Oral and Dental Care

Acknowledgements Estonia

This Handbook has been produced by Mrs. Tiina Juhansoo, who offers grateful thanks to the following for their guidance, support, donation of appropriate materials and proof reading for accuracy of this package of information.

Mr. Laine Paavo Lecturer, Tallinn University Mrs. Eve Epner Team Member, Tallinn Health College Mr. Tõnu Kauba Head of the Chair of Dental Technology, Tallinn Health College Mr. Veikko Keimann, Dentist, Novamed OÜ Mr. Andry Tulp, Assistant, Novamed OÜ Mr. Gunnar Riisenberg Project Assistant, Tallinn Health College

Graphic Design Rhinoceros Ltd for layout Mr. Matti Remsu (co-ordination of the project)

All materials of the project are downloadable for free from partner colleges’ websites: Oral and Dental Care www.hesote.edu.hel.ﬁ Tallinn Tervishoiu Kõrgkool www.davinci.nl www.ttk.ee www.kbs-pﬂ ege.de www.kellebeek.nl www.vitaliscollege.nl This Handbook for Students has been produced within Leonardo www.linkoping.se/birgitta da Vinci - programme as a pilot project “Learning Materials for www.stevenson.ac.uk Social and Health Care Students’ Foreign Placements / ETM II” www.oszee.de (FI-06-B-P-PP-160 704) during 2006 – 2008. This publication has been funded by the European www.dundeecoll.ac.uk/?about_us/european_projects.xml Commission. The Commission accepts no responsibility for the contents of the publication.

Oral and Dental Care in Estonia Content

Introduction 3

1. Guidelines on Oral and 4 Dental Health Policies of WHO and EU

2. Oral health care services in Estonia 8 2.1. History and Challenges for the Future 8 2.2. Variety of Clinics 12 2.3. Organization of Oral Health Care for Special Groups 14 2.4. Insurance Arrangements 15

3. Oral Health Care Teams 17 3.1. General Dental Clinic 17 3.2. Dental Specialists 19 3.3. Dental Laboratories 19

4. Status and Position of the Dental Nurse 20 4.1. The Law and Ethics 20 4.2 Some Facts 22

5. The Dental Nurse in the Workplace 25 5.1. Hygiene and Maintenance of Equipment 27 5.2. Documentation and Administration 28 5.3. Promotion of Oral Health Care 29 5.4. Treatment, Assisting the Dentist 30

1 6. Communication 34 6.1. Communication with Patients 34 6.2. Communication with the Team 35

7. A Day in the Life of a Dental Nurse 36

8. Vocational Education in Estonia 37 8.1. Studying in Estonia 37 8.2. General Goals of the Dental Nurse Curriculum 37 8.3. Description of the Practical Nurse Profession and Core Competences 39

References 41

Glossary 42

Appendix: Dictionary 43

2 Introduction Dear Student

◆ We are happy that you chose to do you practice in Estonia. Welcome! We hope that you will have a worthwhile learning period here and that you enjoy staying in our country.

The purpose of this handbook is to give you a brief overall view of health and dental nursing education system, focusing more on oral care in Estonia. In the booklet you will also find some practical recommendations which may help you to prepare your visit to Estonia. You fill also find description of a working day in dental centre and some descriptions of the roles of doctors, dental nurse/assistant in a real work situation – we hope that it will help you in your practical placement.

We have added to this booklet a short glossary to be sure that we all have mutual understanding of terms used in oral care and a very short bilingual dictionary (Estonian – English, English – Estonian) for everyday use in your practical placement.

You will also ﬁnd some useful internet addresses in this booklet for additional information.

3 1. Guidelines on Oral and Dental Health Policies of WHO and EU

◆ Oral health is not to be seen just as infections and immune disorders to a specific of health care and promotion mention a few. of well-being – it means more than just good teeth, it is integral and essential From a broad based viewpoint such as to general health. This viewpoint has common oral health issues like caries been identified in the World Health and periodontal diseases are global Organisation’s (WHO) ‘The World problems as well as other oral diseases Oral Health Report 2003’ resulting too, they are to be considered as major in ‘Continuous Improvement of Oral public health problems. This applies Health in the 21st Century – the both to industrialised countries as approach of the WHO Global Oral well as developing ones. According Health Programme’. to WHO’s global estimation some five billion world-wide have experienced The future oriented disease-preventing dental caries. Such estimation is and health promoting policy is based convincing evidence that oral health is on the following common facts: oral an integral part of general health and health as in integral and essential factor any person’s well being. of general health implies being free from chronic oro-facial pain, oral and What makes oral care and combating throat cancer, oral tissue lesions and the most common problem, dental other diseases and disorders that affect caries, challenging is that dental caries oral, dental and craniofacial tissues. has been perceived in developed Oral health problems and general countries, e.g. Member States of the health problems are primarily the result EU, as a problem that has already been of the same common risk factors that overcome. The true situation however is are interrelated. Although these points that it affects 60-90% of school children capture the wider meanings and target and the vast majority of adults. In a it does not take away from the relevance similar manner dental caries is also the major global oral problems such as most prevalent disease in several Asian caries and periodontal diseases. and Latin American countries as well.

Preventative work and early detection While it appears to be less severe in of oral diseases with proper treatment most African countries, the report states is crucial and positive is crucial and that with changing living conditions, has positive as in the reduction of dental caries is expected to increase in premature mortality, microbiological many developing countries in Africa,

4 particularly as a result of the growing Scholl Health Initiative, which seeks consumption of sugars and inadequate to mobilise health promotion and exposure to fluorides. education levels at local, regional, national and global levels, has recently According to WHO’s Global Oral been strengthened by an oral health Health Programme the prevalence of technical document. Increasing oral cancer is the eighth most common emphasis has also been placed on cancer of men worldwide. In south targeting the elderly; by 2050, there central Asia, cancer of the oral cavity will be 2 billion people over the age ranks amongst the three most common of 60, 80% of them living in the types of cancer. The sharp increases developing world. The Oral Health Care of oral/pharyngeal cancers have also Programme will make an important been reported in several countries and contribution to early diagnosis, regions such as Denmark, Germany, prevention and treatment of HIV/AIDS, Scotland, central and Eastern Europe, which often shows up first in oral and to a lesser extent, Australia, New fungal, bacterial or viral infections and Zealand, Japan and the USA. Smoking, lesions. smokeless tobacco, chewing betel and alcohol use are all risk factors. Poor oral health can have a profound effect on general health and the The major priorities and components of quality of life. The experience of pain, WHO’s Global Health Programme focus endurance of dental abcesses, problems on not only to addressing modifiable with eating, chewing and missing, risks such as oral hygiene practices, discoloured or damaged teeth, has a sugar consumption, lack of calcium major impact on people’s daily lives and and micronutrients and tobacco use, wellbeing. but also to major socio-cultural factors. These include: poor living conditions, European Strategy low education level as well as lack for Oral Health of traditions supporting oral health. In 2007 the European Council Globally countries should ensure the of European Dentists outlines appropriate use of fluorides for the recommendations at a conference in prevention of caries, while unsafe water Lisbon; ‘Health Strategies in Europe’. and poor hygiene are environmental The recommendations are parallel to risk factors for oral as well as general the WHO’s Oral Health Programme health. are based on the same socio- epidemiological surveys. Oral health systems need to be focused towards primary health Oral health is an integral part of general care and prevention. WHO’s Global health and well-being. Good oral health

5 enables individuals to communicate according to their differing lifestyles, effectively, to eat a variety of foods, and life stages and life conditions, is important to the overall quality of including children and elderly people. life, self-esteem and social confidence. ◆ Oral health promotion, based on A range of diseases can be classified as a common-risk approach, must be oral diseases, including dental caries, an integral part of chronic disease periodontal disease, oral pathology prevention. and cancers, dentofacial trauma and ◆ The public, patients and oral health dental erosion. These diseases, although care professionals must be educated largely preventable, affect a significant to promote a healthy lifestyle. proportion of the European Union ◆ Member States need to recognise population and exact a heavy burden on their role in actively and financially the individuals quality of life and costs supporting measures relating to oral to the health care system. health promotion.

