msimang, Minister of Health. Debate on the State Of The Nation Address, 10 February 2004.
[6] Preamble to Act No. 13 of 2006, the Older Persons Act of 2006
[7] Convention on the Rights of Persons with Disabilities  - Prepared by the UN Web Services Section, Department of Public Information Copyright United Nations 2006
[8] Zak Gordon Fatagodien The Big Issue of Clinical Dental Technology – Report by the Denturism Committee  Chairman, Newsletter of the South African Dental Technicians Council December 2002, Volume 1 No 2.
[9] A DRAFT STRATEGIC FRAMEWORK FOR THE HUMAN RESOURCES FOR HEALTH PLAN – Executive Summary Dr Percy Mahlathi, Deputy Director General: HR, National Department Of Health. August 2005.
[10] Memorandum by The Society for Clinical Dental Technology to the Human Resources Cluster of the National Department of Health as a GENERAL MOTIVATION FOR THE ESTABLISHMENT OF A CATEGORY OF CLINICAL DENTAL TECHNOLOGIST IN ORAL HEALTH CARE. – In response to the Draft Strategic Framework for Human Resources for Health Plan. August 2005
[11] Documents forwarded/copied by the SADTC

Dentists and Denturists have globally been subject to inter-professional rivalries and struggles for mutual respect and understanding. Historically, the relationship between Dentists and Denturists has in most countries been ambivalent at best, and more often than not, hostile and antagonistic. Legislation, and by implication, community dental health care, has often been shaped and defined by inter-professional conflicts and rivalries[1]. Globally the popularity of Denturism is spreading gradually with most of the initial legislation being upgraded to keep track of global developments and bringing the work demarcation in line with local demands and international tendencies[2].

Dentists have expressed concern that Denturists do not accept their field of expertise and continuously want to encroach into more areas of Dentistry [3]. The concern is unfounded! Denturists worldwide have always wanted to specialize in all areas of removable prosthetics. It is the Dentists themselves that insisted initially that Denturists be restricted to full dentures only. Logic dictated in the end that Denturists were right all along to insist on all areas of removable prosthetics, that includes upper and lower, full sets of complete dentures, acrylic & metal partial dentures, including immediate dentures, over-dentures, implant supported dentures and also the provision of mouth guards, oral protectors and sleep apnea appliances, as well as any repair, reline, remodel or adjustment thereto. See also the Scope of Practice on this website. In a nutshell: Denture wearers consult denturists for dentures to replace lost dentition. Patients continues to consult dentists for care and treatment of their natural teeth. Oral pathology and oral disease are referred to a dentist. This is a win/win situation of mutual referral, with the patient having the freedom of choice about which service provider to use for removable dentures.

Fortunately, there are many competent conscientious dentists doing excellent work in a wide variety of dental disciplines. The concept of denturism is not to take anything away from the dentist, nor restrict dentists in any way, but to allow patients to make a free choice. It is simply about trained Denturists to be in a legal profession to supply patients directly with accurate, aesthetic, and functional dentures, that provide denture-satisfaction and optimal success. Denturists have no ambitions to become dentists, or to practice dentistry. There is a perfectly clear route to enter that profession. Denturists do not want to crown teeth, treat caries or dental disease, fill cavities, do root canal treatments, administer injections, do orthodontic treatment, oral surgery or scale and polish natural teeth. Those are examples of the areas that only dentists are expertly trained for. Likewise only dentists are qualified to extract teeth, insert implants into the patient’s jaw and modify any natural tissue in the patient’s mouth. Dentists work on natural teeth and living oral tissue in contrast to denturists that work on the clinical procedures and all aspects of the fabrication of artificial removable teeth, without doing any modification of natural tissue. As in the case of oral & other diseases, those aspects of health treatment are referred to dentists or other medical specialists! Denturists are denture experts. They want recognition for their expert abilities and training to specialize in their own field, which is to provide the partially or fully edentulous patient with the best possible dentures (and some other removable appliances that they are expertly trained to manufacture) on a one-to-one basis in a compassionate and professional manner. See also Denturism is pro-denture wearer, not anti-dentistry also on this website. 

 

Dentistry have evolved into an highly specialized team of expertly trained professionals working co-operatively to best serve all the oral health needs of the population. See also Dental Care providers also on this website. The introduction of the specialized category of Denturist will free the hands and time of dentists to focus on more pressing Oral Health priorities and more advanced procedures only a dentist is qualified for, and provide for a more efficient utilization of Oral Health Human Resources [4].

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[1] International Federation of Denturists www.international-denturists.org/ Denturism  
[2] Gerry Hanson Globalization of Denturism Presentation by the Chief Executive of the International Federation of Denturism to the National Denturist Association (US, May 2005) and the Australian Dental Prosthetists Association (Sydney, August 2005)
[3] Letter by the SADA under signature of the President Dr DH Conradie to The Society in response to a letter about the Dental Technicians Act and Denturism dated 5 December 2005
[4] Memorandum by The Society for Clinical Dental Technology to the Human Resources Cluster of the National Department of Health as a GENERAL MOTIVATION FOR THE ESTABLISHMENT OF A CATEGORY OF CLINICAL DENTAL TECHNOLOGIST IN ORAL HEALTH CARE. – In response to the Draft Strategic Framework for Human Resources for Health Plan. August 2005  

  

 

Dentist's deficient training in Prosthetics

 

The US Federal Trade Commission [1] did extensive research into all aspects related to the supply of dentures over a period of 5 years . In relation to the training and competencies of dentists, these are some of their findings: 

•  With the exclusion of those few states where denturists are legislated, only dentists may fit and furnish complete dentures to customers; however, virtually all dentures are fabricated not by dentists, but by dental technicians, most of whom work outside of dentists' offices in commercial dental laboratories. (FTCR page31)

• The majority of dentists furnish very few dentures. notwithstanding the fact that dentures are one of the most profitable dental procedures, denture care is apparently a service many dentists do not enjoy providing. (FTCR page33)

• Although denture care is profitable to dentists, a very large portion of dentists, particularly younger dentists, have little interest in providing these services. (FTCR page34)

• It is widely believed that dental education has recently de-emphasized removable prosthodontics and that dental students may not have received sufficient training to feel confident in their skills. (FTCR page35)

• Repeatedly the Commission heard that the emphasis on preventive dentistry in recent years have diminished the attention given to denture prosthetics. (FTCR page36)

• The Commission believes that contemporary undergraduate dental education programs too often produce dentists who are so ill-equipped in denture fabrication, that they are not capable of judging the adequacy of the denture prosthesis that they order from a dental laboratory. (FTCR page36)

• Concern about the inadequacy of dentists' education in removable prosthetics has similarly been expressed in a substantial body of dental literature. (FTCR page37) 

It is confirmed from various training institutions internationally that dental curricula worldwide have slowly but inexorably contained a de-emphasis on the technical component, in favour of the biological basis of dentistry and there is no doubt that dental trainees are qualifying with fewer technical skills than was the case in the past and are needed to meet the routine requirements of general practice [2]  

 

In the USA a newly graduating dentist could typically only have seen ±3 patients for removal dentures during their entire training. The complete course of removable prosthetics, including lectures, runs about 80 hours. This has been confirmed to be about the norm for US Dental Schools. In stark contrast, Denturism graduates in the USA are required to complete 10 patients’ removable cases, so at a minimum, they are completing 3 times the clinical cases than at dental school. However, when denturist students externs in their second year, they may have 5 - 10 times the clinical exposure in denture work that dental students get. In addition to the clinical cases, Removable Prosthetics covers about 1,000 - 1,200 hours of the >2,000 hours of Denturist study [3] Over the past 3 decades US dental schools have cut back curriculum hours in denture training for dental students by 90% and over the next ten years, one-third of all dentists who currently provide denture care are expected to retire from practice, leaving the rapidly increasing US denture population in a vacuum. The reason that dentistry is unable to provide adequate denture training for it's students is that there are not enough hours available in it's curriculum. Dentistry's scope of practice is so overloaded and complex that dental schools cannot adequately provide its students proficient denture care training in only four years of study [4].

 

In Australia[5] and New Zealand a Denturist has up to six times the level of training in removable prosthetics that a Dentist has [6] It is further reported that Denturism is so well established and accepted in Australia and dentists do so little denture work themselves, that Dental Universities are considering the removal all together of prosthetic training from the dental curriculum [7], they also find it difficult to find dentists with sufficient experience in this field to come forward as tutors. 

 

In South Africa the current training of dental students in their shortened training program has resulted in an unacceptably low level of instruction in prosthetics. A dentist may now qualify with having only set up one or two sets of dentures him/herself and sometimes having to ask advice from their contracted dental technician about basic prosthetic procedures (even clinical procedures ). Each patient presents individual problems that require a multi-disciplinary approach to understanding the problem and devising a solution, the provision of which needs highly developed dexterity skills.  Oral Health Professionals serving these patients must be competent to design and manufacture removable prostheses to a clinically acceptable standard. Advanced forms of prostheses can involve occlusal rehabilitation, sophisticated metal technology, precision attachments and implants [8]. 

 

It has been suggested that The Society document and present cases of incompetence due to deficient training of dentists on this website. It would be simple to demonstrate and prove the fact of deficiency, but The Society do not want to gain recognition for denturists to practice, due to our ability to rubbish the reputation of an Oral Health Team member. That is not the type of morality The Society wants denturism to be associated with. Individual dentists should not personally be held accountable for inadequacy in the training system they attended. The Denturism lobby in South Africa have always recognized Dentists to have an important role in serving the oral health of our people and have been working towards recognition that denturists also has their own intrinsic merit.[9][10] 

 

Denturists receive more intense training in prosthetics than dental students and see a much higher amount of denture patients on a daily basis than dentists. The continued fragmentation of this service in South Africa through a go-between with the given communication impediments, can often not produce the same level of specialized prosthetic service provided by denturists. The result of continuing to provide dentures through a go-between is often a dissatisfied patient and a frustrated dentist having to inform the dental technician that yet another denture must be remade [11] (free of charge? - with the technician  having to absorb the costs ).

It is not surprising to note that the National Oral Health Survey of 1988-89 confirms that the construction of complete dentures is identified as one of the most difficult procedures a dentist may be called on to perform. In the training in denture prosthodontics, technical and clinical skills can only be acquired after many hours of laboratory and clinical hands-on time. Denture prosthodontics is a science and an art and is one of the most challenging branches of dental practice in which to succeed [12]. In view of the de-emphasis in some aspects relating to prosthetic training, some newly qualifying dentists in South Africa are incompetent to giving clear instructions or cognitive guidance to dental laboratories, resulting in an unacceptable level of remakes and eventual referral of patients to the dental laboratory to “fix it” [13] Dental technicians are the recognized experts in making dentures and already have a three-dimensional cognitive understanding of the clinical procedures required. In view of these facts, a course devoted to specializing in denture prosthodontics must therefore lead to a superior clinician in the denturist than in the dentist [14].

It makes operational sense to add clinical/biological skills to the work of dental technicians with regards to the de-fragmentation of the process of providing dentures and have one-and-the-same person doing both the clinical and technical procedures involved and for that purpose deal directly with the person for whom the denture is being made. Most people would still need a dentist, for care of their natural teeth.  The provision of dentures by CDTs will free the hands of dentists to use their time and specialized skills more effectively towards the prevention and treatment of oral disease and the promotion of oral health  - the primary focus of their training and reason for having dentists. Delegation of the essentially technical process of denture manufacture (including the simple clinical procedures involved) away from a multi-disciplined dentist to an expert with more specialized duties must inevitably produce efficiency or service gains not only for the dentist and the denture-maker, but especially for the denture wearer. Such denturists specialized by nature of their training and education in discipline-specific removable prosthetic work, will gain more experience and serve more denture patients per day than dentists.

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[1] Federal Trade Commission Report (1987) Sale of complete dentures: Effect on Present and Alternative Regulations

 [2] Professor Cyril Thomas. Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. E-mail to The Society-Tue 03/07/2007
[3] Dr Kenneth Kais DDS, Head of Bates Technical College, Washington. Member of the Education Committee of the National Denturist Association, USA. E-mail to The Society-2007-06-25
[4] E Van den Eeden, DDM, CD, CDT,  "Denturists – The Solution to America’s Denture Crisis". (May 16, 2007) Michigan Denture Reform Committee. 160 pages. Global Professionals 720 E. Eighth St, Ste # 1., Holland, Michigan 49423;

[5] Graham Key, Head Teacher (Dental Technology and Dental Prosthetics at the Sydney Institute), Chair of the Education Committee for the IFD. Blogg comment to an article about denturism in the Casper Star-Tribune at http://www.casperstartribune.com/articles/2007/12/26/news/casper/cb4919823e2256c4872573bd0001144f.txt comment published online on 4/01/2008

[6] Neil Waddell MDipTech(DentTech)(TN), HDE(UN), PGDipCDTech(Otago) Senior Teaching Fellow, Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, Dunedin. New Zealand. E-mail to The Society- Fri 02/03/2007
[7] Graham Key, former President of the Australian Dental Prosthetist Association, Chair of the Education Committee, IFD. E-mail to The Society- Thu 08/03/2007 
[8] Naude DA, van Rooy HK, Faber HS, Barrie RB. Complete Upper and Lower Dentures: Results from the Sociological questionnaire of the National Oral Health survey, (1988-89) p105  
[9] C du Plessis & DF Malherbe Denturism – A New Profession  (1990) A Report by the SA Federation of Dental Technicians

[10] DF Malherbe - Presentation by The Society for CDT to the workshop on Clinical Dental Technology held in Pretoria by the SADTC on 27/11/1998

[11] Malherbe DF, Steyn LA, du Plessis C, Fatagodien Z, Clinical Dental Technology: A Quest for Equity in Oral Health Care. 1998 - Chapter 5: CDT in perspective/Standard of dentures – page113  
[10] Professor Cyril Thomas. Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. E-mail to The Society- Tue 03/07/2007
[11] Memorandum by The Society for Clinical Dental Technology to the Human Resources Cluster of the National Department of Health as a GENERAL MOTIVATION FOR THE ESTABLISHMENT OF A CATEGORY OF CLINICAL DENTAL TECHNOLOGIST IN ORAL HEALTH CARE. – In response to the Draft Strategic Framework for Human Resources for Health Plan. August 2005  
[12]  E-mail to The Society  from Professor Cyril Thomas. Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. 03/07/2007

The definition of Practicing Dentistry

Section 38 of the Health Professions Act (Act 56 of 1974) deals with the penalties for practicing as a dentist and in this regard very specifically defines the practice of the profession as follows:

 

(2) For the purposes of this Act the practice of dentistry means the performance of any such operation or the giving of any such treatment or advice as is usually performed or given by a dentist, or any operation, treatment or advice preparatory to or for the purpose of or in connection with the making, repairing, supplying, fitting, insertion or fixing of artificial dentures or other similar dental appliances.[1]

By virtue of their training and function, dental technicians make dentures and according to this definition are guilty of practicing dentistry. However, dental technicians do not claim to be dentists or get confused to be practicing dentistry. This manufacturing process of dentures and other dental appliances is a function sub-contracted to dental technicians because dentists do not make them any more, although they insist to maintain the monopoly for the selling of dentures as a go-between[2]. By the strength of this archaic definition, dentists often accuse denturists for the illegal practice of dentistry. That is  basic monopolistic protectionism, but gets twisted around to the gullible public and presented as concern for their oral health! Surely in this new millennium, even dentists must realize themselves that these archaic methods to create public panic has been outdated beyond any reason, knowing very well that none of it can be substantiated. When one reflects on the history of Medicine, physicians were given carte blanche; they handled everything. As they realized they couldn’t do it all themselves, support professions developed. Likewise, Dentists and Government need to understand how professional offshoots could benefit Dentistry and more importantly - the dental consumer![3] Denturism is a separate profession from dentistry and therefore it is critical to be regulated as such. As a typical example, the North American Industry Classification system (NAIC) has given the denturist profession a completely separate Standard Industry Code from the practice of dentistry, which is #621210, but for the practice of denturism it is #621399, showing them to be distinctly separate [4].

