Things that Matter: Getting to the root of our dental problems
“Pain is perfect misery, the worst of evils, and excessive, overturns all patience.” (Paradise Lost by John Milton, poet, 1608 – 1674)
“Dentistry is not expensive, neglect is.” (Anonymous)
“My patients - by accepting me, have made my working life a joy and not a job.” (Dr. Victor Eastmond, in opening the Dental Conference.)
Everyone has mixed feelings about dentists – you might call it a love-hate relationship. We hate going to the dentist, and many people procrastinate and neglect their precious teeth. We hate the drill and we hate the toothache that we associate with the dentist, even though we’re desperate for the dentist to relieve our pain. But relief from pain is perfect pleasure – and then, suddenly, we love the wielder of those frightening tools!
I’ve had a life-long emotional connection with dentists and dentistry – not just because of those visits 60 plus years ago to Dr. Kenneth Nicholls in the famous Nicholls building in the school holidays, but because my grandfather, Dr. Henry Fraser, who qualified as a dentist more than 130 years ago at the University of Pennsylvania, was quite a legend in his own time. Oral history claims that he was the first University qualified dentist in Barbados, and that for about thirty years he had the responsibility of assessing and approving every dental practitioner coming into the island. He was therefore, in a sense, the fore-runner of our Dental Council! Sadly, again according to oral history, he died penniless in 1934 because he hated charging people. In those far-off days there was no receptionist to deal with such mundane matters, and he didn’t have the heart to hold out his hand.
It was my father’s wish that I too should be a dentist, but I knew I could never be – hence my huge admiration for the good, dedicated dentists I’ve known, and my deep appreciation for the superb dental care I’ve had and continue to have. And that’s why I remain very concerned about the inadequate dental care provided for the majority of our population who can’t afford conservative care. And to modernise the old saw, not only does an ounce of prevention save a pound of cure, but it saves lives.
And so I must again point out the disjunction between the comprehensive general health care in Barbados and dental care - thoughts stimulated by the latest “Dentistry in Paradise” Conference. This was again hosted in Barbados, from the 18th to the 23rd of April, at the Accra Beach Resort under the auspices of Caribbean Dental Programs Inc. and the chairmanship of the energetic and “ever-young” Dr. Victor Eastmond. The theme for this 15th annual convention was “Incorporating Aptitude with Attitude - A Plan for Success” with special emphasis on incorporating approved modern technologies.
In his Opening Address Dr. Eastmond covered several hugely important issues, which must be addressed if good preventive and conservative dental care is to reach most Barbadians. These are:
• The inadequacy of the public health services in dentistry
• The importance of Continuing Professional Education
• The high cost of dental equipment and supplies and hence of private dental care
First, a few facts. There are 89 registered dentists in Barbados (although a few are not practising here right now), 18 hygienists, 9 auxiliary dental officers and 12 dental technicians. The number of people per dentist is therefore about 3,300. In Canada, with a full National Health Service and comprehensive dental care for many years, the national average is 1,700 people per dentist; that’s half the numbers per dentist compared with Barbados. It’s a far cry from 1886 when my grandfather returned as the only qualified dentist, but we’re still underserved nationally and very, very much so in the public sector.
There are just 7 dentists working in the polyclinics, most part time, so there is not a dentist in every polyclinic every day. In addition, there are 8 auxiliary dental officers - staff who have training equivalent to a dental therapist, so that they can treat only children, and can’t treat adults with extractions, root canals etc. Also, at least 2 of these officers are approaching retirement age. In fact, adult care is restricted to emergency extractions! There is no conservative or restorative care. My heart bleeds for my brothers and sisters, because I know the pain of dental abscesses and tooth decay. For as the poet Milton wrote, pain is perfect misery.
These seven dentists are also responsible for school screenings at primary schools. They are supposed to cover all schools, but I understand this isn’t always possible. Other problems, I understand, are equipment and supply problems, as in the general polyclinic services,. The lack of conservative care may be a major contribution to our huge epidemic of cardiovascular disease, because it’s now well established that dental infection – both periodontitis and dental abscesses – are among the contributory causes to our ever-increasing epidemic of atherosclerotic disease.
An option for Government, which may well be an option with economic benefits to both government and patients, rather than employing many more dentists in the polyclinics and upgrading equipment and supplies, would be to develop a system where patients are referred to private dentists for care covered by government. This could work as a co-payment system analogous to the Drug Benefit Service, available to all patients with the designated chronic diseases, who can see their private practitioner but receive drugs through the Drug Benefit Service.
Dr. Eastmond’s second major theme was the continuing lack of requirement for Continuing Professional Education (CPE) and hence the lack of participation of many of our dentists, who will not avail themselves of the high-quality CPE provided. Many local dentists, like many doctors in the past, seem to be totally casual about their continuing professional education. I remember one local (late) physician of the past boasting proudly that he had never had any kind of CPE since graduating 40 years before! Dr. Michael Hoyos and I, followed by Professor Prussia and others, co-ordinated and advocated for formal CPE for thirty years before the Medical Council made it mandatory. Will dentistry have to wait another thirty years, to achieve highest quality care here?
Dr. Eastmond’s third theme was the issue of the high cost of dental equipment and supplies and hence of private dental care. This places an enormous burden on that large segment of the lower-earning population who must turn to private care if they understand the importance of conservative and reparatory dental care. The Dental Association has, like the Medical Association, been pointing out that the high cost of equipment, exacerbated by the high duty, obviously has to be passed on in professional service fees, and is asking for waiver of duty on equipment critical to dental care.. In fact, the cost of setting up a new dental practice from scratch is estimated, I’m told, at about $300 000 for the purchase of all the costly equipment essential for the job. And the practice must be supported by a minimum support staff of receptionist and dental assistant. Senator Jeptor Ince, keynote speaker at the conference opening, promised to address this issue.
The improvement of public dental services, the quality of dental care, and the reduction in private care costs can only be achieved by full discussion between the Barbados Dental Association, the Dental Council and the Ministry of Health. Dental care must not continue to be the Cinderella of health care in Barbados.
Bouquet: To the Barbados 4 X 100 relay team, winning the silver medal in the recent IAAF championships. The secret? Teamwork, teamwork, teamwork!
And another bouquet to the wonderful staff at BRA for their efficiency assisting us this week – especially Mr. Joseph Marshall, Jodi and Mr. Waithe. Keep up the good work!
(Professor Fraser is Past Dean of Medical Sciences, UWI and Professor Emeritus of Medicine and Clinical Pharmacology. Website: profhenryfraser.com)