The major risk factors for oral diseases Action on health inequalities are the same as for major chronic ◆ Evidence-based population non-communicable diseases such strategies need to be developed as obesity, heart disease, stroke, and implemented to address cancers, diabetes and mental illness. underlying determinants of Rather than attempting to tackle each oral health inequalities, paying chronic disease in isolation, a more particular attention to high-risk and effective approach is needed with disadvantaged individuals or groups. greater emphasis on prevention and ◆ A multi-strategy approach is needed health promotion. Directing action at – clinical prevention and health the common-risk factors – e.g. diet, education are not enough to reduce smoking, alcohol, stress Improvements oral health inequalities, so further – is an effective and efficient way of measures such as legislation, fiscal reducing the burden of these diseases. policy and community development need to be considered. The European Council of ◆ Policies must be encouraged and Dentists’ recommendations in promoted to ensure access to fluoride short: for the whole population; this should include the decrease of VAT on Prevention and oral health promotion fluoride products. ◆ A reorientation of oral health care systems is needed to focus more on Oral health surveillance prevention. ◆ Essential oral health indicators must ◆ Preventive measures must take into be integrated in health surveillance account different population groups and data systems.

6 ◆ An EU Oral Health Surveillance Institute should be considered. ◆ Oral health indicators should be used as markers of health inequalities. ◆ Oral epidemiology needs to be regularly monitored across the EU – at national, regional and local levels.

Quality assurance ◆ Availability and access to high quality and affordable oral health care needs to be guaranteed. ◆ Quality assurance, clinical governance and patient safety initiatives should be supported. ◆ Access for patients to accurate oral health and service information needs to be improved.

Capacity building ◆ Oral health professionals need to be trained in evidence-based prevention and health promotion at undergraduate level and during continuing professional development (CPD). ◆ General medical training should include an oral health component. ◆ Better use of resources should be ensured by the evaluation, sharing and dissemination of knowledge and experiences across the European Union – at national, regional and local level.

National level recommendations should be in line with stated recommendations.

7 2. Oral Health Care Services in Estonia

Molotov-Ribbentrop Pact, the gradual 2.1 History and development of the health care system Challenges for the was interrupted. The system of centralized control was implemented, Future in which health care was funded from the state budget and controlled by the ◆ The development of the health government through central planning. care system in Estonia during the There was no private sector for any 20th century has been influenced aspect of health care. All citizens had by dramatic political events. It has, free access to health services, including therefore, not been gradual but marked dental care, which were provided by by abrupt changes in direction and salaried government employees. organization. The development can be looked at in three periods. During the Soviet time all schoolchildren were in special Before 1940 prophylactic program that meant Estonia has a long tradition of regular annual control and treatment. medical education, dating back to the Adults’ visits to the dentist mostly establishment of Tartu University in happened only when a tooth hurt. 1632. By the beginning of the 20th Toothpaste and brushes meant whatever century, Estonia had the necessary was available - there was no big choice. foundation for the development of a Soviet-era teeth were notoriously bad; health care system appropriate to the the average 35-year-old had 12 to 14 needs of the population. There were cavities, fillings or missing teeth. three kinds of hospitals: state-owned, municipal and private. There were From 1990 until today clinics for mothers and children, dental By the time that independence was clinics, dispensaries for those with declared in August 1991, it was tuberculosis, sanatoria, institutions for already clear that the planning and the mentally ill and so on. Out-patient organization of health care system care, including dental care, was carried had to change to respond to the needs out mostly by private physicians, with of the Estonian population. Reforms dispensaries owned by sick funds and were broadly intended to decentralize schools. the health care delivery system and to finance it through health insurance. 1940–1990 They, therefore, aimed at completely With the occupation of the Estonian reorganizing and changing the Republic by the USSR under the orientation of the health care system.

8 At the beginning of that period a private The lectureship of oral and dental a private vocational school “Dentes” was diseases was opened in 1936. The opened in Tartu. For some years they chair itself was created in 1938. The prepared dentist assistants and started lectureship as well as the chair of oral a curriculum of dental hygienists, but and dental diseases (later named as in connection with different changes stomatology) was managed by prof. in health care and education system Valter Hiie until his decease in 1963. the plan did not realise and the school The goal of the chair was to provide finished its work. general knowledge about dental and maxillary diseases and their treatment Oral examinations would normally be to medical students: two hours of undertaken every 6 to 12 months, more lectures and two to four hours of frequently for patients with periodontal practicing a week during two semesters. conditions. There is no prior approval system for treatment. The Estonian The department of dental science Dental Association reports that they (current dentistry) was established by believe that most of the population visit a the decree of the director of education dentist within any 2-year period. This is on August 29th 1942, with 25 student what dentists ask from patients. In some vacancies. The studying period in the private clinics dentists give a guarantee new department started on October for the technicians work only if the 15th, 1942. A competition was held patient visits the dentist every 6 months and 25 students were accepted. But as for two years. Access to oral healthcare the number of applicants was much may be difficult for patients who live in higher, the actual number of those some urban areas, as well as all those in immatriculated was 37. On October rural areas, as salaries there are generally 19, 1942, a dental science department too low for what is almost private curriculum of 32 hours a week, care, with the low reimbursements. composed by prof. Valter Hiie, was Indeed, there may be difficulties for approved by university rector’s decree patients, all over Estonia, obtaining that included: 5 hours of anatomy, 4 prosthetic treatment under the scheme. hours of physics, 2 hours practical The proportion of total governmental training of physics, 5 hours of anorganic spending on healthcare which is spent chemistry, 4 hours of histology and on dentistry is about 4.5%. embryology, 4 hours of practical training in histology, 2 hours of dental History of the University of technical propaedeutics and 6 hours Tartu’s Stomatology Clinic of practical training in dental technical The subject of stomatological diseases has propaedeutics in a week. Initially the been in the curriculum of Tartu University planned duration of studying period Medical Department since 1814. was 3,5-4 years.