Being edentulous or partially edentulous is not a disease. It may be the result of oral disease but is essentially a healthy condition or state that needs rehabilitation. The process of denture delivery and all it’s stages is not a medical, but a technical procedure that takes place in a bio-clinical environment[5]. Dentists only does some of the fragmented procedures as a go-between clinician and outsource the fabrication of the denture to commercial laboratories. Dentists have become retailers that sells dentures at handsomely inflated markups to the consumer[6]. The bottom line in this regard is that there is no sustainable reason why removable dentures should not be provided directly by a denturist. Partial dentures can be provided by a denturist in a co-operative spirit with a dentist when required, as it is successfully practiced in numerous countries and states around the world. To restrict a definition of dentistry to the limited and uncomplicated clinical procedures of supplying dentures does a huge disservice to the status of dentistry by not recognizing their vast scope of training and education in the surgical and rehabilitation disciplines included in the oral health science of dentistry as part of the definition of their profession[7]. It is also blatantly dishonest to deliberately prevent another category from being recognized, if that category is in fact better qualified to provide that specific service more efficiently and at better affordable fees than themselves. The clumsy wording in this archaic definition is a remnant from the original Act dating to 1928, and is out of touch with international benchmarks. South Africa lags behind to embrace the positive results of implementing this addition to the Oral Health team, despite having made provision for Clinical Dental Technology through enabling legislation in 1997[8]. The introduction of a cadre of clinical dental technologist is long overdue [9].

How can the practice of dentistry be described? By the procedures a dentist carries out daily in his/her service to the public and for which he/she is expertly trained and qualified for. Dentists are general dental practitioners (doctors of oral health) and their work is mainly concerned with the science of prevention, diagnosis, and treatment of conditions, diseases, and disorders of the oral cavity, the maxillofacial region, and its associated structures as it relates to human beings (patients) and is responsible for treatment planning and the quality control of the treatment provided. While the work of dentists is often surgical in nature, they also treat many diseases of the oral cavity and the face chemotherapeutically. Dentists spend much of their time on the physical rehabilitation of damaged dentition. In order to ensure that they effectively execute their responsibilities, dentists may refer patients to specialists or other independent health professionals or employ Dental Technicians, Dental Assistants, Dental Therapists and Oral Hygienists, and utilize the services of Dental Technicians working in commercial dental laboratories or even outsourced to commercial businesses overseas. The nature of the respective responsibilities of these categories can either be independent, complimentary or supplementary (or a combination) to the services of a dentist.[10]

When the supply of dentures was added to the customary procedures exclusively reserved for dentist only, it became an international tendency to define dentistry in legislation in terms of the clinical procedures of supplying dentures. It was then convenient to prosecute a non-dentist supplying dentures of practicing dentistry  illegally, when it was in fact often a qualified denturist (who's qualification is conveniently not recognized) providing a higher specialized service than many registered dentists. Dentists' training concentrates on the care and restoration of natural teeth. They study the procedures of manufacturing and supplying dentures and partial dentures only as a minute portion of their very extensive dentistry training program and provide only a fragmented go-between role in this regard as a retailer[11]. Denturists specialize in patient removable appliances and are fully trained to perform both intra-oral and laboratory procedures of complete and partial denture construction and maintenance. Both professions, working together through referrals are integral to providing complete oral health care and compliment one another very well, when allowed to[12].  

Being edentulous or partially edentulous is not a disease. It may be the result of oral disease but is essentially a healthy condition or state that needs rehabilitation. The process of denture delivery and all it’s stages is not a medical, but a technical procedure that takes place in a bio-clinical environment. Dentists only does some of the fragmented procedures as a go-between clinician and outsource the fabrication of the denture to commercial laboratories. Dentists have become retailers that sells dentures at handsomely inflated markups to the consumer. The bottom line in this regard is that there is no sustainable reason why removable dentures should not be provided directly by a denturist. Partial dentures can be provided by a denturist in a co-operative spirit with a dentist when required, as it is successfully practiced in numerous countries and states around the world.

As in many other countries the international tendencies are that Dental curricula have slowly but inexorably contained a de-emphasis on the technical component in favour of the biological basis of dentistry and there is no doubt that dental trainees are qualifying with fewer technical skills than was the case in the past and in fact are needed to meet the routine requirements of general practice[13]. It is noteworthy that the National Oral Health Survey of 1988-89 already concluded that the construction of complete dentures is identified as one of the most difficult procedures a dentist may be called on to perform [14]. In the training in denture prosthodontics, technical and clinical skills can only be acquired after many hundreds of hours of laboratory and clinical hands-on time[15]. In view of the de-emphasis in some aspects relating to prosthetic training, some newly qualifying dentists in South Africa are finding it difficult to giving clear instructions or cognitive guidance to dental laboratories. The current training of dental students in their shortened training program has resulted in an unacceptably low level of instruction in prosthetics. A dentist may now qualify with having only set up one or two sets of dentures him/herself and sometimes having to ask advice from a contracted dental technician about basic prosthetic procedures (even clinical procedures)[16].

Denture prosthodontics is a science and an art and is one of the most challenging branches of dental practice in which to succeed. Each patient presents individual problems that require a multi-disciplinary approach to understanding the problem and devising a solution, the provision of which needs highly developed dexterity skills. Oral Health Professionals serving these patients must be competent to design and manufacture removable prostheses to a clinically acceptable standard. Advanced forms of prostheses can involve occlusal rehabilitation, sophisticated metal technology, precision attachments and implants[17].

Dentists do not make dentures and only sees denture patients only occasionally. It is becoming common in most countries for dentists to have auxiliary personnel see the patient for an impression, then send that impression to a laboratory for denture fabrication (even outsourced to another country). They buy dentures and resell them with a substantial mark-up. Denturists are committed to only providing removable prosthetic appliances – it is their calling, serving only denture patients all the time. Denturists are very capable of recognizing oral abnormalities and referring their patients to the proper medical specialists. They do not sell dentures; they provide a personalized service to patients, fabricating a custom appliance that they create themselves[18]. 

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[1]    Section 38(2) of the Health Professions Act (Act 56 of 1974)

[2]    Letter by The Society for CDT to the Chairman of the OHHR Task Team Dr Mcuba, Department of Health  – 4 February 2004

[3]    Paul Levasseur, President of the IFD (2003) as quoted in "Provision of Removable Prosthetics by Denturists – What is the Controversy?" International Dentistry South Africa, Feb 2006 

[4]   E Van den Eeden, DDM, CD, CDT,  "Denturists – The Solution to America’s Denture Crisis". (May 16, 2007) Michigan Denture Reform Committee. 160 pages. ISBN 978-0-9794403-0-4 Global Professionals Publication 720 E. Eighth St, Ste # 1., Holland, Michigan 49423

[5]   DF Malherbe - Presentation by The Society for CDT to the workshop on Clinical Dental Technology held in Pretoria by the SADTC on 27/11/1998

[6]   Paul Levasseur, President of the IFD commenting online to the article: "Not Giving Up" by Allison Rupp in the Casper Star Tribune of 26/12/2007

[7]   Memorandum by The Society for CDT to the Director-General: Department of Health dated 19 November 200,7 RE: Comments to Regulations defining the Scope of the profession of Dentistry as invited by Government Gazette, No 30374 of 19 October 2007.

[8]    Duffy Malherbe.  Provision Of Removable Prosthetics By Denturists – What Is The Controversy? International Dentistry South Africa, Laboratory World. Vol 8 No 1. Jan 2006

[9]    Mr. CL Frizzel HD DRCS (Edin) LDS (Birm): A Plea For A Special Dental Course. The Dental Magazine and Oral Topics, Vol 60, April 1943

[10]    Proposals for An Integrated Oral Health Statutory Structure For South Africa: Integration of the governance of the oral health professions in South Africa, July 2007. Prepared by the Human Resources and Management Development branch with input from oral health task team members.

[11]    DF Malherbe, LA Steyn, C Du Plessis, Z Fatagodien. Clinical Dental Technology: A Quest For Equity In Oral Health Care by The Society for   Clinical Dental Technology, 1998 Ó. Motivational Report to the SADTC, Minister of Health and the Department of Health.

[12]    Dr Kenneth Kais DDS, Head of Bates Technical College, Washington. Member of the Education Committee of the National Denturist Association, USA. E-mail to The Society-2007-06-25

[13]    Professor Cyril Thomas. Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. E-mail to The Society-Tue 03/07/2007

[14]    1988-89 National Oral Health Survey of the Department of Health

[15]    Professor Cyril Thomas. Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. E-mail to The Society-Tue 03/07/2007

[16]     Dr Kenneth Kais DDS, Head of Bates Technical College, Washington. Member of the Education Committee of the National Denturist Association, USA. E-mail to The Society-2007-06-25

[17]    Baseline Competency for the Education and Training of Denturists - IFD  2007

[18]    Paul Levasseur, President of the IFD commenting online to the article: "Not Giving Up" by Allison Rupp in the Casper Star Tribune of 26/12/2007

 

Specialists or Quacks?

A degree in dentistry should not be the only qualification-criteria for evaluation of competency to provide oral health services, because some non-dentist categories have sufficient skills, knowledge and professional attitude to serve public oral health needs, and their knowledge base could be further enhanced for expanded public service. Existing Denturist educational programs require studies in the same sciences as dental programs. Denturist are very capable of recognizing oral abnormalities and referring their patients to the proper medical specialists[1]. Organized dentistry has consistently opposed clinical training for dental technicians to qualify as denturists and goes to extreme lengths to prevent them from getting accreditation. They then challenge the ability of denturists to provide comprehensive prosthetic procedures in terms of the fact that they are not qualified dentists or licensed clinicians[2]. It is like saying that you may not receive training because you have not been trained yet. The American experience is a good example of the tendency.  

The American Dental Association (ADA) passed a resolution (2001:436) that the Association vigorously opposes denturism, the denturism movement, and all other similar activities, regardless of how they are designated, in the USA. They further resolved (1976:868; 2001:436) that when the words “denturist” or “denturism” and all synonymous terms are used in American Dental Association publications, the terms should be accompanied by a brief but prominent footnote indicating that a “denturist” is a person who is educationally unqualified to practice dentistry  in any form on the public, and further resolved, that constituent  societies act in concert with the American Dental Association. Another resolution reads that the American Dental Association Board of Trustees be authorized to provide financial aid to any constituent dental society that is faced with the imminent prospect of a substantial effort to legalize or promote denturism or any illegal practice of dentistry in its state through legislative action or use of the initiative process [3]. The ADA further adopted a policy of passing legislation where ever possible in the USA to recognize the provision of dentures by non-dentists as a felony. Many qualified denturists are harassed to pay fines and have been humiliated through the handcuffed-to-jail scene  and some even carried out "criminal " sentences for the crime of serving their communities with their appreciated essential service, because the ADA and it's members are protecting their monopoly greedily by refusing to grant accreditation to denturists' specialized training. (sic!) Surely this can not be the same USA that was portrayed during the Cold-war as the land of freedom and was once called the Capital of Free Enterprise!

The American Dental Association (ADA) have defined denturists as unlicensed people who supply, fit or deliver dentures to patients directly, without supervision by a licensed dentist(?), and have deliberately drawn a parallel of illegal (in terms of the denture monopoly) denturists with common signs of questionable care, fraud and quackery. They define the quack as "an ignorant or dishonest practitioner  " and suggests that all unlicensed dental technicians who practice dentistry illegally are "dishonest " by definition, and ignorant of how much necessary dental knowledge they lack. Denture patients are also insulted by questioning their lack of basic dental knowledge to make informed decisions about their prosthodontics needs, and suggesting that they need the advice of an honest, competent dentist [4] (Does this statement admit that many dentists are not honest and/or competent?). Both assertions are grossly distorted as the reality is that there are good and bad examples in all professions also in both dentistry and denturism, and it serves no purpose to compare the worst in one profession with the best in another. It seems obvious that dentists, who continue to impede denturists' efforts to have denturism recognized hence regulated, do greater harm. Dentistry's argument that only dentists can provide denture services is unsubstantiated and will remain just that; an empty distorted statement!

The ADA has always held the position that only licensed dentists are competent to take impressions and insert or fit dental prostheses. This archaic definition of practicing dentistry  is in fact nothing less than a crude description that more accurately defines partly what denturists do than dentists. To restrict a definition of dentistry to the fragmented clinical procedures involved in supplying dentures, does a huge disservice to the professional status of dentists by ignoring the wide scientific and biological knowledge base of their training, the wide field of oral health services they are qualified for and totally ignores the de-emphasis of their own technical training for these procedures.  We have just discussed the deficient training of dentists in this regard under the previous heading above and could well pose the question as to who the specialist are and who the quack, in this regard.  

Dr Carl Ebert, a practicing dentist from Minnesota, USA that motivated the Denturism initiative in that State, said that the opposition to denturism by organized dentistry in many states of the U.S. was brutally misleading and, ultimately devastating to the passage of any policy to allow denturism. They have a lot to protect and fear losing any small portion of the business to which they have been granted exclusive rights. Organized dentistry sees denturism as a threat and a turf war, but should understand the necessity to find solutions for those not served by the dental profession [5].  Dr. Caswell A. Evans, a dentist and Associate Dean at the University of Illinois-Chicago, said dentists must stop fighting efforts to expand care to patients they are not currently treating. The system is failing many patients, he said. “Right now we have a double standard of care,” Dr. Evans said [6]. Some people have access to conventional providers and can still afford the service. Others have access to dentists but cannot afford the fees. They are prevented from access to alternative service providers because organized dentistry are opposed to the licensing and training of such categories because of the implied competition. The dental profession’s critics — who include public health experts, some physicians and even some dental school professors — say that too many dentists are focused more on money than medicine. “Most dentists consider themselves to be in the business of dentistry rather than the practice of dentistry,” said Dr. David A. Nash, a professor of Pediatric Dentistry at the University of Kentucky.  “I’m a cynic about my profession, but the data are there. It’s embarrassing.” [7]

Laboratory fabrication of denture prosthesis is only a part of prosthodontic treatment. The practitioner must be able to detect oral diseases as well as detect oral manifestations of systemic disease. The more mouths that are seen by Denturists, the more patients exhibiting potential pathological conditions can be referred by them and with this cooperative approach to early detection, help protect the public's oral health and expand the amount of gatekeepers of oral health[8]. The practitioner must be alert to possible hazards to the patient if dentures are placed on unhealthy tissues and the hazards if appropriate precautions are not taken in response to certain observed medical conditions. That is why accredited training, strict competency exams, and a bona fide license for denturists are necessary. Aside from the fit of the denture, there are psychological aspects of prosthodontic treatment. A certain amount of patient cooperation is required, and expectations must be reasonable. Follow-up aftercare, such as denture adjustments for sore spots, must be provided in a professional manner at or above the standard level of care.  

In Canada at George Brown College five hundred applicants applied for fifty seats in the Denturist program for 2008[9]. Educational programs require studies in the same sciences as dental programs and are widely recognized. In stark contrast, similar US programs have been met with severe opposition. The denturist qualification from Mills Grae University and other United States Training Institutions that have started courses in Denturism have been rejected on the grounds of not having accepted accreditation or not feasible because State subsidies could not be attained. The denturist program in Washington State at Bates College is accredited by the Northwest Commission on Colleges and Universities, an institutional accrediting body recognized by the Council for Higher Education Accreditation and the Secretary of the U.S. Department of Education, but not recognized by the ADA. The strategy to oppose denturism is simple: With no denturism training programs available, it may become impossible for any new denturist to become licensed in any U.S. state. The denturist's legal movement could wither on the vine if the present handful of licensed denturists eventually retire and are not replaced by younger licensed denturists [10].