9 The first class – only 6 dentists - care system; the micro-ecology of graduated in 1946 because the rest of gum pocket of patients with chronic entrants had dropped off due to critical parodontic disease; factors influencing political events. the effectiveness of treatment of parodontic diseases; infants’ caries After the war, during the 1944 / detrimentation resulting from mother’s 1945 academic year the stomatology cavity micro-flora, set of teeth condition department of State University of and the adjustment to regular dental Tartu (the chair of oral and dental care. diseases was named as the chair of stomatology) started, applying the In the area of orthodontics, the studying curriculum of former Soviet research subjects have been: children’s Union Stomatology Institute with four- incorrect location of front teeth, the year studying cycle. During the 1949 / peculiarities of children’s scull structure 1950 academic year a five-year studying with toothing anomalies; effectiveness period was adopted and this has been of early orthodontic treatment with in force up today. standard equipment; the research of non - syndromic hard palate appearance The subjects of research work in frequency and genetics in Estonia has the area of oral and dental diseases been launched. (including children’s dental diseases) have been: chemical components of Important research problems in the dental hard-tissue in case of dental area of face-chinbone surgery have caries and parodontic diseases; the been and are currently: sorting out and role of biochemical changes of spittle, the complex treatment of etiological malfunctions in endocrinal system factors of inherent facial and chinbone and immunological processes in the abnormalities; enhancing surgical as pathogenesis of caries and parodontic well as orthodontic treatment methods; diseases; the appearing frequency clinical - morphological research about of caries, non-carious damages and pathogenesis of parodontic diseases toothing anomalies in different age- (including the relative importance groups and regions of Estonia in of prostaglandin E2) and surgical 1971-2004; the complex research of treatment; estimating the regeneration health, oral health and anthropology and osseo - integration of alveolar of students from Estonian nationality bone after using bone transplants during 1981-1983; the impact of and tooth implants in the treatment sugar alcohols on excretion of spittle, of the defects in the set of teeth and dental plaque and caries; comparative parodontic disease; the epidemiology, estimation of Estonian and Danish pathogenesis and clinical aspects of children’s dental health and health odontogenical tumors; evaluative

10 analysis of age determination and In 1944 Samuel Kaplan, having worked identification methods in forensic in Tallinn before the war and having medicine; pathogenesis of jowl bursa returned from evacuation of Soviet diseases: inflammation mediators, Union’s rear, started immediately cytokines, pain, antagonists and organizing a workshop for dental treatment of serotonin: the effectiveness technicians in Tallinn. of artrocenthesis and artroscopy in the treatment of jowl bursa. 4 doctor Dental technicians studied under the degrees have been defended in the instructions of experienced technician. leadership of prof. Edvitar Leibur. Those who wanted to acquire a diploma, had to apply for it in Riga, History of dental technician Vienna or other parts of Europe. speciality in Estonia, Tallinn Medical School and Tallinn In autumn 1945, the re-opened Tallinn Health College Medical School accepted a new course One of the first known dental of dental technicians – 42 students, 22 technicians in Estonia was Mr Rohlin, of those graduated in 1947. In addition who had travelled to Tallinn from to speciality-subjects the curriculum Odessa and had started practicing in his contained also physics, mathematics, own house on Kinga Street. chemistry, anatomy, history of Soviet Union Communist Party, Russian There were approximately 25 dental language, gas protection, military technicians practicing in the Republic training. of Estonia (according to 1939/40 phone book). Generally they worked alone The first speciality teacher and in private laboratories, sometimes also practicing instructor was mrs Lydia with pupils or assistants. Replicas and Nurmetu-Dobrjanskaja, who instructed works were forwarded between doctor’s how to make plate-dentures. private cabinet and technicians. A doctor could make orders to different Parallel with stationary study of dental laboratories, at the same time a technician speciality, it was possible technician could offer his services to through distance study to obtain the different doctors. profession for those technicians, who had previously studied and worked for All the materials, equipment and an experienced dental technician, but instruments needed were ordered and had no diploma. Three groups of dental bought mainly from “Dental Ltd”, technicians graduated in distance study aka Dentaldepot, located at 30 Harju in 1947, 1961 and 1969. Street. All the practicing equipment was imported and extremely expensive.

11 In the autumn of 1979, 32 students legislation and several standards that were accepted; practical study took have to be followed. One part of the place in two shifts over a day because quality assurance system is feedback there were 16 positions for students from the patients. and 2 for teachers. The following rooms were equipped: plaster polishing room, In case of a complaint by a patient it polymerizing room, brazing room and is investigated by the head of the unit. annealing room. If the patient is not satisfied with the answer of the head of the unit, he/ The quality of training satisfied the she has a possibility to turn to the needs of labour market up to the start “Treatment Quality Commission”, of the 1990’s. which is appointed by the Ministry of Social Affairs, Health Department’s Tallinn Medical School obtained Supervision Department. the status of pilot-school in PHARE project “Vocational Education Reform Patients may also write an application in Estonia”, with the objective of to the Consumer Protection Service, modernizing the training of dental but they have to send their complaint technicians in the school. The project to the Health Department’s Supervision comprised of working out a curriculum, Department first. changing material-technical base and training of teaching staff. The dental technicians department of Copenhagen 2.2. Variety of Clinics Polytechnic acted in the role of foreign expert and partner. As the eventual ◆ About 90% of oral healthcare in result, 2 studying laboratories and two Estonia is provided through general assisting rooms have been equipped on (private) practice, clinics under modern level with everything necessary fully (liberal) private contract between for training in dental technician patients and their dentists. speciality. All together there are 24 positions for students and 4 positions Most of the clinics have agreements for teachers. with the Health Insurance Fund which gives the right to apply for refunding of Since 1995 the study-period for dental cost of treatment set by the law. technicians is 3 years, following a higher vocational education curriculum. There is a pricelist, suggested by the Health Insurance Fund, but every The Quality of Care private clinic has its own price list All dental clinics have to compile own (which is in most cases available in documents in accordance with the internet).

12 Dental care costs in 2008 (some data) 1 EUR = 15,6466 EEK

Complicated problems are treated in specialized units like Clinic of Stomatology and Dental Prostheses Centre, Tartu University, that are also serving as training centres for specialist education.

13 A special orthodontia clinic has been People in the prison ofﬁcially must get opened in Tallinn and preparations for the same dental health care as all citizen the opening of endodontics clinic are but the funds for them are coming from almost ﬁnished. the Estonian Ministry of Justice.

Several dental laboratories are Dental clinics in Estonia have modern in Tallinn, Tartu, Rakvere for the equipment, including high- frequency preparation of dentures. digital x-ray machine, with low radiation level. Many clinics have laser equipment and panorama x-ray 2.3. Organisation of machines. Such expensive equipment plays an important role in the diagnoses Oral Health Care for and treatment of oral and dental Special Groups diseases.

All children till the age of 19th are There is a wide range of services covered by insurance and get the provided by private dental clinics therapeutic treatment free of charge if and dentist in Estonia: examination/ the treatment is made by doctor who has cost estimation, X-ray photograph, contract with Health Insurance Fund. panorama X-ray photograph, anaesthesia, placing of rubber dam, From 19 years every person can get aesthetic filling, construction filling, compensation from Health Insurance gold inlay, ceramic inlay, removing of Fund: 300.00 EEK in a year. crowns and bridges, metal ceramic crown, titan ceramic crown, gold Pregnant women can get compensation ceramic crown, temporary crown, from Health Insurance Fund 450.00 metal plate, root-canal filling per EEK in a year. canal, retention pin, building of post- crown, extraction, mouth hygiene Mother, having a baby under a year: and prophylaxis, bleaching, implants, 450.00 EEK in a year. telescope crown, tooth jewellery etc.

Persons with the enlarged need of Example of services provided by a dental treatment (have got surgical and common dental clinic: X-ray therapy of head or neck; labial or mouth anomaly needed surgical Dental care: treatment, face traumas, preparation ◆ Radix treatment (treatment of the or transplantation of tissues, large dental root) inﬂammation of neck and head): 450.00 ◆ Treatment with different ﬁlling EEK in a year. materials

14 ◆ Prevention of dental diseases insurance is applied from January, 1, ◆ Instruction for teeth care 1992.

Dental surgery: Health insurance is based on the ◆ Teeth extraction solidarity of and limited cost – sharing ◆ Day surgery by insured persons and on the principle ◆ Implantation (“planting” of the that services are provided according artificial dental root, upon which a to the needs of insured persons that tooth is built) treatment is equally available in all regions and that health insurance funds Denture making: are used for their intended purposes. ◆ Crowns and dental bridges Different benefits are available if the ◆ Conventional immediate complete doctor has a contract for financing denture (teeth built on a plastic medical treatment with health insurance carcass) fund. The health insurance fund enters ◆ Inlay denture (teeth built on a metal into a contract for financing medical carcass) treatment with health care provider or ◆ Filler (laboratory-made dental filling providers. The health insurance fund material) is not required to enter into contract ◆ Bar-fixation (of dentures, instead of for financing medical treatment with dentures with visible clasps) all health care providers. It means that the person must know very well has the Orthodontics: doctor contract and she/he can get some ◆ Plates (dental arch extension) benefits or not. ◆ Quad-Helixes (dental arch extension) ◆ Bracket systems Health care services for the citizens having health insurance are covered by the finances from Estonian Health 2.4. Insurance Insurance Fund.

Arrangements Health Insurance Fund uses the social tax paid for the working population ◆ The purpose of health insurance in also for covering cost of health services Estonia is to cover the costs of health provided to persons who have no services provided to insured persons, income with regard to work activities. prevent and cure diseases, finance the purchase of medical products and Internet bank clients or he owners of medical technical aids, and provide the Estonian ID – card can use the e- the benefit for temporary incapacity services to chock the validity of their for work and other benefits. Health health insurance, their address, their

15 name of the family physician and the Pregnant women, or nursing mothers payment of sickness beneﬁts through whose child is less than one year of age, internet bank or Kodanikuportaal can receive reimbursement of up to (https://portaal.riik.ee/x/kodanik). Also, 450.00 EEK. the internet allows correcting data related to the place of residence. T Pensioners (over the age of 63) may receive reimbursement of up to 4000.00 The client information line of the EEK once in a 3-year period, for one Health Insurance Fund is 16363 and prosthodontic appliance. calling from abroad + 372 6696630. The dentists, who are members of the About 90% of oral healthcare in Estonia Estonian Medical Association, and their is provided through general (private) whole praxis are covered with civil practice. Dental care services for adult responsibility insurance. patients (over 19) are paid by patients and reimbursed by the sick fund. Emergency care (traumas, infections) is actually paid by the sick fund, but only for those who are members of it. Patients who do not have insurance can have only ﬁrst aid (what is reimbursed by the local government).

Since October 1st 2002 the Sick Funds have provided limited ﬁnancial support for oral healthcare. Treatment is provided and is free for children under 19 years of age.

Other patients may receive a reimbursement for the fees they have paid, up to 300.00 EEK in a year. The health insurance provides this cover for 41 conservative and surgical items but crowns and bridges, implants, ﬁxed orthodontic appliances and other complex or cosmetic treatments have to be paid for fully by the patient.

16 3. Oral Health Care Teams

◆ To become a dentist a 5 year study patient interest always to the fi rst place, course has to be passed. To become a all patients are equal as persons, all the specialist in the fi led more training activities must be agreed with patient during 3 or 5 years is obligatory. on the basis of informed consent, and the information connected with the At the present moment there are 547 patient must be treated as confi dential. dental care institutions, 1430 dentists, 294 dental assistants/nurses, 16 oral hygienists, 35 orthodontics and 130 3.1. General Dental dental technicians registered in Estonia. Some dentists practise in more than Clinic one sphere of practice. There is lack of dentists in Estonia. Dentist Dentist education in Estonia is provided Specialists work mainly in big hospitals by the University of Tartu. The duration and patients access them by referral of study program for dentist is 5 years. from other dentists. The system of use The residency training of medical of dental auxiliaries is still developing specialists in dentistry is available in in Estonia. The only type of dental three different programs: restorative auxiliary is a nurse, graduated as dentistry, orthodontics, oral and general nurse and then trained by maxillary surgery. The duration of dentist or has passed some courses. residency is from 3 to 5 years. There are also working dental assistants without any medical education, who have been trained by dentist or passed special courses.

Dental clinics in Estonia can be divided: ◆ general dental clinics, ◆ specialised departments in a big clinic, ◆ specialised clinics.

Clinics can also be classiﬁ ed as outpatient clinics and stationary clinics. In all stages of treatment the ethical Dentist Veikko Keimann with his principles should be followed: put the assistant Andry Tulp in the clinic Novamed

17 In the ﬁ eld of health care and welfare there are two institutions providing nursing education in Estonia – Tallinna Tervishoiu Kõrgkool (Tallinn Health College) and Tartu Tervishoiu Kõrgkool (Tartu School of Health Care). Nurses pass a 3.5 years nursing program. They Part of the working receive a diploma of general nurse and room in the clinic Novamed. have the possibility to be entered in the register. To work as a dental nurse The postgraduate medical training aperson has to learn by him/herself; can is carried out in the best facilities in be trained in dentistry by a dentist, with Estonia in Tartu University under the institutional support; or pass a special supervision of the best specialists of the professional additional course in Tallinn profession. In addition to developing or Tartu Health College or abroad. Their practical professional skills and duties are to assist the dentist, including experience while performing procedures cross infection control. and investigations, the residents have to participate in theoretical courses, They are paid by their employers. conferences, clinical rounds and educate themselves with the help of Dental hygienist scientiﬁ c literature. Dental hygienist’s main task is to plan, implement, and evaluate dental After the graduation of specialization hygiene care for the individual and and have shown interest in research, the community. Dental hygienists note defence the PhD, the person can apply abnormalities, plan care, teach oral the post in University Clinic and start to hygiene, clean teeth, apply preventive work as a university teacher. agents, complete necessary chart entries, and perform other procedures Dental Nurse related to dental hygiene care. Applied higher education institutions offer professional applied higher Most of the 16 dental hygienists education programs from the study year working in Estonia have had special 2002/3: this is one stage non-academic preparation abroad or have passed higher education aimed at providing special courses. necessary skills and knowledge for working in a certain profession or Dental assistant continuing studies at master level in Dental assistant is a person who is universities. helping dentist is everyday work.

18 Dental assistant is educated by dentist or has passed special courses. 3.3 Dental Laboratories

◆ “Dental technician” is a registered 3.2. Dental Specialists qualifi cation in Estonia. Professional preparation is provided by Tallinn ◆ Specialist training is available in 3 Health College. Nominal length of specialties for doctors: studies is 3.5 years. ◆ Orthodontics ◆ Oral Maxillofacial Surgery Dental technicians are health care ◆ Restorative dentistry professionals who manufacture dental appliances following specifi cations Specialist training is provided by Tartu and instructions provided by dentists. University. There is no minimum The work of a dental technician may of pre-training years (working as a include designing, building, repairing dentist after basic education), before and adjusting dental devices for entering specialist training. Training clients, who have lost teeth, or require lasts for 3 years for Orthodontics, and assistance in correcting the appearance 5 years for Oral Maxillofacial Surgery and performance of their teeth. Their and Clinical Dentistry, and includes a duties are to prepare dental prosthetic University examination. The specialist and orthodontic appliances to the education and training also leads to a prescription of a dentist and they may degree, “Specialist in Orthodontics”, not work independently, except for the “Maxillofacial Surgeon” or “Specialist in provision of repairs to prostheses. Restorative Dentistry”. Specialists in Restorative Dentistry Dental technicians are normally salaried undertake training in endodontics, and there is no reported unemployment periodontics and prosthodontics. in Estonia. Orthodontics are recognized by the Healthcare Board/General Dental Council and registered as a specialty, in addition to Oral Maxillo-facial surgery, which offi cially is a dental specialty under a law introduced in 2002. Specialists in Clinical Dentistry are recognized and need to register since 2004.