American denturists generally acquired the Canadian qualification from the George Brown College in Toronto[11], (widely accepted as the benchmark denturist qualification) because local training Institutions always found stumbling blocks put in their way that prevented accreditation of local training courses in the USA. To discredit the qualification on the grounds of it not being USA-based and/or to reject the knowledge base of the profession without any opportunity for denturists to prove their specialized competence is simply dishonest. Many qualified denturists with many years of practical experience have been prosecuted and jailed for a felony for "practicing dentistry without a license " simply because Organized Dentistry prevents their qualification from being recognized[12]. The denturist's message about their knowledge about health matters, biologic training and professional standards is often lost in the misleading arguments of the turf war[13].

The more dentists warn against the threat of illegal denturists, the more denture wearers realize that dentists are waging a turf war and are hiding the facts from them. Denturists are the choice of service provider of the poor and the wealthy.  In the final analysis a denturist is a highly skilled oral health professional worthy of acceptance by the other members of the oral health team, and in terms of their education and training the true experts in their field, whether dentists recognize them as specialists or not.  The fact that the Denturist as an expert is personally responsible for the chair-side as well as the technical procedures and direct communication with the end-user, results in a more individualized and optimally constructed functional denture. The expansion of the Oral Health Team to include Denturists is effective Human Resource Development and an improvement in productive service-efficiency for both dentists and dental technicians.

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 [1] Paul Lavasseur LD, DD(Can), HMCDP(UK) President, National Denturist Association (USA) President, Intenational Federation of Denturists. -  Blogg Comment to an article about denturism published on 31/12/2007 at http://www.casperstartribune.com/articles/2007/12/26/news/casper/cb4919823e2256c4872573bd0001144f.txt

 [2] E-mail debate about clinician status of non-dentists with Lesley Naidoo, President of the Dental Therapy Association of SA 28-29/10/2006
[3] Current Policies of the ADA. Major policies adopted by the American Dental Association House of Delegates from 1954 through 2004 that are still in effect in 2005, except for policies that appear in the Association’s Constitution and Bylaws and Principles of Ethics and Code of Professional Conduct. Page 131. Illegal Dentistry

 [4] Robert B. Stevenson, DDS, MS, MA - Quackery, Fraud and Denturists

 [5] [6] [7] Alex Berenson - Boom times for Dentists, but not for Teeth. The New York Times October 11, 2007 nytimes.co 

 [8] A Study of Denturitry Directed by the Kentucky General Assembly - Research Report No. 292 - Legislative Research Commission, Frankfort, Kentucky. January 2000
 [9] Paul Levasseur, President of the IFD commenting online to the article: "Not Giving Up" by Allison Rupp in the Casper Star Tribune of 26/12/2007

 [10] Alex Berenson - Boom times for Dentists, but not for Teeth. The New York Times October 11, 2007 nytimes.com

 [11] Paul Levasseur, President of the IFD commenting online to the article: "Not Giving Up" by Allison Rupp in the Casper Star Tribune of 26/12/2007

 [12] e-mail from Wanda Anderson to The Society for CDT in connection with the article: In Kentucky's Teeth, Toll of Poverty and Neglect  by Ian Urbina in the New York Times of 24/12/2007

 [13] Bruce Anderson in a letter to the Editor of the New York Times on 26/12/2007 in reply to the article : In Kentucky's Teeth, Toll of Poverty and Neglect  by Ian Urbina 

 

Acceptance of legislated practice  

 

The Dental Dean of Sydney University (former SA Prosthodontist & academic) supports the introduction of denturists wherever there is a need for them (around the world)  in view of their superior skills as clinicians[1].  In Australia the Denturist professional indemnity insurance is the lowest of any health profession because they do their job so well that complaints are minimal compared to Dentists.[2] After conducting a five-year study, the US Federal Trade Commission sent all state governments a letter of recommendation, encouraging them to institute the profession of denturism throughout all the States of America [3].

 

Dr Curry and FW Brunelle, Director General - Special Health and Support Services, Department of Social Services and Community Health in Alberta, Canada report that the public appears to be extremely pleased with denturists' services and that few complaints about poor service have been received. Similarly, WJ Camozzi, Manager of the Health Division, Ministry of Human Resources in British Columbia, Canada reported no record of complaints from denturist services and a few particular expressions of satisfaction, an unusual occurrence with respect to welfare services [4].

 

The acceptance of denturists in Canada in general and the Northwest United States particularly has improved greatly over the last few years. Only isolated cases of dentists bullied openly by their Association when co-operating with denturists have been reported lately. Most enlightened dentists view denturists as colleagues who provide competent, professional continuity of care to their patients. They have also demonstrated the ability to be a source of new patients to dentists as well. [5] Very little negative comments have been reported about Denturism graduates from local Dentists in Washington and in fact, most dentists refer their patients to Denturists because they either don't want to be bothered by dentures and can make much more, cutting crown preps all day, or they realize their patients will be getting a better result from a provider with more experience in prosthetics than themselves [6].

 

Good co-operation and mutual acceptance between denturists and dentists have also been reported from Finland. Denturist routinely refers patients with pathology and maintenance work on remaining natural teeth, while dentists often refers patients in need of prosthetic work to denturists. Dentists only lost 2,7% of work turnover due to the introduction of denturism but was more than adequately compensated for, by the patients referred to them by denturists [7].

It is common for New Zealand [8] and Australian dentists to call upon denturists when they have “complicated" Full Upper and Full Lower Dentures to do. These patients are often "Intellectually Impaired" or Psychosomatic patients. The dentists tend to transfer the onus of responsibility onto the Denturist by sub-contracting such patients to them. Some Dentists refers all their difficult cases and those with complications to the specialized denture care of Denturists [9]. In Australia the supportive co-operation and professional interaction between Dentist and Denturist are laudable. They are both an integral part of the Dental Team with no conflict between the two. In many dental practices, dentists cannot work without a denturist in the mix of services offered. It releases them from General Prosthetics and enables them to occupy their time with much more financially rewarding measures, preventative Dentistry and Implantology [10].

See also EU recognition of Denturist Qualification and Recognition of Denturists as the most Efficient denture service providers

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[1] Visitor's Comment on this website by Professor Cyril Thomas.Former South African Prosthodontist, Formerly: Head of Dental Prosthetics, University of Stellenbosch. Formerly: Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. 03/07/2007

[2] Graham Key, Head Teacher (Dental Technology and Dental Prosthetics at the Sydney Institute), Chair of the Education Committee for the IFD. Blogg comment to an article about denturism in the Casper Star-Tribune at http://www.casperstartribune.com/articles/2007/12/26/news/casper/cb4919823e2256c4872573bd0001144f.txt comment published online on 4/01/2008

[3] http://www.usdenturist.com/Facts/rule_making.htm

[4] E Van den Eeden, DDM, CD, CDT,  "Denturists – The Solution to America’s Denture Crisis". (May 16, 2007) Michigan Denture Reform Committee. 160 pages. ISBN 978-0-9794403-0-4 Global Professionals Publication 720 E. Eighth St, Ste # 1., Holland, Michigan 49423

[5] Joe Coss (Outreach and Education Coordinator) - Oregon State Denturist Association. E-mail to The Society- 28 June 2007  
[6] Dr Kenneth Kais, DDS Dean of Bates Technical College, Tacoma, Washington. E-mail to The Society- 25/06/2007- 
[7] Jan Jansen quoting Prof Risto Touminen, Helsinki, Sweden in Internationaal Nieuws, (October 1989) Tandprotetisch Nieuws
[8] Graham Morrissey NDip DentTech (RSA) PG Dip CDT(NZ). E-mail to The Society on 20/05/2007 
[9] Graham Key, National President (Australian Dental Prosthetist Association), Head Teacher (Dental Technology and Dental Prosthetics at the Sydney Institute), Chair of the Education Committee for the IFD E-mail to The Society on 17/08/2004
[10] Ismail Larney, Senior Lecturer in Dental Prosthetics at the Sydney Institute and part-time Denturist at a group practice in Sydney. Australia. E-mail to The Society- Fri 27/01/2006

 

Serving the needs 

 

South African Dentists should not view the emergence of Denturism as encroachment on their rights, but rather as a genuine attempt to find solutions to provide the most basic of all oral health services to (especially ) the elderly and the poor, but also to other denture wearers who should also have the freedom to choose them as direct service provider. Why are we not following the international trend, moving forward together, in a spirit of mutual respect, to champion the only real cause worth tackling, that of the oral health and well being of our communities? That goal can best be achieved by all categories doing their very best in their own expert capacities [1].  

 

"Where-ever you get into contact with Denturists, they have compassion for denture wearers and are striving to serve their needs with a human touch of caring (and clinical & technical competence too). Here in British Columbia, denturism runs in my family. About a year ago, my aunt, cousin, sister and I were talking about how we would like to go to an underprivileged area of the world, and make dentures free of charge for the locals who normally could not afford this service "[2].

Regardless of how successful fluoridation of drinking water and other programs in the fight against oral disease are, tooth loss will inevitably eventually occur. There will always be denture wearers and denture needs. 11% of the population aged between 22-65 is edentulous[3]. The bulk of those older than 65 are toothless, ranging to 88% of the institutionalised elderly[4]. We have an aging population in South Africa with more people living longer[5]. This elderly group was projected to exceed 18% of the population. The projected (if successful ) decline in edentulism will be more than offset by the increase in the adult population older than 55 years. All denture wearers will need their dentures replaced every 5-8 years. As a result, a  sizable minority of the patient population will continue to need complete and other dentures. If training of denture prostheses is eliminated from the dental education curriculum, millions of dentures will have to be supplied through alternative providers.

The Department of Health has officially classified denture provision as tertiary prevention[6] and as such a low priority can never provide funding for the prevailing backlog that exists due to the need to focus health expenditure on more pressing priorities, such as HIV/Aids, communicable diseases, malaria, cholera, tuberculosis, etc. Due to budget restraints, there is little priority to employ sufficient numbers of dentists to provide adequate community dental services, even more funding dentures. If the state cannot provide the destitute, the poor and the old with dentures, then surely the Department of Health as the custodian of Health services in this country, should accept the responsibility of Stewardship for Health Care to assure that an alternative accountable category such as a Denturist be developed to provide an alternative better affordable service that will safeguard the oral health of the denture wearer[7].

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[1] Duffy Malherbe. Provision Of Removable Prosthetics By Denturists – What Is The Controversy? International Dentistry South Africa, Laboratory World. January 2006  
[2] Erika Coldbank. Visitor's Comment on this website on 06/08/2007 by a Denturist from Duncan, British Columbia, Canada 
[3] National Oral Health Survey 1988-89, Department of Health.
[4] Van Wyk, Farman, Staz (1977), Dreyer (1977), Louw & Moola (1979), Watermeyer, Thomas & Van Wyk (1979), Thomas & Watermeyer (1979), 
[5] Watermeyer, Thomas & Van Wyk (1979), Thomas & Watermeyer (1979), Naude, van Rooy, Faber & Barry (1989)
[6] FJ Smit National Oral Health Policy for South Africa  - Technical Working Committee of the Directorate of Oral Health of the Department of Health 1996
[7] DF Malherbe, LA Steyn, C du Plessis, Z Fatagodien Clinical Dental Technology: A Quest for Equity in Oral Health Care.  The Society for Clinical Dental Technology - Copyright © 1998. Motivational Report to the SADTC, the Minister of Health and the Department of Health
 

Humanitarian Outreach Program

The Society have made contact with an internationally established Humanitarian Foundation (involved in blindness prevention campaigns) that trains paramedical individuals to perform cataract eye operations on patients in many exceedingly destitute communities, also in South Africa [1]. The Foundation may be able to provide the answer to the legal clause that allows them to perform medical procedures in South Africa without fulfilling extensive medical studies. There may be a similarity with Denturists (Clinically trained Dental Technicians) to fulfill the enormous gap of denture needs that a large part of the SA population suffers [2]. The Society of Clinical Dental Technology may be able to take the (moral) lead and provide cost effective dentures to the underprivileged communities in SA, without undergoing a Dentistry degree.  

The Society are currently looking into the concept of providing free dentures to people in a destitute area, possibly through a district clinic and getting sponsors from dental suppliers and manufacturers to provide materials and teeth for this project. Dental technicians with ambitions to become Denturists will be making the dentures and do the clinical work under the supervision of a qualified Denturist as a Humanitarian Outreach Program, which will prove competence and need to our Government [3]. Possibly this work could be evaluated as part of a practical module of a training program in a specific formal education track connected to a distance learning program from a recognized Denturism Training Institution with International accreditation. 

There are obvious legal prescriptions that will have to be complied with, but at this stage we are more concerned that the unhygienic practices by quacks providing dentures, be displaced by accountable professionals who knows what they are doing, and that all oral health, infection control and hygiene protocols are followed. The intra-oral procedures, which experienced dental technicians understand better than many newly qualified dentists (with a de-emphasis and very superficial exposure to prosthetics) will be carried out under supervision of a Denturist [4] registered elsewhere. We have also received interest from practicing denturists overseas to come and do voluntary work on this project (and possibly sponsors too) [5][6][7]. This project is not about a license to practice illegally in the open market without control, or in competition with registered professionals, it is about FREE humanitarian services to destitute people in need, that are not served by the monopoly holder in private practice or the State.

---

[1] The Fred Hollows Foundation has worked in collaboration with local blindness prevention and other health organizations in more than 38 countries throughout Africa, Asia (South and South East), Australia and the Pacific. www.hollows.org
[2] e-mail correspondence from Ismael Larney, academic and practicing Denturist from Sydney, Australia on working with the Fred Hollows Foundation 17/04/2007.
[3] e-mail update by the Secretary of The Society to the dentaltechniciansforum (www.dentaltechforum@yahoogroups.com)
[4] There are at least 10 South African dental technicians qualified and registered as CDTs in New Zealand that we have contact with. There are also a few working in Australia, Canada and the UK. There is already one back in South Africa registered as a dental technician (but qualified and registered as a denturist elsewhere) who is a very committed active member of The Society 
[5] Visitor’s Comment by Erika Coldman from BC, Canada about compassion and potential co-operation in our Humanitarian Outreach Project.

[6] Visitor's comment on our website by André Massé  from Quebec, CANADA on 22/10/2007 expressing willingness to come to SA in 2009

[7] Visitor's comment on our website by Costa Nassar, DD, Ontario Canada on 5/11/2007eager to participate in our Humanitarian Outreach Project

 

• Patients, when a delay of over three months elapsed between onset of symptoms and visiting their physician and when they refused to accept their advice.

• Physicians if they committed one of the following errors:
  Wrong treatment.
  Wrong advice.
  No treatment or advice.
  Acceptable treatment but delayed referral when no improvement for a month or more.
  Unable to diagnose within a month, implying observation without treatment.

Dentists often get confused about the difference between Dental Technicians carrying out clinical treatment illegally and those that have been mandated through additional training to legally practice as Denturists, Denturologists, Clinical Dental Technicians, Dental Prosthetists or Tandprothetici, etc [43], depending on the geography where they are licensed to practice. The reference to illegal denturism is a contradiction in term. In Denmark dentists never had a monopoly in the supply of dentures, therefore denturists and dentists had equally legitimate standing in terms of the law. In Canada, Denturists have been carrying out clinical work legally since 1958, after organizing public support [44]. A survey regarding the opinions of dentists 20 years later showed the majority thought it was possible to work closely with a denturist, though they did not think they should be allowed to treat patients with natural teeth remaining [45]. Almost another 30 years have lapsed and today Denturists have been recognized in all 10 states and 2 territories of Canada individually recognizing the qualification and merits of the professional category with a full scope of practice including all removable prosthetic appliances. There is a high level of general acceptance by the public and the oral health professions with established referral pathways. Only a few members of the old school can't tolerate the idea of equality and those who simply don't get it [46], still remains, but the professional relationships in Canada and the Northwest USA in general has improved greatly over the last few years [47]. Denturists are appreciated by most enlightened dentists as colleagues who provide competent, professional continuity of care to their patients [48] and would not question the importance of all professional categories of Oral Health Team members to recognize and refer oral pathology for diagnosis and early treatment.

[27] A National Health Plan for South Africa. (1994) by the African National Congress. Assisted by the WHO and UNICEF  
[28] Office for National Statistics. Cancer trends in England and Wales: 1950-1999 London: The Stationary Office 2001;
[29] Florio SJ & Hurd TC. Gastric carcinoma metastatic to the mucosa of the hard palate. J Oral Maxillofac Surg 1995; 53:  1097−1098. 
[30] Tsang WM, Tong ACK, Lam KY & Tideman H. Nasal T/NK lymphoma: Report of three cases involving the palate. J Oral Maxillofac Surg 2000; 58: 1323−1327. 
[31] Robin PE, Jean PowellD & Stansbie JM. Carcinoma of the nasal cavity and paranasal sinuses: incidence and presentation of different histological types. Clin Otolaryngol 1979; 4: 431−456. 
[32] Platz H, Fries R & Hudec M. Prognoses of oral cavity carcinomas p 187 München: Carl Hanser Verlag 1986;
[33] Bhattacharyya N. Cancer of the nasal cavity. Survival and factors influencing prognosis. Arch Otolaryngol Head Neck Surg 2002; 128: 1079−1083. 
[34] Schnetler JFC. Oral cancer diagnosis and delays in referral. Br J Oral Maxillofac Surg 1992; 30: 210−213. 
[35] Shafer WG. Initial mismanagement and delay in diagnosis of oral cancer. J Am Dent Assoc 1975; 90: 1262−1264. 
[36] Cooke BED & Tapper-Jones L. Recognition of oral cancer. Br Dent J 1977; 142: 96−98. 
[37] Gallagher CS & Svirsky JA. Misdiagnosis of squamous cell carcinoma as advanced periodontal disease. J Oral Med 1984; 39: 35−38. 
[38] Lovas JGL, Daley TD, Kaugers GE & Wright JM. Errors in the diagnosis of oral malignancies. J Can Dent Assoc 1993; 59: 935−938. 
[39] Pack GT & Gallo JS. The culpability for delay in the treatment of cancer. Am J Cancer 1938; 33: 443−462.reported by G. St George, R. D. Welfare and V. J. Lund. An undiagnosed case of malignancy: Case report. British Dental Journal (2005); 198, 341-343. doi: 10.1038/sj.bdj.4812173 
[40] Schnetler JFC. Oral cancer diagnosis and delays in referral. Br J Oral Maxillofac Surg 1992; 30: 210−213. 
[41] Hollows P, McAndrew PG & Perini MG. Delays in the referral and treatment of oral squamous cell carcinoma. Br Dent J 2000; 188: 262−265. 
[42] G. St George, R. D. Welfare and V. J. Lund. An undiagnosed case of malignancy: Case report. British Dental Journal (2005); 198, 341-343. 10.1038/sj.bdj.4812173
[43] Rubinoff MS. Denturism — is the public at risk? J Can Dent Assoc 1996; 62: 167. 
[44] MacEntee MI. The denturist movement in Canada, Part I: growth and development in the western provinces. J Can Dent Assoc 1981; 47: 521−544. 
[45] MacEntee MI, Pierce CA & Williamson MF. Removable prosthodontic services by dentists in BC. J Can Dent Assoc 1980; 46: 764−767. 
[46] Visitor’s Comments posted on this website by the “Father” of Denturism in the USA, Floyd Spiva, on 14/05/2007
[47] Visitor’s Comments posted on this website by Joe Coss for the Oregon Denturist Association, 28 June 2007
[48] E-mail and Visitor’s Comments by Prof. Cyril Thomas, Dental Dean of Sydney University on 12 July 2007
[49] Everett van den Eeden DDM, CD,CDT. Denturists - The Solution to America's Denture Crisis. A Global Professional Publication, Michigan 2007. ISBN 978-0-9794403-0-4
[50] G. St George, R. D. Welfare and V. J. Lund. An undiagnosed case of malignancy: Case report. British Dental Journal (2005); 198, 341-343. 10.1038/sj.bdj.
[51] General Dental Council. Developing the dental team: Curricula frameworks for registrable qualifications for Professions Complimentary to Dentistry (PCDs) London: GDC 2003

Rationale offered for the Restraint

When the Dental Mechanicians Act was introduced in 1945, and the monopoly was created exclusively for dentists to profit from the clinical procedures of providing dentures, it was motivated in Parliament 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 were to serve the public oral health interest[26]. The difference in price was vindicated in terms of years of study and for the amount of free welfare cases that dentists do[27]. None of those reasons seems relevant to a well-established dental profession in this new millennium, which has become an exclusive elitist service to the wealthy and medical scheme patients. (In fact, the student intake for dentistry has recently been lowered [28] for reasons of sustainability, and did not at any stage acquire an altruistic reputation [29] for providing free or affordable services ).

When the attempted debate about introducing denturism started in the late 1980’s, the SADA officially opposed Denturism because of a predicted loss of income to Dentists and "fears " that Medical Scheme benefits of the family unit could be compromised if prevention benefits were used for dentures[30]. It is not understood why tooth-impaired (edentulous ) members of Medical Schemes should pay for inapt benefit allocations for prevention of tooth decay after they have already lost their natural teeth and prevented from using their Medical Scheme benefits to fund the supply of dentures for oral rehabilitation? Other additional excuses previously cited were irrational health-threats to the public that have never been and simply can’t be substantiated[31].

 During the workshops conducted by the SADTC into the desirability of introducing denturism as a new oral health care category during 1990-91 and 1998, it was agreed by all stakeholders concerned that only suitably trained and qualified persons should be permitted to practice dentistry and that these persons must be registered by the appropriate health authority to ensure that the patient is at all times protected in the delivery of services, especially with regards to hygiene procedures and infection control. The term "practicing dentistry " is however interpreted differently by various groups as either a wide all-inclusive term enveloping all oral health care professionals or as a narrow exclusive cartel only practiced by dental surgeons. In practical terms a blind eye is turned on the unsavory practice of Quacks and opposition to the introduction of denturism is escalated behind the scenes.

For a compact synopsis about the rationale offered in favour of and in opposition to the implementation of denturism, see The Debate: Arguments For & Arguments Against.

During recent correspondence between the SADA[32] and The Society[33] the following arguments (in blue text) were made for continuing to prevent dental technicians with suitable clinical training from supplying their services directly to the public. Dr Neil Campbell (CEO of the SADA ) used similar arguments in a letter to the Editor[34] in reply to an article published by Mr Duffy Malherbe (Secretary of The Society ) in a local Dental Journal[35]:

1. SADA’s objections to ‘denturism’ are not predicated on fears or the need to maintain any incorrectly perceived ‘monopoly’ but on sound and cogent reasons including lessons from international experience.

Until such time when the SADA provide these unspecified reasons, The Society must assume that the real reason is about protecting a vested right that in fact provides a very handsome yield to the monopoly holder. Dentists spend 10% of their time on denture work and generate 26% of their income during that time[36]. The International experience in Denturism has been a phenomenal success! SADA cannot assess Denturists’ worldwide as the Nuffield Foundation[37] and Fair Trading Commission[38] in the UK did. The recommendations of such a survey can only be accepted when conducted with integrity by an independent body that has the inherent knowledge and capacity to evaluate relevant information but also have the practical planning skills and aptitude to be objective.

2. The major objection to denturism is that denturists are not competent to diagnose cancers or other diseases within the mouth, to screen for underlying disease, or to recognize when structural problems of the mouth (such as unseen broken-off roots of teeth) can lead to injury if not corrected before the installation of dentures.

There is no cancer-scare fabricated against South African Dentists who do not diagnose oral cancer either; as such patients are referred to Oral Pathologists. In many countries such as Australia, Canada, Finland, Switzerland, etc Denturists do not diagnose but are trained in pathology to recognize abnormalities (any condition that need specialized attention ) and refer to the appropriate Clinician for treatment. There have been absolutely no complaints in any of those countries against Denturists in this regard[39]. In Alberta, Canada, where denturism has been legal since 1961, there was no increase in the rate of oral cancer over the next 15 years or since. In the UK, the latest new legislation for denturism, taking & processing dental radiographs is part of their training and practice.

This argument contends, without foundation, that legalizing denturists will result in more ill fitting dentures (the assumption that denturist will provide ill-fitting dentures has no factual foundation ) and an increase in oral cancer. The relationship of dentures to oral cancer is based on the hypothesis that chronic physical irritation of the oral mucosa (caused by ill-fitting dentures ) is a contributing factor in the incidence of oral cancers. A scientific study conducted in 1984 [40] on denture wearing and oral cancer found no evidence that denture wearing, even wearing ill-fitting dentures, is a significant factor in oral cancer. The study was conducted on 400 patients with oral carcinoma seen in the Oral Medicine Clinic, University of California, San Francisco, between 1968 and 1982. This study included recorded data on tumor site and stage, smoking habits, and dental/denture status. "When denture and non-denture wearers were compared, there was no apparent risk relationship in regard to tobacco use, tumor state, or delay in diagnosis." This study also concluded "denture wearing in a population of oral cancer patients does not appear to be associated statistically with an increased risk of the development of a malignancy." The study concludes that there is no correlation between the wearing of dentures and any specific cancer sites. Furthermore, there is no difference between denture wearers and control groups in the occurrence of oral cancer.

Oral cancer is frequently alleged to be caused by ill-fitting dentures, as an excuse used by Organized Dentistry to prevent competition in the denture market by Denturists. Oral cancer is extremely rare in the United States, and indeed globally. In extensive research, no scientific evidence of a correlation between ill-fitting dentures and oral cancer had been found. The same conclusion has been reached by the American Dental Association, following an inquiry by its Council on Dental Health to nearly 50 cancer research treatment centres in the United States. Nor has constant trauma or irritation alone been correlated with any type of cancer.  Federal Trade Commission Report in 2000 <www.usdenturist.com/Facts/ftc_index.htm #5>

This attempted argument against Denturism is nothing more than a decoy. There has never been any evidence to back-up this scare tactic that was contrived with the devious purpose to cause public panic! Regardless of how this rationale is presented, it remains "an excuse " and as such does not warrant further discussion. Early diagnoses of oral cancer, however is extremely important, in connection with the benefits of an oral examination which are not obtained by more than 60% of edentulous persons who have not visited a dentist in more than five years. In reality, the more mouths that are seen by denturists, the more patients exhibiting potential pathological conditions can be referred by them and with this cooperative approach help protect the public's oral health[41]. A recent study in the Western Cape have indicated that the extent of oral pathoses involved is not that great and could easily be incorporated in the syllabi or as an additional module.

3. In the United States, denturism is illegal in most states and although they have campaigned for the right to practice independently in many states, most of these campaigns have failed for good reason. Clinical treatment by dental technicians in the United Kingdom is also illegal.

The "good reasons " why the majority of United States has so far been unsuccessful in convincing the legislator to legalize denturism, is about control by the American Dental Association (ADA) and is about "good business " and not about good dentistry. The powerful ADA and the various States Dental Associations is extremely aggressive and authoritarian in their approach to resist any encroachment on the Dentists' monopoly. US Dentists are using their control over State Dental Boards to manipulate all decisions related to oral health matters in favour of dentistry. Non-substantiated health scares have been invented to intimidate the legislator and the public[42]. Furthermore, the ADA have succeeded in preventing the recognition of the Canadian Denturist qualification (widely regarded as the global benchmark qualification) and managed to have the provision of dentures by non-dentists made a felony[43]. In the state of Florida, for example, where the denture business is worth 300 million dollars a year, the ADA’s lobby (who contribute ±1 million dollars a year to hire lobbyists to push their agenda at legislative level) have succeeded in making it a felony for a Denturist to construct dentures for a member of the public. If convicted, the Denturist is liable to receive a sentence of up to 10 years in jail. This has not dissuaded those interested in furthering the cause of Denturism or diminished their determination to have their qualification recognized and establish legal recognition for their popular service. USA Denturists numbers are not great, maybe one or two thousand, but they are truly seen as David up against the 145,000-member strong ADA Goliath[44].

In 1980 the ADA advocated the development of inexpensive techniques (the Triad-system) to reduce the cost of services as a method of reducing the impact of Denturists in the provision of services at much lower cost. Dental clinics were opened in Oregon, Maine and Arizona and operated by Dentists to provide a low cost denture service in competition with privately practicing Denturists[45]. These clinics were financially supported and subsidized by the ADA, but this did not, however, end the popularity of Denturists and these clinics have since closed and the counter-offensive failed[46].  

In the States of Idaho (1982), Montana (1984) and Washington (1994) the profession of Denturism have since been legislated bringing the USA total to six and in a number of other states such as: California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, Oklahoma, Pennsylvania, Tennessee, Texas, Wyoming, etc  major battles have been going on for some time. The anti-denturism lobby have managed to frustrate the efforts of the pro-denturism advocators in their attempts despite the recommendations of the US Federal Trade Commission Report[47] to implement denturism in all states. This slow advance of denturism legislation in the USA relates to the superior financial ability of the anti-denturism lobby and has little to do with the merits of denturism or consumer needs. A dentist from Minnesota recently posted a comment on this website indicating that Organized Dentistry were "brutally misleading" in their representations to manipulate the truth during efforts to prevent Denturism from spreading further in the USA. It is widely reported that American denture wearers often travel to neighboring states with legalized denturism or to Canada to find affordable denture services. They find that the traveling & accommodation expense are offset by the savings in cost, compared to a dentist in their own state, and they claim to end up with more satisfactory dentures.

Furthermore, in the western world, the large group of people born after World War II called the Baby Boomers, have become Middle-aged Boomers and are going to be Geriatric Boomers by 2010. Those older than 65 are living longer and this group is getting bigger as their % of the total population have increased from 10-11% in most Western countries in 1985 estimated to reach 17-18 % by 2025. There is undisputedly a direct correlation between age and denture needs. In a recent study by Van den Eeden (2007) in Michigan, USA about the the solution to America’s Denture Crisis, a sharp focus was placed on all levels of society to understand, not only the pain and suffering that America’s denture wearers are experiencing, but also to help them understand the related social, economic and health issues that are linked to the crisis. The message is critical, since many dentists are discontinuing to offer denture services, dental schools have cut back their curriculum hours in denture training for dental students by 90% over the past thirty years and over the next ten years, one-third of all dentists who currently provide denture care are expected to retire from practice, leaving the US denture population in a vacuum.

The statement by the SADA is correct that clinical treatment by Dental Technicians is illegal in the United Kingdom. In fact, as far as we are aware it is illegal in almost all countries of the world, as dental technicians have neither the clinical training nor the legislated mandate for this function. Dental technicians provide a dental laboratory service on contract to dentists, and may not have contact with the dentist’s patient. However, on the 19th July 2005 the Privy Council passed the legislation order, to the effect that Clinical Dental Technicians are now recognized by law in the UK.[48] Over 100 graduates from Great Britain have already completed the Denturist diploma program from the Distance Education Centre of George Brown College in Toronto, Canada. This qualification is now being accredited by the Royal College of Surgeons of England and has become a recognized diploma for registration in the UK. In their new Act, they will be referred to as registered Dental Care Professionals, not Professions Complimentary to Dentistry. At present it is estimated that there are 8000 Dental Technicians within Great Britain and the Republic of Ireland and approximately 1500 Denturists who have been working illegally because they are not recognized[49]. The scope of practice of UK Denturists includes unsupervised provision of complete dentures, partial dentures, other removable dental appliances and taking & processing dental radiographs.