Dental technicians lab in Tallinn Health College

19 4. Status and Position of the Dental Nurse

for non-conformities, violence and 4.1 The Law and Ethics perpetrations. ◆ Procedure for Entry into a Price ◆ There are several laws regulating Agreement – the regulation prophylactic measures and treatment of establishes the procedure for entry the patient. into agreements governing the price of medicinal products between the List of legal acts and codes Ministry of Social Affairs and the regulating the sphere: manufacture of a medicinal product ◆ Public Health Act – describes of the person holding the marketing solidarity – based health insurance, authorization for a medicinal product. used in Estonia and also how these ◆ Procedure for Drawing up and funds are formed and used (social tax, modifying the Estonian Health amounts, terms. Insurance Funds` list of medicinal ◆ Estonian Health Insurance Fund products; criteria for establishing Act – this Act provides the objective, the list and bodies assessing functions, competence, legal status, conformity with these criteria – the bases for activities and the bodies of regulation lays down: the procedure the Estonian Health Insurance Fund. for drawing up and modifying the ◆ Health Insurance Act - describes Estonian health Insurance Funds` the duties of health insurance fund list of medicinal products, the exact in organization of health insurance, content of the criteria referred in competence of health insurance fund Health Insurance Act and the bodies for ensuring purposeful use of health assessing the conformity with these insurance funds, describes the legal criteria. status of health insurance fund. ◆ Personal Data Protection Act - The ◆ Health Services Organization Act – purpose of this Act is protection of provides the organization of and the the fundamental rights and freedoms requirements of health services, and of natural persons in accordance the procedure for the management, with public interests with regard o financing and supervision of health processing of personal data. (Personal care (not in the Defence Forces). data are information relating to an ◆ Medical Devices Act – the Medical identified natural person or a natural Devices Act and related regulations person identifiable by reference regulate manufacturing, marketing, to the persons` physical, mental, advertising of medical devices and physiological, economic, cultural or give rules for market supervision, social characteristics, relations and also regulate liability of market actors associations).

20 ◆ Professions Act - regulates of valid reference price or price the qualifications system. This agreement, subject to entry in the Act provides the basis for the list of medicinal products with a development of the requirements for 100 or 75 per cent discount rate – professional qualifications and the describes the diseases and diagnosis conditions and procedure for the where the patient have a right to get attestation and award of professional discount from the medicine. qualifications. ◆ Method of the calculation, ◆ Code of Ethics – gives ethical terms for the establishment and principles in health care. conditions and terms for the ◆ List of Health Services of the Estonian amendment of reference prices of Health Insurance Fund - describes the medicinal products – this regulation services available in Estonia. sets out the method of calculating ◆ Quality assurance of Health reference prices, the terms for the services in Estonia - describes establishment of referent prices, and Estonian health care quality the conditions and terms for the improvement strategy and other amendment of reference prices. evidence based information, quality, quality assurance, quality Regulation on the working place of management, quality of health Every clinic has their own regulations services, and quality management and rules, made on the basis of Estonian system for health services. Regulations and Acts and approved ◆ Requirements for the Premises, by the head of the clinic. Every new Fixtures and Fittings, and co-worker gets the package with the Apparatuses Necessary for the information. There are also special Provision of Specialized Medical courses connected with the safety on Services outside Hospitals – the workplace. In case of bigger clinics describes the requirements. individual tutor is supporting the ◆ Gross margins for wholesale and newcomer. In smaller clinics usually the retail trade of medicinal products doctor takes care of instructions to the and the procedure for their new person. implementation – this regulation sets out the dross margins for Most common regulations on the the wholesale and retail trade of workplace are: medicinal products and the procedure ◆ regulation of the safety on the for their implementation. workplace ◆ List diseases in the case of which ◆ health certificate of the worker a medicinal product intended for ◆ health promotion plan the treatment or alleviation of ◆ internal work regulations the disease is, upon the existence ◆ individual contract

21 ◆ individual work description Area of Estonia is 45,226 km ◆ schedule of individual work hours The population of Estonia is about ◆ regulations for a -and antiseptics 1,342, 409 million (2007). ◆ regulations how to behave during the Male: 46%, female: 54%. fire or accident Urban: 69%, rural: 31%. ◆ information of first aid ◆ schedule of holidays Holidays in Estonia All official holidays in Estonia are established by acts of parliament. 4.2. Some Facts January 1 – New Years Day ◆ Republic of Estonia is a country in February 24 – Independence Day (this Northen Europe. Estonia has borders is by the law the most important to the south with Latvia and to the east holiday, commemorating the with Russia, separated from Finland in declaration of independence in 1918) the North by the Gulf of Finland and Moveable Friday – Good Friday (the from Sweden in the West by Baltic Sea. Friday before Easter Sunday) May 1 – May Day The modern name Estonia is thought Moveable Pentecost (50 days after to originate from the Roman historian Easterr, and 10 days after Ascension, Tacitus, who in his book Germania (ca. which is not a national holiday) AD 98) described the people called June 23 – Victory Day (German forces Aestii. were defeated in the Battle of Cesis

Map of Estonia

22 Similarly, the nursing profession in Estonia experienced in overcoming its history of limited education, low status and low pay following independence in 1991 after ﬁ fty years of Soviet rule. In 1995 was reported an ongoing shortage of nurses with long working weeks, very long shifts and small salaries. Nurses in Estonia not only had to deal with major changes in employment policy including Tallinn Health College teacher employment insecurity, but they also Mare Tupits in Haapsalu, Estonia. had to adjust to new technological, organisational and educational during the Estonian Liberation War) demands. June 24 – St. Johns’ Day August 20 Restoration (Celebrates Current employment situation Estonia`s return to independence in Currently there are about 7 nurses 1991) per 1000 people. 57% of them work Working hours, salaries, holidays. in hospitals and the greatest need December 24 – Christmas Eve is in specialist areas (see table 4). December 25 – Christmas Day The Ministry of Social Affairs has already recognized that the increasing Prior to World War II the nursing shortage of nurses threatens the further profession in Estonia could be implementation of hospital reforms, characterized by powerful professional which include major increases in long- associations, international connections, term and nursing care capacity. In 2004, prestige and control over nursing it put forward a proposal to the Ministry curricula and working conditions. of Education to fund training for 500 After involuntary incorporation into basic nurses plus 200 specialist nurses, the Soviet Union, nurses lost their also the extra training was needed professional standing and nurse due to the fact that 28% of nurses are education was assimilated into the 50 years or older. The proposal was Soviet system where nurses received based to meet the target of 8-9 nurses their education in vocational schools per 1000 people by the year 2015. after primary school and later on also However, while there is political will after secondary school, graduating to increase the number of nurses being as mid-level medical workers which trained, according to the most optimistic meant lack of autonomy, poor working prognosis and not taking into account conditions and inadequate salaries. the possible emigration we could reach a

23 level where there are only 7,5 nurses per demand for qualified nurses means that 1000 people by the year 2015. a nurse who can do his/her work well is highly appreciated and can earn quite Nurses’ professional associations well in Estonia. have been working to standardize the different nursing specialities. The Dental hygienist Ministry of Education approved their There are 16 dental hygienists working standards in 2003. These standards in Estonia. and terms of reference are compatible with similar requirements elsewhere in Dental assistant the European Union, thus enabling the There is no official data how many free movement of nursing professionals persons are working on the post of within the EU. For example in 2005, assistant. 300 nurses took the documents for working abroad, during the last two Dental technicians years the number of nurses expected The Estonian Association of Dental to go abroad is diminishing and the Technicians was created in 2001 and number of nurses wanting to work in is an official representative of dental the field is growing. technicians. The members are: AS Nurses who trained during Soviet times Hambastuudio – 10 persons, OÜ have to undergo a retraining process Rakvere Hambalabor – 0 persons, and pass examinations according to the OÜ MN – Modicus – 2 persons, AS new curriculum, elaborated pursuant Erakliinik Dentes – 30 persons, OÜ Kai to EU standard, to raise their status and Hambalabor – 3 persons and OÜ Kohila market value as qualified staff. The great Meedikum 1 person.