Gradually the popularity of Denturism are spreading globally[50], including all the individual independent states and territories of both Australia and Canada, and is also recognized in New Zealand, Denmark, Finland, Switzerland, the Netherlands, Mauritius, etc. To date 34 pieces of Denturism legislation have been passed internationally by independent Parliaments.  In addition, in at least 15 other additional countries an official Denturism Association exists to lobby for legislated practice. Acceptance of the Denturism qualification by the EU[51] and various Accords and other developments[52] within the EU will encourage speeding-up of Denturism legislation in Europe.

4. In South Africa the general socio-economic profile of edentulous subjects without dentures is that of an elderly, less educated, economically non-active or low-income group. From an economic perspective this population at risk is not a viable market for the private sector [dentists or clinical dental technologists]. Therefore the Society’s assertions about dentists protecting their turf are ludicrous.

If this market were so non-viable as SADA claims, it would be ludicrous to hang on to that monopoly (See reply to argument 1 for the handsome profit dentists make on dentures). From the point of view of expensive overheads that Dentists have, or the profit-level that dentists are used to, this market might seem non-viable, but it is not understood how SADA could measure the economic level of CDT’s, as the category does not exist yet in South Africa. Denturists provide removable prosthetics only and won’t have to finance the availability of the wide range of services that Dentists are mandated to provide, from denture patients, as Dentists have to. Neither will Denturists need the delivery infrastructure that dental laboratories have to maintain to deliver work to and from the dental surgery before and after every clinical stage[53]. In the process of implementing a comprehensive removable denture service by Denturists in South Africa to all denture wearers, many of the poor and the elderly who have currently little means or no access to dentures, will be afforded opportunities to rehabilitation of their full speech, mastication and oral health functioning[54]. In all countries with Denturism legislation the Denturist is the denture-provider of choice for both the rich as well as the poor. Are the SADA implying that affluent people should be limited to a restricted choice of only Dentists who are not as well trained in all aspects of providing dentures as a Denturist?

In South Africa much of the poor community’s access to denture services are deplorable. The State does not cater for them sufficiently and they cannot afford to utilize the services of privately practicing Dentists. As a result they often have no alternative other than to get their dentures provided by untrained, unqualified, unregistered Dentists called "backdoor quacks ". SADA apparently condones this uncaring practice[55], but The Society is opposed to it[56] because of the criminal nature of the system and because the patient is subjected to:  

•        Cross-infection of Hepatitis B, tuberculosis and other communicable diseases (possibly even AIDS), due to unhygienic practices and non-existence of sterilization;

•        The materials are normally stolen;

•         No taxes are levied on any of these cash-upfront transactions (although we agree that basic health procedures should be exempted from VAT);

•         The quality of dentures is often unsuitable due to limited technical knowledge resulting in design and/or manufacturing flaws; and in such cases:

•         The poor patients are often left without the money they paid and a useless denture, because these fly-by-night characters are unaccountable for recourse after the dentures have been delivered.

Clearly this type of choice is unacceptable as a health service! In The society's view it is as a fundamental violation on a poor person’s human rights and dignity to have to be limited to such desperation, without the freedom of choice[57]. An appropriately trained Denturist should be introduced to provide a safe, responsible and compassionate service to displace these providers from the dental market. The public deserves the best service available at better affordable rates[58]. Once Denturism is instituted, the reason for having dentures made by "quacks " will in all likelihood become obsolete[59].

5. We believe conditions associated with the elderly demand special diagnostic skills and therefore the oral health of the public is best protected by dentists who are appropriately trained to assess total oral health needs and provide comprehensive oral health care.

One doesn’t need special skills to diagnose that the elderly who has lost all their teeth needs a denture to rehabilitate their speech, mastication and oral health functioning[60]. The toothless elderly needs basic prosthetic services. This intervention will have a major revitalizing effect on almost all aspects of their standard of life, nutritional health, oral health and general health. The spirit of the Older Persons Act  is certainly underpinned by the sense of compassion of denturists for providing rehabilitation services to the elderly and other edentulous people in need of having their dignity restored by dentures! Due to their flexibility, Denturists are often the only denture service available for institutionalised or hospitalized geriatric patients. 

Objective Health Professionals assess that the patient is treated more effectively when dentistry is viewed as a team of experts. Dentists are poorly trained in the manufacture of dentures and should leave this specialist field to the denture experts, just as Dentists are recognized as Oral Surgeons and the experts in the prevention and treatment of oral disease and the promotion of oral health. In Australia, New Zealand and Canada (as examples) a Denturist has 4 times and up to six times the level of training in removable prosthetics that a Dentist has[61],[62]. Indeed, it is becoming common practice for Dentists to refer or sub-contract their denture cases with complications, "difficult " patients and psychosomatic patients to the "Specialized Denture Service " of Denturists! There is excellent professional co-operation and finally no more conflict between Dentists and Denturists.[63]

6. Clinical dental technologists will not be able to economically sustain themselves in a country with an overwhelming number of public sector patients as in South Africa. We doubt the economic viability of a purely prosthetic practice, especially if an appropriately equipped surgery with adequate means of sterilization has to be set up. This may result in over servicing and abuse of their defined scope of duties by clinical dental technologists as a means of sustaining themselves.

("Surgery " was an unfortunate word choice, because surgical training and surgical skills used during operations have nothing to do with providing dentures or sterilization. Internationally the workplace of Denturists is generally termed: a denture clinic.)

Many Dental Technicians have always managed to sustain themselves despite economic hardships and the continuance of manipulation[64] from greedy dentists demanding financial kickbacks[65] from dental laboratories. This is a novel phenomenon to hear the SADA’s concern for the economic sustainability of dental technicians and quite a refreshing departure from the normal allegation that dental technicians are over-paid at less than a quarter of dentists’ hourly labor-rate.

How many Dentists are serving the denture needs of the impoverished population? The State-budget does not make provision for denture provision and never will have that priority for as long as life-threatening diseases such as Aids, TB, Cholera, Malaria, Hepatitis, etc is rampant[66]. It has been argued that the need for Denturism has become redundant because newly qualified Dentists will be doing community service[67]. Another decoy ! The reality is that the Department of Health has inadequate financial resources for such posts and no budget at all for supplying dentures.

The proposed State Medical Scheme becoming a reality soon, might change the future scenario for financing basic health services. Denture services are as basic as it gets and it must be kept in mind that many denture wearers are amongst the elderly and the poor. Funding the services of Denturists in the private sector through this Scheme (similar to National Health in the UK) will be the most cost-effective way of providing dentures, especially to the indigent "patient of the State ". Clinical Dental Technologists will retain their dental technology skills and may be allowed to continue providing a dental laboratory service to their dentist-clients (if/when they have the time), as is the custom in many other countries. In such a dispensation the economic viability of CDT’s will remain to be at least the same as that of a dental technician.

Is SADA saying that only Dentists can be trusted not to over-service their patients? That is a mooted argument, since Dentists have a questionable reputation in this regard. Denturists, in contrast, have a much better track record globally as it is reported from regulation Authorities that over-servicing is minute!

7. Studies have also shown that there is a greater incidence of oral cancer amongst males who persisted with old and presumably poorly fitting dentures. Evidence presented to the Australian Dental Association demonstrated that inadequately trained dental technicians fitted dentures over existing oral cancers, thereby placing lives of patients in jeopardy.

The President of the Australian Dental Prosthetist Association (at that time), Mr Graham Key, rejected this statement with contempt as false and without foundation. He has a close relationship with the Australian Dental Association and had never heard this expressed once[68]. Claims such as those suggesting that dentures supplied by Denturists "cause cancer " fail to be supported by any empirical data[69]. Such claims are, in fact, undercut by case studies from Canada, Finland, Tasmania, Australia and other countries where Denturists have been successfully integrated into community dental health care programs for several decades[70]. According to the Federal Trade Commission Report, there has been no increase in the spread of infectious disease attributable to the practice of denturism in the United States or Canada[71].

All the negative claims made by Dentistry in order to protect its monopoly have been produced without evidence. All their claims have been proven invalid by Health Ministers, Oral Pathologists, Cancer Societies, Surgeon Generals, and State legislative studies and by Senior Citizen- and Consumer Survey reports[72]. However, the best testimonial for the profession of Denturism is their flawless track record. The truth remains; Denturists are highly trained health professionals. The only health risks appear to be related to occasional ill-functioning and ill-fitting dentures rather than to the impact of any integrated flaw in their service delivery system (which is a claim that dentists can’t make themselves).

8. It has been reported overseas that denturists do not adhere to the restrictions of regulatory boards, as stipulated, and there is evidence that dentures are produced while disease present in the mouth is ignored. It hoped that the Board regulating the conduct of clinical dental technologists show the commitment and ability to regulate denturism in the public interest.

In some countries initial legislation made it a legal requirement, that Denturists could only provide dentures to patients in possession of a "certificate of oral health  " issued by a Dentist. That provision became obsolete when patients started suing Dentists for oral pathoses  that was not identified during the certification check-up or might have manifested later[73]. Denturists in those countries did not initially get training in pathology recognition, and the withdrawal of the provision of the "certificate of oral health " has created an interim system flaw. It is acknowledged that occasional ignorance/disregard by Denturists for oral disease might have occurred in such situations, but these provisions have been rectified by continuous education programs a long time ago. Additionally, acceptance of baseline competencies and by upgrading training and legislation to deal with local needs and global trends has elevated the competencies of Denturists[74].

The chairperson of the "Council of Regulating Authorities " that overseas all the Australian boards that register Dental Technicians and Dental Prosthetists, stated emphatically that he is not aware of a single case that has been brought to their attention. Similar reaction has been received from Canada and the IFD. The SADA cannot produce the reports they claim to be quoting from.

9. Internationally it has been shown that patients attending both dentists and denturists come from similar socio-economic backgrounds and on average pay similar fees for their dentures despite an attempt by some countries to introduce denturism to decrease the cost of prostheses.

Denturists simply do a better job. In some countries low cost denture services were subsidized by Dentists to compete with privately practicing Denturists in an effort to oppose the popularity of Denturists, but this system have failed. The fact that dentures provided by Denturists are generally more cost-effective and better affordable must be considered in context of a whole range of global variables. Worldwide denturist’s charge about 30% less than Dentists, with variations. In some states of the US the saving through Denturists is claimed to be as high as 50%[75].

Denturists in different parts of the world can provide a wide range of standards of prosthetic appliances at relative pricing structures ranging from, in comparison to motorcar terms, from a Fiat Uno to a Rolls Royce. When using the most expensive techniques and materials and/or special attachments in a Harley-street type of service, such specialist fees, especially in cases with severe complications, can justifiably be expensive and comparable with what some Dentists charge. In many countries Denturism have been introduced as an alternative service provider to meet the demand for better affordable denture services, because basic services and access to dental care for lower income people was deplorable.

The overall complex and sometimes clumsy and roundabout procedures of the conventional supply route through a Dentist could be streamlined if it was all done by the one-and-the-same person, who would be trained to do both the clinical and manufacturing procedures[76] required of the whole range of removable prosthetics and who collaborates personally and directly with the consumer – resulting in a much higher degree of patient satisfaction, at lower fees! Access to state subsidized clinics and programs will possibly be the only feasible way to provide the same functional quality services to indigent patients, as mentioned under point 6.

10. At present, the only clinical professions complementary to dentistry are oral hygienists and dental therapists. Oral hygienists work to prescription from registered dentists and dental therapists serve one year under supervision of a dentist or dental therapist. This situation has been mutually beneficial, though hygienists and therapists have both had training in clinically related matters

In South Africa Dentists do not want to let go of the financial benefits associated with their monopoly. There is no other cogent reason for restricting clinical training and independent practice to other Oral Health categories. One can’t help to wonder whether oral hygienists and dental therapists would have been allowed to exist in the first place, have they not made "mutually beneficial " contributions to the income of the dentist in private practice. Some procedures are allowed by such categories while employed by Dentists but denied from providing the same services for their own account as independent practitioners. To deny the reality of Denturism as a growing global dental care fact, will not make them disappear[77]. Denturists have been independent in Denmark since 1843 and in Australia and Canada since the 1950s. In some countries it is common to find Dentists, Denturists, Oral Hygienists and other Oral Health professionals to compliment each other’s services in group practices to serve the consumer better !

11. World wide, including in South Africa, the dental profession has changed its emphasis in dental practice from a removal and replacement-orientated approach to a preventive and treatment-orientated approach. Since fewer people today need to have teeth extracted and replaced with dentures, little permanent cost saving is likely to result from introducing the profession of clinical dental technologists.

The National Advisory Committee on Oral Health (NACOH) in Australia, concluded that despite having fewer individuals wearing dentures, the population base was older and the number of dentures overall was not reducing. Likewise in the USA and Canada, the same tendency is also recorded in South Africa that people get older and will continue to need replacement dentures over intervals of every 5-8 years[78].

In a recent study by Van den Eeden (2007) in Michigan, USA about the the solution to America’s Denture Crisis, a sharp focus was placed on all levels of society to understand, not only the pain and suffering that America’s denture wearers are experiencing, but also to help them understand the related social, economic and health issues that are linked to the crisis. The message is critical, since many dentists are discontinuing to offer denture services, dental schools have cut back their curriculum hours in denture training for dental students by 90% over the past thirty years and over the next ten years, one-third of all dentists who currently provide denture care are expected to retire from practice, leaving the US denture population in a vacuum.

With an extended life cycle pattern amongst the elderly[79], the general decline in edentulism projections for South Africa will be more than offset by the increase in needs for replacement dentures of the adult population older than 55 years. The clinical implications of these findings are twofold: First, a sizable minority of the patient population will continue to need complete denture services; and second, if training in complete denture prostheses is not restored in the dental education curriculum to a functional level, the circa 1.12 million full denture wearers will be forced to seek denture services from alternative providers[80].

Amongst the poorer segments of the population demand for extraction of decayed natural teeth will remain a tendency[81]. Once a person has lost their teeth, no amount of fluoride or any other program to reduce tooth decay will bring back their natural teeth. They will need dentures ! There is more than sufficient evidence to indicate that at least part of the population will always remain edentulous[82]. If dentists are no longer trained for and not keen to serve these needs, they should not prevent the establishment of alternative services by denturists!

12. If political and consumer demand for denturism is a function of unmet needs for complete dentures, this demand should decrease as the percent of edentulous adults declines during the next 10 to 15 years.

The reply to point 11 above applies. Despite efforts to fluoridate drinking water (which sadly appears to have failed ) and other programs, the war against tooth decay is unlikely to be won in the foreseeable future. The fact that a substantial segment of the population will continue to become partially and fully edentulous imposes a responsibility on the State to assure effective Human Resources for their oral rehabilitation[83]. Denturists can provide partial dentures and implant retained dentures and other removable appliances  in addition to the referred complete dentures - as they do in other countries, in accordance with their training ! The Society has always advocated a scope of practice that specifies the provision of a comprehensive removable prosthetic service [84], that includes full sets of complete dentures, partial dentures, immediate dentures, over-dentures, implant supported dentures with or without metal substructures, strengtheners or incorporated metal clasps & rests and also the provision of mouth guards, oral protectors and sleep apnea appliances, as well as any repair, reline, remodel or adjustment thereto. The provision of these specialist services by Denturists will free the hands of Dentists to focus more efficiently on preventive measures to combat tooth decay[85].

13. In view of developments in the field of dentistry, more elderly people will retain at least some of their natural teeth and the provision of partial dentures will be an inseparable part of the total oral health care of the elderly patient.

We agree and Denturists make the best partial dentures. Dentists will still need to keep the natural teeth healthy. By far the majority of partial dentures provided by qualified practicing Dentists in South Africa do not have rests or clasps, are manufactured on primary models and are tissue borne[86]. Such poorly designed unstable dentures are referred to as "gum-strippers ", because it often traumatizes periodontal tissue and impacts negatively on the vitality of individual remaining abutment teeth and abets degeneration of soft tissue. Dentists do not survey models and only in extremely rare cases design partial dentures themselves. This failure to survey is also reported in many other countries (Canada[87], Finland[88], etc). It is not in line with academic prescription, but it is in fact the reality in practice. Although Dentists are supposed to be trained to have better insight, practice shows that in reality they prescribe and place inferiorly designed partial dentures into their patient’s mouths. Often economic considerations determine that the advice from the contracting dental technician, on optimal denture-design, gets ignored/rejected. Direct provision of dentures by Denturists, without the interference and expensive infrastructure of Dentists may result in the ability of a more affordable package being offered to the consumer[89].

It has been stated that for anybody to carry out the design phase of the construction of a partial denture, would require almost all the training that a Dentist receives[90]. It might sound like an impressive academic theory, but that is all it is: Rhetoric ! In practice the reality is somewhat different. The Dentist rarely ever designs partial dentures; they usually leave it to the discretion of the Dental Technician working in a commercial dental laboratory[91]. Dental Technicians with a B.Tech degree have an excellent working knowledge of Physiology and Anatomy and are well trained in the design and construction of partial dentures. In South Africa they are in fact the experts! The optimal design of a partial denture can only be determined once the plaster model of the remaining teeth have been assessed on a Surveyor (an instrument used by Dental Technicians to measure the undercut depths of tooth surfaces to determine the best route of insertion, the optimal undercut areas to utilize for clasp placement and clasp design to keep the denture firmly in place and minimize food-traps).

When Dental Technicians (who chooses the denturism option ) get the opportunity of additional training in the clinical handling of the denture wearer, such as the taking of impressions and the identification of oral pathology as well, such a CDT will be in a much better position than a Dentist to pinpoint and correct specific problems with a denture, be it partial or otherwise, because they have the training and dexterity skills to do this work[92]. Often patients have to accept the denture they get, and don't get what they ask for, simply because of the breakdown of communication and fragmented process during the various stages of the conventional denture delivery system of separating the clinical and technical procedures. By designing the partial denture in personal consultation with the denture wearer, doing both[93] clinical and laboratory work and personally fitting the partial denture in the mouth, a much better fitting custom-designed denture with a higher level of denture satisfaction are achieved and also at much lower overhead cost.

However, it would be ideal if the Denturist had formed a good working relationship with a Dentist so that referral can take place and the Denturist can attend chair side consultation with the patient, him/herself and the Dentist. Through such liaison the best possible outcome can be gained for the patient[94]. The Dentists remain responsible for the vitality and state of natural teeth, while Denturists are responsible for the manufacture and placement of the partial denture[95]. In some countries Denturists are required to take/order and read radiographs to assess the condition of root rests and abutment teeth. The addition of this module to the curriculum is part of the program in those countries.

14. More auxiliaries should be utilised in the public sector to meet the demands for such services with the primary goal of maintaining a healthy dentition for life.

That is true and the first employed should be Denturists even though they are not auxiliaries. Deployment of Denturists and by focusing on optimal usage of the whole range of oral health professionals that each category are specialized in, would be a more cost-effective utilization of Human Resources. The Dentist is trained to provide a wide variety of services and as a result virtually the whole staffing budget for Community Dentistry in the Department of Health is used-up by employment of the most expensive category of Oral Health Human Resources. That is most inefficient and is a reflection on how basic services are that are catered for by the State.

15. Prosthetic oral health care must be regarded as part of an essential continuum of service rather than a commodity. Patients should not, under any pretext, be separated from the routine of surveillance, supervision and maintenance care that only dentists provide and which is essential for long-term success of full or partial dentures and oral health in general.

The Society agrees. This is not an anti-denturism argument. We all believe this.

16. As stated above, there is no evidence that services provided by denturists are cheaper than those provided by dentists. In addition, there is also the lack of clinical training of denturists that does not serve the patient’s interests.

SADA seem to have an obsession about costs and fees. (This matter has already been addressed under point 9). Denturists simply do a better job, more efficiently at more economic rates. It is a significant global trend that within a very short time span after legitimization Denturists generally provide a higher percentage of removable dental prostheses than Dentists. A 1999 survey in Denmark revealed that denturists were making and fitting 75-80 % of all removable dentures.

For as long as CDT is prohibited by the Health Professions Act (Act 56 of 1974) and related Regulations no clinical training can be implemented. A NHD in CDT were registered with the SAQA on a NQF level 7 with 120 credits[96]. This clinical training program can be adjusted to meet the requirements of a cogent scope of practice and the Baseline Competencies currently prescribed for accreditation by the International Federation of Denturists (IFD). Local Universities of Technology are willing and ready to introduce training. Denturists in Australia, New Zealand, Canada, etc can progress to a Masters Degree if they choose to do so[97].

Many qualified Denturists practicing overseas because their chosen profession is illegal in South Africa would consider returning if their qualification would be recognized[98]. In New Zealand alone The Society are in contact with at least 10 South African Dental Technicians who have qualified and currently practice as Denturists. They are eagerly following developments locally as they would consider repatriating if they will be allowed to register and work as Denturists locally. The Head of Dental Technician & Denturism training at the Faculty of Dentistry, University of Otago in New Zealand also originates from South Africa and are more than willing to partner with local Universities of Technology in a distance education program[99]. A number of experienced denturists from Canada have indicated their eagerness to come and work on our envisaged Outreach Program to provide free dentures to the poor (See Visitors Comments).

Effects of the Proposed Solution

•        The introduction of Denturism will bring the consumer and the manufacturer into direct contact with one another without the inevitable misunderstandings and economic consequences that are associated with working though a go-between. The fact that the Denturist as an expert is personally responsible for the chair-side as well as the technical procedures and direct communication with the end-user, results in a more individualized and optimally constructed functional denture and takes into account the consumer’s personal preferences and needs.

•         The creation of a register of clinical dental technicians, who will be allowed to sell dentures direct to the public, will provide competition to dentists in the sale of dentures.

•        Buyers of dentures will have more choice for at least the same, or a better quality service then currently exists, provided by qualified professionals and thereby displace the current illegal and unsafe supply of dentures by quacks .

•        The introduction of Denturism will result in a more efficient denture service and better access to dental care for consumers  

•        There will be downward pressure on the price of denture.

•        Creating this career path will result in a more efficient use of dental technicians' skills and time, for those choosing to specialize in this discipline to work as a CDT.

•        There will remain to be sufficient numbers of dental technicians to provide dental technology services making appliances for dentists' patients on contract.

•        The provision of dentures by CDTs will free the hands of dentists to use their time and specialized skills more effectively towards the prevention and treatment of oral disease and the promotion of oral health.

---

[1] C du Plessis & DF Malherbe DENTURISM – A NEW PROFESSION  (1990) A Report by the SA Federation of Dental Technicians

[2] Friedman M. CAPITALISM AND FREEDOM (1962) University of Chicago Press

[3] Frizzel CL: A PLEA FOR A SPECIAL DENTAL COURSE. The Dental Magazine and Oral Topics, Vol 60, April 1943

[4] Gerry Hanson, GLOBALIZATION OF DENTURISM - Presentation by the CEO of the International Federation of Denturism to the National Denturist Association Conference (US, May 2005) and the Australian Dental Prosthetists Association Conference (Sydney, August 2005).

[5] DF Malherbe, LA Steyn, C Du Plessis, Z Fatagodien. CLINICAL DENTAL TECHNOLOGY: A QUEST FOR EQUITY IN ORAL HEALTH CARE by The Society for   Clinical Dental Technology, 1998. Motivational Report to the SADTC, Minister of Health and the Department of Health.

[6] Letter of recommendation from the Sir Geoffrey Foot, former Premier of Tasmania to the Leader of Opposition in Western Australia, The Honorable Mr Hassell, about the positive effects of the Denturism Legislation, dated 14th August 1984 

[7] THE COMPETITION AUTHORITY REPORT: Competition in professional services – Dentists/ Executive Summary. Dublin, Ireland. December 2005 www.tca.ie

[8] Letter of recommendation for the implementation of Denturism by the former Chief Director for Oral Health  of the Department of National Health and Population Development, Dr Lennox Mathews to the Chairman of The Society for CDT, dated 15 March 1998

[9] Memorandum to the Human Resources Cluster of the Department of Health as a general motivation for the establishment of a category of Clinical Dental Technologist in Oral Health Care submitted by The Society on 9 September 2005 under covering letter to the Deputy Director General: Human Resources of the Dept of Health, Dr Percy Mahlathi.

[10] A “grandfather clause” is a provision exempting persons or other entities already engaged in an activity from rules or legislation affecting this activity.

[11] Letter by Mr DF Malherbe to Prof Vic Exner Chairperson of the HPCSA workshop RE- A LADDERED APPROACH TO EDUCATION AND TRAINING OF ORAL HEALTH PROFESSIONALS dated 5 June 2005

[12] Duffy Malherbe. Provision Of Removable Prosthetics By Denturists – What Is The Controversy? International Dentistry South Africa, Laboratory World. January 2006

[13] Frizzel CL: A Plea For A Special Dental Course. The Dental Magazine and Oral Topics, Vol 60, April 1943

[14] THE COMPETITION AUTHORITY REPORT: Competition in professional services – Dentists/ Executive Summary. Dublin, Ireland. December 2005 www.tca.ie

[15] OFFICE OF FAIR TRADING: Report into private dentistry in the UK – 2003 www.oft.gov.uk/ market+investigations/ investigations/ dentistry

[16] Under the MEDICAL, DENTAL AND SUPPLEMENTARY HEALTH PROFESSIONS ACT, 1974 (Act 56 of 1974), this is considered to be “practising dentistry” which is reserved exclusively for registered dentists

[17] Duffy Malherbe. Provision Of Removable Prosthetics By Denturists – What Is The Controversy? International Dentistry South Africa, Laboratory World. Vol 8 No 1. January 2006

[18] Report about the legal situation in South Africa by the Secretary of The Society for CDT requested by the CEO of the International Federation of Denturists in 2005, that was included in the IFD Presentation – Globalization of Denturism.

[19] DF Malherbe, LA Steyn, C Du Plessis, Z Fatagodien. Clinical Dental Technology: A Quest For Equity In Oral Health Care by The Society for Clinical Dental Technology, 1998. Motivational Report to the SADTC, Minister of Health and the Department of Health.

[20] C du Plessis & DF Malherbe DENTURISM – A NEW PROFESSION  (1990) A Report by the SA Federation of Dental Technicians

[21] Letter of recommendation from the Deputy Premier and former Minister of Health of Tasmania to the Minister of Health of New Zealand about the positive effects of the Australian Denturism Legislation, dated 16th April 1973.

[22] DF Malherbe, LA Steyn, C Du Plessis, Z Fatagodien. Clinical Dental Technology: A Quest For Equity In Oral Health Care by The Society for Clinical Dental Technology, 1998. Motivational Report to the SADTC, Minister of Health and the Department of Health.

[23] The Nuffield Foundation - EDUCATION AND TRAINING OF PERSONNEL AUXILIARY TO DENTISTRY, 1993 London UK

[24] Letter to the Minister of Health by the SADA dated 11 October 2005, with regards to repealing certain provisions of the Dental Technicians Act and Regulations.

[25] Letter to the Minister of Health by The Society dated 28 November 2005, in reply a request by the SADA to the Minister to repeal certain provisions of the Dental Technicians Act specifically relating to dental technicians fees and clinical dental technology.

[26] Mr HG Lawrence Minister of Welfare and Demobilization, 28 March 1945. Hansard – House of Assembly Debates Page 4382

[27] Dr Vernon L Shearer MP for Durban (Point), 28 March 1945. Hansard – House of Assembly Debates Page 4410-4411

[28]A NATIONAL HUMAN RESOURCES PLAN FOR HEALTH Department of Health. Table 11: Duration and Location of Training. Page 59 

[29] Letter to the Minister of Health by The Society dated 28 November 2005, in reply a request by the SADA to the Minister to repeal certain provisions of the Dental Technicians Act specifically relating to dental technicians fees and clinical dental technology. 

[30] Report on Denturism by Dr MI Shreef www.edoc.co.za/sadanet/publications/westerncape.html 1999

[31] Letter to the Minister of Health by The Society dated 28 November 2005, in reply a request by the SADA to the Minister to repeal certain provisions of the Dental Technicians Act specifically relating to dental technicians fees and clinical dental technology. 

[32] Letter to the Secretary of the Society by the President of the SADA dated 5 December 2005, stating their reasons for opposing the implementation of Denturism in South Africa

[33] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[34] LETTER TO THE EDITOR of International Dentistry South Africa by Neil Campbell about an article about Denturism - Laboratory World. Vol 8 No 3. May/June 2006

[35] Duffy Malherbe. Provision Of Removable Prosthetics By Denturists – What Is The Controversy? Article published in International Dentistry South Africa, Laboratory World. Vol 8 No 1. January 2006

[36]  Dr Johan Hartshorne Ph D (Odontology). DENTURISM – REPORT ON A FEASIBILITY STUDY IN THE WESTERN CAPE, SADJ September 2001, Volume 56 No 9

[37] The Nuffield Foundation - EDUCATION AND TRAINING OF PERSONNEL AUXILIARY TO DENTISTRY, 1993 London UK

[38] Office of Fair Trading: REPORT INTO PRIVATE DENTISTRY IN THE UK – 2003 www.oft.gov.uk/market+investigations investigations/dentistry

[39] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[40] Meir Gorsky, D.M.D., and Sol Silverman, Jr., M.A., D.D.S., "Denture wearing and oral cancer," Journal of Prosthetic Dentistry, 52:2 (1984),

[41]  A Study of Denturitry Directed by the Kentucky General Assembly - Research Report No. 292 - Legislative Research Commission, Frankfort, Kentucky. January 2000

[42] DENTURE WEARERS CRY OUT, WHO WILL HEAR THEM? www.usdenturist.com/index/facts.html

[43] Various newspaper articles and Reports also reflected in correspondence with our colleagues in Canada and the USA

[44] THE LEGISLATION OF DENTURISM: A FIGHT LED BY FEW, June/July 2004 www.lmtcommunications.com/article/denturism.asp

[45] DENTURISM – A NEW PROFESSION. A Report by the SA Federation of Dental Technicians 1990 Authors: C du Plessis & DF Malherbe

[46] MacEntree MI. The Denturist movement in Canada. Part II: ACCEPTANCE IN EASTERN CANADA. Journal of the Canadian Dental Association, Vol 8. – 1981 

[47] FEDERAL TRADE COMMISSION REPORT. - American Denturist Advocacy Council – a Public Information Website: www.usdenturist.com/Facts/Federal Trade Commission report

[48] Report by Chris Allen for the CLINICAL DENTAL TECHNICIANS ASSOCIATION OF THE UK to the IFD Congress in 2006. www. International-denturists.org/Country Reports 2006

[49] Gerry Hanson, GLOBALIZATION OF DENTURISM - Presentation by the CEO of the International Federation of Denturism to the National Denturist Association Conference (US, May 2005) and the Australian Dental Prosthetists Association Conference (Sydney, August 2005).   