Table. Employment situation of practising nursing and caring professionals.

24 5. The Dental Nurse in the Workplace

◆ My name is Andry and I have worked already 2 years in the ﬁ led as a dental assistant. I have got my preparation for this work studying under the supervision of my father, who is a dentist. I have also passed some courses prepared by Tallinn Health College for dental assistants. As dental technology is continually developing and a lots of new information is coming in, I learn almost every day something new on the workplace. More checking.

I have a possibility to apply for additional training courses, so I have participated in courses in Tallinn Health College and also abroad. All our workers must attend at least one supplementary course per year.

I like my work. I work ﬁ ve days in a week. My workday starts usually at 8.30 and the dentist usually starts from nine o’clock. Preparations for the dentist work.

In bigger clinics there is a special person – a secretary - who is taking care of registration, takes fees, does accounting, gives information about services and price list. In smaller clinics this may be a duty of a dental nurse/dental assistant or doctor. In the clinic where I am working we have a registration desk and we have also a secretary. The secretary is taking care of registration, gives information to Morning starts with checking patients, makes calls when there is a and controlling the equipment. need to change time or to give some

25 additional information to the patient, lamp handgrip, X - Ray tubes, and ﬁlls in bills and registration journals chair. about visits. After that I change my clothes and start There are several methods for to prepare for the new patient. registration: by phone, by e-mail and in the clinic. The time between previous and a new patients is about 5 – 10 minutes. This is Now the ﬁrst patient is entering into enough to do all necessary preparations. the dentist room. I help him to sit Usually I do this 10 – 12 times in a comfortably, switch on a lamp, offer working day. glasses for the protection of eyes and help him/her to put on the apron. If there is planned orthopedics Usually we have a patient every 30 work I must know well all sorts of minutes, but for serious procedures that materials for making impressions. I take more time there is planned one have to check that all materials are hour for the patient. restored in the conditions required for these materials. For example, some I always need to have some anesthetics materials need to be stored only in the to be always ready if they are needed. I refrigerator. This is my task to follow have checked the list of patients, I know that all materials are in a right place their diagnoses and I know all the steps and in right conditions. and am always ready to help. At the end of the working day I clean In case of extirpation of the teeth I will again all the room, pack materials prepare forceps and all sterile materials. for sterilization and bring to the In these cases it takes usually one hour sterilization room. for the patient, or sometimes even more. Then I clean and disinfect all instruments that stay in the room and When the patient is leaving I will pick then switch out. up all the instruments and put them to the disinfector. After that I will check the information needed for the new day, inform the Disposable instruments I will through secretary of about the needed supplies away to the special dish. There several and end my workday. dishes for different types of garbage. The information in this chapter refers to I also disinfect all the working areas, the duties undertaken by a dental nurse used instruments, aspiration system, or assistant.

26 When you come on placement you mirror, special apron for the patient, supervisor/mentor will discuss with cloves and mask for the doctor. you what courses you have passed already, what kind of knowledge There is a centralised sterilisation for and practical skills do you have and instruments and this is made regularly what do you need to learn more; twice a day. and discusses the goals of that concrete practical placement and Then I will check the timetable to the tasks that you can do. During see, what kind of work is planned by the placement regular discussions the dentist to prepare the necessary between the dentist, dental nurse and instruments. For example: if the dentist student take place. will have a patient with implantation, I will prepare physiodispenser, control Organization of the work can be all the instruments and all what is different in different clinics. needed on the place and sterile, and also insurance data. As we use a lot of sterile materials in the same 5.1. Hygiene and time, I will also have to check if our supplies are adequate. If not, I make maintenance of the a corresponding registration in the equipment registration table.

◆ The first thing I do when I come to I will also take all the necessary work is that I switch on the apparatus documents for all day reception to the and ventilation system. After that I dentist table. will change my clothes, wash and disinfect my hands, and then start the My job requires me to be always well preparation for the fluent reception. groomed and wear a special uniform Our apparatus are working with (usually it is different in different distilled water and all the system has clinics). to be controlled before the start. I will check the level of distilled water and Nurse/assistant has to check the if it is needed, take some more water accuracy and readiness of the clinic: from other system and add it. For every is all the equipment prepared for the patient I will prepare a tray with all work, materials and table are ready the needed materials and apparatus. for the first patient. Hygiene and For example: if there are planned 10 maintenance of the equipment are also patients for that day, then I will prepare the tasks of nurse/assistant. 10 trays. On every tray there have to be stomatological forcepts, probe, catheter,

27 After every patient the whole chair is patient case record. All possible disinfected and dispensable supplies allergy cases must be recorded. are thrown away. The whole working surface is also disinfected, including the The description may be made either floor if necessary. by doctor or by nurse, the information is double checked quite often and For recyclable instruments there is a signed by the person who filled in the special re - cycling plan. document. Case records may be either on paper or Cleaning staff in digital form or in both. The cleaning staff in bigger clinics has usually special preparation and usually Dental part includes following data: there are also working special persons ◆ Dental history and actual clinical for disinfection. condition: condition of oral cavity and teeth are inspected during the first appointment and the actual 5.2. Documentation condition is registered. and administration ◆ Diagnosis: is made. ◆ Treatment plan: possible treatment plans are discussed with a patient ◆ There are different forms of patient’s and final decision is made using the medical history for oral health: for principles of informed consent. treatment general and specific data and special for orthodontic patients. (see Orthodontic medical history attachment). comprises the same general information and specific orthodontic information. Patient’s medical history: General part includes the following All information included in the data: patient record is confidential and ◆ Requisites of the clinic: name, must be kept in conditions that it is registration code, address, phone/ available only for these persons who fax numbers, e-mail address, have right for that. homepage ◆ Patient’s personal data: name, address, Administration personal ID-code, phone numbers, e- There is lot of administration work and mail address it is divided between dentists, dental ◆ Patient’s general health indicators: nurses and the person working in all the information about patient’s reception (supplying with medicaments, general health, what is important equipment, etc., archiving, and for the oral care is described in the accounting).