[50] Paul Levasseur, GLOBALIZATION OF DENTURISM - Presentation by the President of the International Federation of Denturism to the World Symposium on Denturism and Dental Technology, Coventry, England, May 12, 2007

[51] COMMITTEE OF THE ENVIRONMENT, PUBLIC HEALTH AND CONSUMER PROTECTION OF THE EUROPEAN PARLIAMENT recognized the Denturist qualification and recommended the implementation of the profession throughout the EEC (EU) as reported by FA Wijsenbeek (Member of the European Parliament for the Netherlands) at the Annual Congress of the IFD in Mandelieu France, 28 September 1989.

[52] THE TREATY OF ROME -1989 , THE MAASTRICHT TREATY -1993, THE LEONARDO DA VINCI PROJECT - 2004  and also EUROPEAN UNION RECOGNITION OF PROFESSIONAL QUALIFICATIONS www. International-denturists.org/Country Reports 2004

[53] LETTER TO THE EDITOR of International Dentistry South Africa by Mohutsuwa Kgothule in reply to Neil Campbell’s letter about an article on Denturism, Laboratory World - Sept/Oct  2006. Vol 8 No 5.

[54] Memorandum by The Society for Clinical Dental Technology to the Human Resources Cluster of the National Department of Health as a GENERAL MOTIVATION FOR THE ESTABLISHMENT OF A CATEGORY OF CLINICAL DENTAL TECHNOLOGIST IN ORAL HEALTH CARE. – In response to the Draft Strategic Framework for Human Resources for Health Plan. August 2005

[55] Dr Johan Hartshorne Ph D (Odontology). DENTURISM – REPORT ON A FEASIBILITY STUDY IN THE WESTERN CAPE, SADJ September 2001, Volume 56 No 9

[56] Duffy Malherbe. Provision Of Removable Prosthetics By Denturists – What Is The Controversy? Article published in International Dentistry South Africa, Laboratory World. Vol 8 No 1. January 2006

[57] PATIENT PERSPECTIVE  www.international-denturist.org/denturism.html

[58] Mr DF Malherbe, Presentation by The Society for CDT to the workshop of the SADTC about the Feasibility of Denturism conducted at Pretoria Technikon in 1998  

[59] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[60] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[61] Correspondence from Graham Key, Chairperson of the Education Committee of the International Federation of Denturists,
           Correspondence from Neil Waddell , Head of Dental Technology Dept - New Zealand's National School of Dentistry, University of Otago, Dunedin, and
           Correspondence from Ismael Larney, Senior Lecturer in Dental Prosthetist training at Randwick College of TAFE, Sydney during 2005 and 2006

[62] Correspondence from Prof Cyril Thomas former South African Prosthetics Academic, Sydney University Dental Dean, to the President of The Society dated 27 January 1998

[63] Correspondence from Ismael Larney, Senior Lecturer in Dental Prosthetist training at Randwick College of TAFE, Sydney during 2006

[64] DENTISTS ALLEGEDLY INVOLVED IN DODGY DEALS 22/08/2006 www.dentasa.org.za/documents/news.html      (See also www.dentaltechforum@yahoogroups.com for 22/08/2007)

[65] TECHNICIANS WITH INFO TO COME FORWARD 22/08/2006 www.dentasa.org.za/documents/news.html

[66] DF Malherbe, LA Steyn, C du Plessis, Z Fatagodien Clinical Dental Technology: A Quest for Equity in Oral Health Care The Society for Clinical Dental Technology - Copyright © 1998. Motivational Report to the SADTC, the Minister of Health and the Department of Health

[67] Zak Gordon Fatagodien The Big Issue of Clinical Dental Technology – Report by the Denturism Committee Chairman, Newsletter of the South African Dental Technicians Council December 2002, Volume 1 No 2

[68] Correspondence from the President of the Australian Dental Prosthetist Association with regards to accusations claimed by the SADA about practices in Australia.

[69] The Federal Trade Commission - DENTURE WEARERS CRY OUT, WHO WILL HEAR THEM? www.usdenturist.com/index/facts.htm

[70] RELATIONSHIP BETWEEN DENTISTS AND DENTURISTS www.international-denturist.org/denturism.html

[71] A Study of Denturitry Directed by the Kentucky General Assembly - Research Report No. 292 - Legislative Research Commission, Frankfort, Kentucky. January 2000

[72] FEDERAL TRADE COMMISSION REPORT The Sale of Complete Dentures: Effects of Present & Alternative Regulations (5 Year study) www.usdenturist.com/index.htm 2000

[73] Country Reports  presented at the Annual Congress of the IFD in Mandelieu France, 28 September 1989.

[74] www.international-denturist.org/denturism.html

[75] www.denture.com/ www.onlinedenturecenter.com/ www.dentures.info/oregondentures/ www.sashdentures.info/ www.perma-laboratories.com/affordable, etc, etc

[76] Memorandum by The Society for Clinical Dental Technology to the Human Resources Cluster of the National Department of Health as a GENERAL MOTIVATION FOR THE ESTABLISHMENT OF A CATEGORY OF CLINICAL DENTAL TECHNOLOGIST IN ORAL HEALTH CARE. – In response to the Draft Strategic Framework for Human Resources for Health Plan. August 2005

[77] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[78] DF Malherbe, LA Steyn, C du Plessis, Z Fatagodien Clinical Dental Technology: A Quest for Equity in Oral Health Care The Society for Clinical Dental Technology - Copyright © 1998. Motivational Report to the SADTC, the Minister of Health and the Department of Health

[79]  Hofmeyer BE, Mostert WP. Demographic Aging of the South African Population - 1989. Report by the Human Sciences Research Council (HSRC)

[80] Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the United States in 2020? Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA 02115, USA. chester_douglass@hms.harvard.edu  J Prosthet Dent. 2002 Jan;87. PMID: 11807476 [PubMed - indexed for MEDLINE]

[81] Dr Johan Hartshorne Ph D (Odontology). DENTURISM – REPORT ON A FEASIBILITY STUDY IN THE WESTERN CAPE, SADJ September 2001, Volume 56 No 9

[82] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[83] Dr Johan Hartshorne Ph D (Odontology). DENTURISM – REPORT ON A FEASIBILITY STUDY IN THE WESTERN CAPE, SADJ September 2001, Volume 56 No 9

[84] DF Malherbe, LA Steyn, C du Plessis, Z Fatagodien Clinical Dental Technology: A Quest for Equity in Oral Health Care The Society for Clinical Dental Technology - Copyright © 1998. Motivational Report to the SADTC, the Minister of Health and the Department of Health

[85] DENTURISM – A NEW PROFESSION. A Report by the SA Federation of Dental Technicians 1990 Authors: C du Plessis & DF Malherbe

[86] Mr DF Malherbe, Presentation by The Society for CDT to the workshop of the SADTC about the Feasibility of Denturism conducted at Pretoria Technikon in 1998  

[87] REMOVABLE PARTIAL DENTURE DESIGN IN ALBERTA DENTAL PRACTICES. Wolfaardt JF, Tan HK, Basker RM. Misericordia Hospital, Edmonton, Alberta. PMID: 8771998 [PubMed - indexed for MEDLINE]

[88] CLINICAL QUALITY OF REMOVABLE DENTURES PROVIDED BY DENTISTS, DENTURISTS AND LABORATORY TECHNICIANS. Tuominen R. Department of Public Health, University of Helsinki, Helsinki, Finland. risto.tuominen@helsinki.fi

[89] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[90] Prof Peter Owen in a memorandum presented to the workshop of the SADTC about the Feasibility of Denturism conducted at Pretoria Technikon in 1998   

[91] Mr DF Malherbe, Presentation by The Society for CDT to the workshop of the SADTC about the Feasibility of Denturism conducted at Pretoria Technikon in 1998  

[92] Memorandum by The Society for Clinical Dental Technology to the Human Resources Cluster of the National Department of Health as a GENERAL MOTIVATION FOR THE ESTABLISHMENT OF A CATEGORY OF CLINICAL DENTAL TECHNOLOGIST IN ORAL HEALTH CARE. – In response to the Draft Strategic Framework for Human Resources for Health Plan. August 2005

[93] PATIENT PERSPECTIVE  www.international-denturist.org/denturism.html

[94] Consistent reporting in personal correspondence from practicing denturists in Canada, Denmark, New Zealand & Malta

[95] Letter to the President of the SADA by the Secretary of the Society dated 30 January 2006, in response to opposition to the implementation of Denturism in South Africa

[96] Letter to the Minister of Health by The Society dated 28 November 2005, in reply a request by the SADA to the Minister to repeal certain provisions of the Dental Technicians Act specifically relating to dental technicians fees and clinical dental technology

[97] Correspondence with the Chairperson of the Education Committee of the International Federation of Denturists, since 2004
           Correspondence with Head of Denturist Training of New Zealand's National School of Dentistry - University of Otago, Dunedin and
           Correspondence with Head of Dental Prosthetist training at Randwick College of TAFE, Sydney during 2005 and 2006
[98] Correspondence from South African qualified dental technicians who have qualified as Denturists in Australia & NZ: Ismael Larney, Oliver Meier, Berty Matthews, Hein Swanevelder, Prabhu Varma, Graham Morrissey, etc from 2005 to 2007
[99] Ongoing correspondence with the Head of Denturist Training of New Zealand's National School of Dentistry - University of Otago, Dunedin, Mr Neil Waddell since 2005.

[100] FEDERAL TRADE COMMISSION REPORT. - American Denturist Advocacy Council – a Public Information Website: www.usdenturist.com/Facts/Federal Trade Commission report

[101] A Study of Denturitry Directed by the Kentucky General Assembly - Research Report No. 292 - Legislative Research Commission, Frankfort, Kentucky. January 2000

[102] DENTURE NEEDS - National Oral Health Survey 1988-89 Department of Health.

Restricting the sale of dentures to dentists alone, prevents the emergence of competition between dentists and qualified denturists in the supply of dentures. As a result, patients in South Africa pay more for their dentures than is necessary and have less choice. By law, anyone who requires dentures must visit a dentist. The dentist examines the patient, takes measurements and sends an order for a set of dentures to a dental laboratory. A dental technician who delivers and collects the work backwards and forwards to the dentist between all the clinical stages manufactures the dentures. The dentist then fits the dentures in the patient’s mouth. Patients do not have the choice of going directly to a Denturist – for a one-stop-shop service of measurement, manufacture and fitting of dentures - as is the case in numerous other countries. The suppressing of the establishment of a cadre of Clinical Dental Technologists in South Africa means that price competition and choice in the legal sale of dentures to the public is limited to competition between dentists. Some degree of corrupt incentive have been in place in the past where dental technicians were encouraged by individual dentists to provide cheaper dentures in turn for more work orders, resulting in inferior work standards. Dentists excepts these standards and does not pass on such discounted fees to their patients but by nature of the chain of services as a go-between, places a mark-up on the prices which they pay dental technicians for dentures as their "professional fee  " (for taking impressions, registering the bite and the administration of selling dentures ).

The introduction of this new category of Oral Health Professional will give people that need dentures a choice of qualified, and appropriately regulated, professionals from whom they can purchase the dental services they require. Clinical dental technologists will provide competition to dentists for the range of services they are qualified to provide, thus putting downward pressure on the prices of these dental services. This is the case in other countries where clinical dental technicians are legally recognized including Australia, Canada, Denmark, Finland, Mauritius, the Netherlands, New Zealand, Sweden, Switzerland, USA, UK, etc. The 2003 Office of Fair Trading Report  into private Dentistry in the UK and also the 2005 Irish Competition Authority Report  into the professional services of Dentists both did in depth investigations into the results of restrictive practices of denture provision.  In conclusion both Reports made specific direct recommendations for the immediate introduction of a class of Clinical Dental Technician to provide this service in competition to dentists, as it will inevitably improve the efficiency of the service and decrease the cost  to the patient. (To access these reports, see International Reports and other Websites of Interest)

The Irish Competition Authority wants significant reform of the dental system as it says a lack of competition is pushing up prices, with Irish consumers paying above the odds. In a report published on 3 October 2007, the Authority concludes that competition is restricted and discouraged by an 'outdated system of regulation'. The report says consumers do not have the option of going directly to qualified hygienists and technicians for services and dentures, and the number of professionals being trained is not sufficient for the demand that is there. Chairperson Bill Prasifka said the Competition Authority is calling for significant reform, which places the consumer first <http://www.rte. ie/news/2007/ 1003/dentist. html>

Some procedures carried out by OHHR are charged at unjustifiable rates. An in depth investigation into all professional fees should be undertaken to provide a fair and just basis of remuneration that is also acceptable to the consumer. Anticompetitive fund allocation by medical schemes and restrictions and manipulation of the market by monopolies and professional groups to exclude competition needs to be brought into the public domain. Maybe the time have now arrived for the Consumer Council and the Competition Commission of South Africa to get involved!  

The anti-denturism lobby  in South Africa have often suggested that despite several international scientific studies, no evidence has emerged that denturists does the job cheaper than dentists and that there are no evidence to suggest that it would be the case in South Africa. Surely it must be apparent to an objective observer that such attempted arguments is merely a case of being selectively blind to what does not suit a given Agenda. By virtue of the difference in the training pathway, dentists' fees will always be higher, and in addition, overheads for denturists are generally lower and this may assist in lowering professional fees [1].

It is important to compare apples with apples, otherwise one will end up with fruit-salad.  Any comparison of tendencies between countries should take into consideration a multitude of different factors that should not be assumed as constants. It is acknowledged that it is problematic to measure such tendencies and provide empirical data on a scientific basis. In many of those countries where denturists have been established for a long time, dentists have reacted to the competition from denturists and lowered their fees to similar levels. The acceptance of denturists by dentists as part of the Dental Team, the need to cooperate to serve the patient jointly and the amount of additional income generated from cross-referrals has made proof of price differentiation between dentist and denturist redundant in many countries. Furthermore not all clinicians would design the same treatment plan for a specific patient’s denture needs, especially for hybrid dentures where a number of abutment teeth are still intact. The most economic solution is not always the sole consideration when a patient has to decide which option is best suited for his/her needs.  Due to the lower general fees of denturists, patients can often afford more advanced treatment options than would be the case if treatment was through a dentist. A whole range of outside factors may impact on indicators, that could influence a comparison of dentists' and denturists' fees, such as:

• the extent and level of price collusion by dentists in a specific country,

•  the level of training and attitude of dentists towards the provision of dentures in a specific country,

• reliability and fluctuation of data used for calculation of fees by dentists, dental technicians and denturists,

• the extent to which dentists have adjusted their fees to remain competitive with denturists, 

• the effect of pressure from dentists on dental laboratories to retain their combined market share,

• and probably many more factors, etc

Denturism is about providing better dentures and a more affordable fee is an added bonus, not necessary the only motivation to implement the category as the SADA has often implied. Due to the fact that the same person does the chair-side consultation, clinical procedures and also manufactures the denture, a better end product results, quality of care is constant and allows the patient to get their dentures sooner. Denturists work as part of the Dental Team to provide the best possible patient care. When appropriate, they work in close co-operation with dentists, which allows for coordination of all aspects of dental care. Unlike other health care practitioners who provide dentures, the denturist who also provides the chair side consultation to the patient does most denturists’ laboratory work in-house. Denturist fees are better affordable because their service are discipline-specific, removes the monopolistic restrictions to allow the interaction of competitive market forces, and there are no cost mark-ups, cross-subsidies for other services not applicable to dentures, or outside delays.

Due to the wide range of services dentists provide and the cost of specialized training and equipment, a high hourly-rate has to be charged to cover the expense as an availability fee[2], whether those services are needed, can be utilized or not. Dentists individually are quite happy to pay dental technicians a professional fee calculated at an hourly rate of R168/hour[3] while they charge between R550 - R650/hour[4] (or ±30% more) themselves for clinical procedures.