28 Basics of oral health care, including oral 5.3. Promotion of Oral hygiene and importance of nutrition in Health Care dental health, are covered in the course of subject “Healthy person” taught at secondary schools. ◆ We can not say that enough is done in the promotion of oral hygiene and Diet and nutrition prevention of oral and dental diseases in The interactions between oral health Estonia. In 2007, the Governing Coalition and nutrition are complex, with food has included into its program two aims: and nutrition having the potential for 1) to launch a prevention program at both positive and negative effects on the nursery school level, expanding oral health. the prevention program to other age groups; Sugars (fruit sugar, milk sugar and table 2) to commence educating oral hygiene sugar) and cooked starches (cookies specialists who help us to become and bread, etc.), known as fermentable aware of the optimum oral and dental carbohydrates, are the foods that can health and help us to achieve the impact caries. Because carbohydrates optimum oral and dental health for can be used by caries-promoting children. bacteria to produce acid and ultimately tooth decay, eating habits rather than So far most of the prevention and the foods themselves are key factors in promotion work has been done causing or preventing tooth decay. by dentists, assistants, Estonian Dental Association, Estonian Society Frequency of eating is important of Stomatology and international because the acids are released to work companies providing dental and on the teeth for about twenty to forty oral care products (such as Colgate- minutes following each eating occasion. Palmolive etc.). A project for the The greater the frequency of eating, promotion of healthy teeth among the more opportunity for the acid to children “Healthy teeth by playing” work. Similarly, those foods that tend to has been launched in 2007 by Tartu adhere to the teeth pose greater risks of University Stomatology Clinic, some decay than those that clear the mouth promotion activities were carried out quickly. in kindergartens. Fluoride content in the drinking water in different regions The mouth serves as a window for of Estonia has been investigated and the skilled dental practitioner to view concrete recommendations were overall health status. Taking care of the published by the Department of Public mouth is an important step on the road Health, University of Tartu. to good health. Good eating habits,

29 regular brushing, flossing and fluoride risk of developing tooth decay, gum are all part of maintaining good health. disease and other dental problems. These include: Vitamins and minerals are the ◆ Brushing thoroughly twice a day and important part of the healthy teeth. flossing daily ◆ Eating a balanced diet and limiting Oral hygiene snacks between meals Every dentist and dental hygienist ◆ Use of right dental products explains to the patient how to brush according to the region the teeth, use dental floss and different ◆ Use of basic prophylactic measures as: cleaning fluids for the teeth and mouth, dental floss, brushing, dental sticks remember the prophylactic visit to etc. the dentist and gives all kinds of other important recommendations to the patient. 5.4. Treatment,

Good oral hygiene means a mouth that Assisting the Dentist looks and smells healthy, i.e.: Your teeth are clean and free of debries, gums are Cariology, filling the root: pink and do not hurt or bleed when There is a method of four-handed you brush or floss, bad breath is not a dentistry method used widely used in problem. Estonia (working in the four- handed way – dentist and nurse together). Dentists, dental nurses/assistants or hygienists help to learn good oral All procedures are performed in sterile hygiene techniques and point out conditions; preparations for procedures areas of mouth that may require extra are made by dental nurse or dental attention during brushing and flossing. assistant. Maintaining good oral hygiene is one of the most important things when talking Special tray is prepared for the root about oral health. Daily preventive canal treatment should contain care, including proper brushing and the endometer, injection solvent flossing, will help stop problems before that will be used for anaesthetizing they develop and is much less painful, if needed, mirror, fiberscope, expensive, and worrisome than treating tweezers, different channel- conditions that have been allowed to needles, sterilizing pads, solvates progress. for cleansing channels (chlorine hexidine, physiological salt In between regular visits to the dentist, solution, or sodium hypochlorite), there are simple steps that decrease the lubrication substances.

30 When the dentist opens the tooth, the flushing the cavity (generally on the nurse/assistant checks if the light is basis of chlorine hexidine) first continuously stable. There are always ◆ Specific handling instruments are two aspirators - big and small one. used for the treatment: curet, courvet, The big aspirator is stiff and meant for gum’s probe. The nurse/assistant working with particular tooth; the small prepares the kit for gum treatment aspirator is flexible and usually situated ◆ Different ultrasound apparatus are as close as possible to the pharynx so used for drilling and cutting scale that the patient would not swallow it. ◆ The nurse/assistant prepares lasers for When the tooth has been opened, the procedures doctor looks for orifices of the channel. ◆ In case of heavy bleeding during After that the treatment starts: the procedure the nurse or assistant ◆ In case of pulpitis, which is an acute assists with pads, explains and deals a process in most of the cases, a vital lot with the patient extirpation will be conducted and ◆ In case of airflow cleaning the tooth the nerve will be removed under areas are washed with delicate soda anaesthetics. If the tooth is devital, a pearls with special apparatus mortal extirpation will be conducted ◆ Gingivitis, gingival erythema- with (usually it is not painful for the this treatment hygienist should deal. patient as mostly it is chronic). In more serious or chronic case the ◆ Nurse/assistant measures the length doctor is consulting the treatment. of the channel with endometer, places ◆ X-ray technology: intra-oral, extra- drying-pads into the cavity in certain oral, digital and traditional. order, prepares flushing devices, dries and mixes up the sealer of root-filling X-ray technology used for lubrication. After the canal Nowadays digital X-ray is considered has been hermetically closed and as traditional. There is also widely checked by X-ray, the nurse/assistant used high-frequency digital X-ray. The removes the root-treatment tray difference between those two is in and prepares the filling tray, which doses- in case of high- frequency X- contains all the devices needed for ray level of radiation is approximately placing a filling. half smaller, same as an airport check- ◆ The filling is placed by dentist. in machine.

Parodontology: scalling, Traditional x-rays, where part of pocket treatment (the science of exploration is made using chemicals, parodontology deals with pocket are no more used in Estonia. treatment) ◆ In case of parodontitis the nurse The assistant chooses the right censor prepares treatment solvents for (for child or adult) and the doctor/

31 cloths, instruments (a special set for each operation). If the preparations are ready, the patient is invited in.

Both the nurse/assistant and dentist check if she or he has eaten and drunken, is the blood-pressure normal.

The nurse/assistant prepares oral cavity and area around the mouth, covers it with special material and prepares all needed materials for anesthesia.

Nowadays the scalpel is becoming less used, cuts are being made with different lasers. The nurse/assistant guarantees the correct view in the operation set, removes the saliva, X - ray equipment for panorama x – ray ﬂ ushes. During extractions there are special forceps for each tooth; the elevators and forceps are passed by the dentist sets the tube – sets the central- nurse/assistant. The dentist removes ray, determines the doses and assistant the tooth, the nurse/assistant backs the sets it. There are different possibilities patient’s head so that it does not shake, for X-ray: Panorama x-ray, Extractor – and has prepared a covering for the panorama pictures, posterior-anterior wound (usually a sterile tampon). pictures and bursa-shots from jowls – all digital). There are special cameras From surgical procedures the most that are used for photographing common procedure is extraction. (dental ﬂ ash) – the idea is to show to The removing of impacted teeth in the laboratory what has been done the chinbone starts in youth. In case (diagnostic shots), it is also possible to of abscess abscessed surgery is used. send them digitally. Sometimes a patient needs root-top resection. In case a patients needs Oral surgery: extractions, operation frenulectomy, it is made in dental clinics normal or complicated or sometimes by a family doctor. During those procedures a nurse with special training, a specialist, must be Although implantology is quite new in present. The nurse/assistant sets the Estonia, it is used quite widely in spite table, prepares the room, sterilized of its high cost. Plastic surgeries and

32 cosmetic dentristry in oral cavity are also quite common.

Prosthetics: crowns, bridges, over dentures The task of the nurse/assistant is to recognize, mix and preserve different imitation materials. The principal is that the teeth must be polished before the bridges and crowns are prepared. The polishing causes high temperature and therefore cooling is necessary (the water will be canalized towards the tooth after which it will be sucked away together with tooth dust). After that the impression is taken. For impression there are different materials.