In countries where Denturism has been established for many decades, it is generally accepted that denturists provide a more affordable service than would have been the case if the conventional procedure were still the only option. Many articles in the lay press confirm this[5],[6]. Various International Reports indicates that Denturists provide dentures more economically than through the dentist - dental technician roundabout procedure. Yet, it is also acknowledged that a denturist, using the most advanced techniques and materials, in cases with severe complications, may sometimes charge fees that are similar to what dentists currently charge for a straight-forward uncomplicated standard denture.

MacEntree [7] (1981) reported that the American Dental Association (ADA) advocated the development of inexpensive techniques (the Triad-system) to reduce the cost of services as a method of reducing the impact of Denturists in the provision of services at much lower cost. Dental clinics were opened in Oregon, Maine and Arizona and operated by Dentists to provide a low cost denture service in competition with privately practicing Denturists. These clinics were financially supported and subsidized by the ADA. However, this did not end the popularity of Denturists and these clinics have since closed and the counter-offensive failed.

(The American States of Idaho (1982), Montana (1984) and Washington (1994) have since also legislated the profession of Denturism )

 

Rosenstein, Joseph, Mackenzie and Wyden [8] (1980) reported that in 1978, supporters of denturism in Oregon succeeded in passing an initiative by public referendum, which allows denturists to provide dentures directly to the public. After capturing broad-based consumer support, the issue was placed on the ballot and passed by an overwhelming margin. Both the denturists and the dentists in Oregon adopted strategies similar to those used in Canada over 20 years earlier when the issue was raised in a number of provinces. As was the case in Canada, the denturists prevailed. Denturists stressed the price differential and the issue of freedom of choice. Dentists stressed health and safety issues. The public perceived the dentists' campaign as negative and self-serving. The report speculated that any price differentiation between dentists and denturists would be eliminated once it was legalized, (due to profiteering ).

 

Rosenstein, Empey, Chiodo and Phillips [9] "The Effects of Denturism on Denture Prices." American Journal of Public Health,(1985) In 1978, the USA's first denturism initiative was passed in Oregon, legalizing the independent construction and delivery of dentures by non-dentists. One of the major campaign issues was the effect denturism would have on the cost of dentures. If the prices were to be effected at all, it would be evident 6 years after the initiative was implemented. The cost figures were not based on what Denturists were allowed to charge, but on the actual submitted accounts presented for claims. A review of Oregon dental insurance data shows that the costs of dentures, which had been rising at the same rate as other dental services, had a much lower rate of increase after passage of the denturism initiative. The increase for all dental services increased steadily along the same incline about 14% above the Consumer Price Index, while denture prices had been muted. The percentage change in the price of full dentures showed a marked downward trend, even a 5% drop 2 years after the initiative was implemented compared to where it was before legalization, and thereafter the denture price increase was at a lower incline than the CPI. The effect on the price of partial dentures is of special interest. In 1981 there was an unsuccessful drive to include partial dentures into the scope* of services of denturists. The moderate increase in the price of partial dentures could be attributed to dentists lowering their fees in anticipation of the expected competition from denturists.

(*The Scope of Practice of Oregon Denturists today includes removable full and partial dentures, as well as over dentures and implant retained dentures )

Kushman [10] (1995) State of Michigan. Independent Practice for Denturists: A Way to Provide Safe Dentures At a Lower cost to Consumers. Office of Health and Medical Affairs: Department of Management and Budget, (www.usdenturist.com/index.htm). Dr. John E. Kushman, an associate professor at the University of California at Davis and a consultant on dental care economics to the Federal Trade Commission, has examined the implications of denturist competition. This report concludes that one of the major reasons for failure to obtain denture care is the high cost of that care, especially for the elderly. Denturists competently provide dentures directly to the public for half the price charged by a dentist. Denturists' overheads is lower than dental office practice overheads and  they do not sacrifice quality to keep their prices low. Kushman's research found that denturists offer lower prices and concludes that 'the economic advantages of introducing competition are great, and significant impairments in quality would be required to offset them.' Dr. Kushman notes that such impairments in quality (if any at all ) have not been documented.

 

Devlin [11] (1994) reported that the New Zealand Dental Act of 1988 allowed clinical dental technicians to deal directly with the public in fitting and supplying dentures. This study tested the hypothesis that dentists responded to competition from dental technicians by lowering their fees. The results indicate that there was no significant change in the fees charged by dentists for dentures. It appears that dentists were already charging denture fees at a level dictated by their overhead costs and not by what the competition were charging in the marketplace. The apparent failure of deregulation to produce the expected outcome could be due to the competitive pressure imposed by dental technicians practicing illegally prior to 1988, dentists’ acceptance of denturists as preferred denture providers, to consumers' lack of information, and to barriers to "consumer search " imposed by the Act itself.

 

Van den Eeden [12] (2007) "Denturists – The Solution to America’s Denture Crisis". Michigan Denture Reform Committee. This publication demonstrates how and why other US states have licensed the specialized practice of Denturitry over twenty-five years ago, and how their citizens have benefited from its safe and high quality denture care delivery system at better affordable levels. The purpose of the publication is to help all levels of society to understand, not only the pain and suffering that America’s denture wearers are experiencing, but to help them understand the related social, economic and health issues that are linked to the crisis. Another objective of this book is to give sufficient data in which to recognize the problem on a local level, and to share a model that will enable them to implement the denturist profession as their ultimate denture care solutions. Citizens have a rapidly growing need for denturist care. The book’s message is critical, since many dentists are discontinuing to offer denture services, dental schools have cut back their curriculum hours in denture training for dental students by 90% over the past thirty years and over the next ten years, one-third of all dentists who currently provide denture care are expected to retire from practice, leaving the US denture population in a vacuum.

 

Various other reports confirms the fact that the implementation of Denturism leads to a reduction in the cost of dentures to the consumer, for example:

•         Federal Trade Commission. "The Sale of Complete Dentures: Effects of Present & Alternative Regulations." as reported in  A STUDY OF DENTURITRY - Directed by the 1998 General Assembly, Kentucky. Legislative Research Commission, January 2000. Robert Sherman, Michael Greer, Ann Mayo Peck. Research Report No 292, and also

•        Federal Trade Commission, Intended Rule Making on Sale of Dentures, & State of Washington, Department of Social and Health Services.

•       Consumers and Competition in Health care: The case of Denturism. Prof John E Kushman. 1984 University of California. Journal of Consumer Affairs 18(1) j.1745-6606. 1984.tb00316.x  www.blackwellpublishing.com/

•        The Nuffield Foundation - Education and Training of Personnel Auxiliary to Dentistry, 1993 London UK

•         Kooman, I & van den Heuvel, J, Free Market Dentistry in Europe: A report on a survey of chief dental officers in Europe, Ministry of Health, Welfare and Sport, Netherlands,1998.

•        The 2003 Office of Fair Trading Report into private Dentistry in the UK

•        The 2005 Irish Competition Authority Report into the professional services of Dentists

 

 

The search engine used on The Society's PC found a substantial number of websites advertising denturist fees at more economic rates than dentists (and this is just on the first few out of 20 pages of the random search result), for example:

Affordable Dentures Affordable Partials at 50-75% Savings

Affordable dentures and Affordable Partials at great price savings. ... Denture.com is an all Denturist site. Here you can order dentures online, ... www.denture.com/ -

AFFORDABLE DENTURES - WOW!

Dentures should only cost you around $500-$700 (upper & lower) no joke this should ... So if you want and affordable dentures check out DENTURIST in states  www.perma-laboratories.com/AFFORDABLE.html -

Ban on Denturists Blocks Seniors from Receiving Quality, Cost ...

Ban on Denturists Blocks Seniors from Receiving Quality, Cost-Effective Dentures Claims Suit Filed on Behalf of California Patients. ... www.encyclopedia.com/doc/1G1-111940261.html -

Measure 24 - Arguments in Favor

Oregon's state licensed denturists have dedicated themselves for more than 20 years to serving Oregonians with quality, affordable dentures. ... www.sos.state.or.us/elections/nov52002/guide/measures/m24fav.htm -

Affordable Dentures - Cosmetic Denture Clinic-

Cosmetic Denture Clinic, supplying the most affordable dentures and services. ... Our Denturists will listen to your needs and provide the best solutions to ... www.cosmeticdentureclinic.com/

Smyl.com

Denture work is done at your denturists clinic, so adjustments and ... Denturist fees are affordable because there are no cost markups or outside delays. ... www.smyl.com/index.php -

Dental And Health Links - Dental Products

Affordable dentures and Affordable Partials at great price savings. ... Dentures, Denture, Denturist, Products, Services, Nanaimo, BC, Vancouver Island. ... www.therabreath.com/links/dentalproducts.htm -

Getting Affordable Dentures

Information on getting affordable dentures. ... A well made set of standard dentures fitted by a skilled denturist and manufactured at a reputable denture ... dentures.net/gad_affordable_denture.html -

Making Dentures

Affordable dentures and Affordable Partials at great price savings. ...  A DENTURIST IS FULLY TRAINED, LICENSED AND SPECIALIZES IN THE www.dentalpassport.com/sitemap/4/making-dentures.html -

Premium Dentures and Partials 50% less

Affordable Dentures and Partials online at savings of 50% to 75%. ... It should be pointed out that Denturists have the professional designation "DD" ... www.onlinedenturecenter.com/ -

A socioeconomic comparison of patients receiving prostheses in a ...

Choice Behavior Comparative Study Costs and Cost Analysis Dentists* Denture, Complete*/economics Denture, Partial, Removable*/economics Denturists*  www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507100&dopt=Abstract -

Seattle Dentures in Seattle WA Yellow Pages by SuperPages

Allen Dental Laboratory & Denturist Your Complete Denture Service... Fast, Reliable, Affordable Relines & Repairs. Most Dental Insurance Accepted. ... www.superpages.com/yellowpages/C-Dentures/S-WA/T-Seattle/ -

Website Page Navigation Association E-mail Contacts: President ...

safe and affordable denture services. You will also learn more of our current ... Certainly with our service record, professional denturists do not ... www.denturistofgeorgia.com/ -

Listings British Columbia: Dentists - Complete List

Affordable dentures and Affordable Partials at great price savings. ... The College of Denturists regulates denturists in B.C. Our site contains valuable ... www.listingsca.com/British-Columbia/Health/Dentists/complete.asp -

Dentures " A New Smile"

thanx for the info previously. the closest affordable denture lab to me is 10 hours away. ... I would say, hope the move was to a place where denturists can ... groups.msn.com/DenturesANewSmile/general.msnw?action=get_message&mview=0&ID_Message=27967&Las... -

dentures information - dentures

Affordable Dentures Affordable Partials at 50-75% Savings Affordable dentures and Affordable Partials at great price savings. ... www.sashdentures.info/

oregon dentures information - oregon dentures

AffordableDentures Affordable Partials at 50-75% Savings In the last few years ... The Oregon State Denturist Association As denturists, we are trained not .. www.sashwww.dentures.info/oregondentures -

Hello?

It was all a reminder of why I love the denturist profession providing affordable denture care. When the Lord sends me His special people I just know I give ... www.dissectors.com/community/184/hello/ -

 

Some 30 years ago dentistry was the 7th highest earning profession in South Africa. With various new professions and disciplines evolving since then dentistry does not even rate amongst the top 100 anymore[13], and as a result any suggestion of denturism is viewed as encroachment and a threat to dentists’ earning capacity and vested rights. Begun and Lippincott [14] (1987) identified and described the characteristics and reactions to inter-occupational encroachment. Hartshorne [15] (2001) reported on a feasibility study (?) into Denturism, conducted under supervision of the Stellenbosch University in the Western Cape and sponsored by the SADA, that dentists spend 10% of their time on denture work but generates 26% of their income during that time. A 260% profit on one's investment is an excellent return by anybody’s terms! With such a profitable yield, it is not surprising that dentists are opposed to the competition that will result from the introduction of this category, and retains the tactic of "finding reasons to resist, in the public interest ", even when the truth is evidently the opposite of their claims.

In The Society Report[16] of 1998 to the SADTC and the Minister of Health, an annual saving to the economy of R85 million was indicated, calculated on the assumption that if all local denture-needs were to be met, and replaced every 5 years by denturists charging fees calculated at the hourly labor rate paid to dental technicians in South Africa. Calculated at the current fees charged by Dentists and Dental Technicians applied to these criteria, the savings to the public would exceed R200 million annually  if denturists supplied all the denture needs in South Africa.

See also The Price of Dentures on the Public Interest Page of this website for the details of these calculations.

 

---

[1] John Egan and Professor Alan GT Payne from the Oral Implantology Research Group, Sir John Walsh Research Institute in Dunedin, New Zealand, quoted by Lisa Petter in "Implant overdentures bring new opportunities for denturists", as published in DPR Europe on 12 December 2007. This article is also on-line in the Journal of Oral Rehabilitation

[2] Letter from Dr H Heydt, Executive Director of the DASA to Mr. EAJ (Dickey) Buret former Vice President of the SADTC . Sept 1989

[3] Code 9662: Government Gazette No 28247, 25 November 2005 NOTICE CONCERNING THE TARIFF OF FEES IN RESPECT OF WORK DONE BY DENTAL TECHNICIAN CONTRACTORS FOR DENTISTS

[4] Average hourly rate calculated on dentists' fees listed for common procedures in the National Reference price list, effective from January 2006.

[5] Maisey K. Smile! Your new teeth might cost less in future 16 July 1984 Australian Daily News

[6] Staff writer How to take the bite out of dental bills 3 June 1981 The Australian Woman’s Weekly

[7]  MacEntree MI. The Denturist movement in Canada. Part II: Acceptance in Eastern Canada. Journal of the Canadian Dental Association, Vol 8. – 1981 

[8] Rosenstein DI, Joseph LP, Mackenzie LJ and Wyden R. Professional Encroachment: A Comparison of the emergence of Denturists in Canada and Oregon. American J of Public Health, Vol 70, Issue 6 1980 by American Public Health Association
[9] Rosenstein DI, Empey G, Chiodo GT and Phillips D. The effects of Denturism on denture prices. American Journal of Public Health, Vol 75, Issue 6, 1985 by American Public Health Association.

[10] Kuchman JE State of Michigan. Independent Practice for Denturists: A Way to Provide Safe Dentures At a Lower cost to Consumers.Office of Health and Medical Affairs: Department of Management and Budget, 1985 (www.usdenturist.com/index.htm).
[11] Devlin NJ The effects of Denturism: New Zealand dentists' response to competition Economics Department, Otago Univ, Dunedin, New Zealand. American Journal of Public Health, Vol 84, Issue 10 1994 by American Public Health Association  
[12] Van den Eeden Everett, DDM, CD, CDT,  "Denturists – The Solution to America’s Denture Crisis". (May 16, 2007) Michigan Denture Reform Committee. 160 pages. Global Professionals 720 E. Eighth St, Ste # 1., Holland, Michigan 49423; (616) 355-5500, Fax (616) 355-5502 ev3000@sbcglobal.net
[13] Notes from Neil – October 2005 www.sadanet.co.za/bulletin/index.html

[14] Begun JW (Medical College of Virginia) & Lippincott RC (Univ of Baltimore) The Origins and Resolution of Interoccupational Conflict Work and Occupations, Vol. 14, No. 3, (1987) SAGE Publications

[15] Hartshorne JE (Univ of Stellenbosch) Denturism – Report on a feasibility study conducted in the Western Cape. Ph D (Odontology). SADJ Sept 2001 Vol 56 No 9

[16] Malherbe DF, Steyn LA, du Plessis C, Fatagodien Z Clinical Dental Technology: A Quest for Equity in Oral Health Care. The Society for Clinical Dental Technology - 1998. Motivational Report to the SADTC, the Minister of Health and the Department of Health

 

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