Orthodontic: ﬁxed and removable dentures - it is relatively easy for the nurse/assistant to prepare waxes, blowlamp, and help doctor during the procedure.

33 6. Communication

assistant should respect the patient as 6.1. Communication a person and understand his or her with Patients beliefs. The patient should be treated as a mature, intelligent human being and dealt with honestly. Treat the ◆ Effective medical practice requires patient as you or a member of your positive interaction between dental family would want to be treated. clinic’s stuff and patients/clients. Communication is a two-way process The dentist/nurse/assistant must in which both the member of stuff and clearly and honestly explain the nature the client have a responsibility to the of provided services and make sure other. Communication problems with the patient thoroughly understands patients/clients often lead to patient this information. Good medical care frustration and dissatisfaction. It is involves treating the patient with the responsibility of the dental clinic´ concern and respect, keeping him/her s stuff to establish an atmosphere informed, and allowing the patient conducive to effective communication. to share responsibility in decision - In a good clinic every staff member making. The informed consent is the is prepared to communicate with the main principal. patient and knows her professional duties. In case where second opinion For children special pictures and toys is needed, the staff is ready to consult are used. for the beneﬁt of the patient. All methods - talking, body language - A successful relationship is have to be friendly and supportive. largely dependent upon effective communication skills and the Patient’s responsibility is to describe dentist’s/assistant’s sensitivity to his or her history and symptoms the patient’s needs. Most important honestly and accurately. aspects of the dentist-patient relationship are the establishment Despite of all problems and fear from of good rapport, showing respect, the patient’s side, a dentist/nurse/ and acting as an ally. These aspects assistant has to stay calm, always deal with how the dentist/nurse/ keeping in mind that the patient is in assistant relates to the patient. A the weaker position and needs help compassionate, professional approach and support. can eliminate problems and reduce negative feelings. The dentist/nurse/

34 6.2. Communication with the Team

◆ At the beginning of each working day the dentist’s team has a meeting to discuss the plans and possible problems. During the work there is no other discussion among stuff than the discussions connected with concrete professional activities: for example consultation in case the dentist needs a secondary opinion.

35 7. A Day in the Life of a Dental Nurse

◆ The concrete character of practical dental nurse/assistant’s work day depends on the working place. The main assignment of a dental nurse/ assistant is to assist the dentist in the delivery of dental treatment and to function as integral members of the dental team while performing chair-side and related ofﬁ ce and laboratory procedures.

Here is the description of one working day of Andry, who is working in the Novamed as an assistant of dentist. (you can ﬁ nd more Andry`s information also in the chapter 6.)

My working week is 36 hours and depends on my individual schedule: usually I work two days for 6 hours and three days for 8 hours. In special cases I have also to work in Saturday.

The ﬁ rst thing in the morning is to change clothes for special uniform.

It takes about 30 – 40 minutes to prepare the room for procedures: I check motors, lamps, ﬂ osses, water, check the readiness of the compressor, disinfect necessary equipment and tools, and prepare trays for procedures.

During the working day I assist the dentist and do all the necessary activities according to the patient’s needs.

At the end of the working day I clean the room and do all required preparations for the next day, change my clothes and go home.

Andry on the working place.

36 8. Vocational Education in Estonia

of education: diploma (equivalent to 8.1. Studying in Estonia bachelor), master and doctor. The ﬁrst cycle concentrates on acquiring ◆ The Estonian education system necessary to pursue a job in a certain consists of basic, secondary, vocational, study ﬁeld. Master and doctor studies higher and adult education. are usually carried out in universities.

After completion of the compulsory International students can study either nine-year basic education, pupils in Estonian or in English, every case is may continue their studies either in agreed individually. gymnasiums or in vocational education institutions. Gymnasiums offer three – year secondary general education and 8.2. General Goals of vocational education institutions offer secondary vocational education. After the Dental Nurse completion of both types of secondary Curriculum education, young people may choose between entering the labour market ◆ There are two possibilities in Estonia or continuing studies at the higher to become a dental nurse/assistant: education level. Secondary education ◆ persons, who have acquired the is expectancy for all who are planning to study in health care and welfare area.

The Estonian higher education system consists of professional higher education institutions and universities. Recent trends in higher education in both types of educational institutions, accordance to the Bologna Declaration, have led to the three main cycles

Table: Curriculum of the specialized course for dentist assistants Volume: 400 hours

37 Estonian Educational Structure Table:

38 qualiﬁcation of a general nurse may Dental nurses in Estonia have basic work as a dental nurse after passing a nursing education, followed by a special special course, course in dental care. Preparation ◆ the persons with secondary education includes instruction in general studies, can pass a special course “Course for biomedical sciences, dental sciences, dentist assistants” provided by Tallinn clinical sciences, and clinical practice. A Health College and become a dental combination of lecture, laboratory, and assistant. clinical experiences provide students with knowledge in infection/hazard Some smaller courses (hygiene, control, radiography, dental materials, prosthesis etc.) are also available. preventive dentistry, and clinical procedures.

8.3. Description of the Dental nurse is a speciality of a general nurse in Estonia, i.e. a dental nurse’s Practical Dental Nurse professional requirements include Profession and Core all the general- and basic skills of a general nurse. The Professional Competences Standard describes only additional knowledge and skills acquired during ◆ The dental nurse/assistant curriculum specialisation. prepares individuals to assist the dentist in four- hand method in the delivery Dental nurse’s core of dental treatment and to function as competences proceeding from integral members of the dental team Professional Standard: while performing chair side and related Dental care ofﬁce and laboratory procedures. A ◆ Dental care terminology dental nurse/assistant takes care of ◆ Compilation of orders for dental the preparation and maintenance of clinic, storage of instrument and equipment and materials used in dental materials care, serves the patient supporting him/ ◆ Dental diseases, their causes and her during the procedure. A dental treatment nurse/assistant knows and follows the ◆ Assistance in dental care procedures requirements of professional ethics in ◆ Methods and principles of dental all his/her activities. The profession of treatment in special care dental nurse/assistant presumes service- ◆ Different forms and methods of and communication skills, correctness clinical treatment. Counselling of and accuracy. patients ◆ Equipment, instruments and materials used in dental care

39 Clinical work ◆ Counselling in oral health care ◆ Methods of oral health care and health protection programs ◆ Use and maintenance of orthodontic and orthopedic auxiliaries ◆ Different methods and principles of dental treatment ◆ Techniques of taking replicas and making of gypsum models ◆ Prophylactic procedures for children ◆ Dental x- rays

Administrative work ◆ Organisation dental clinic’s work ◆ Assessment of services provided by dental clinic ◆ Selection of personnel ◆ Assessment and planning of the need of dental care for the district ◆ Economic management/budgeting ◆ Instruction of co- workers and students ◆ Application of professional knowledge both in state and international professional projects.

40 References

D. A. Perry, P. L. Beemsterboer (2007) Periodontology for the hygienist.

Dental Training Assistant CD (2007)

D. S,. Robinson, D. L.Bied (2007) Essentials of dental Assisting.

Estonian Health Insurance Fund http://haigekassa.ee/eng/

Estonian Ministry of Education and Research http://vana.hm.ee/uus/hm/client/index.php?1

Estonian Qualiﬁcation Authority http://www.kutsekoda.ee/default. aspx/3

EU Manual of dental Practice 2004 www.eudental.eu/library/104/ﬁles/ estonia-20051027-1448.pdf

Health Insurance Act http://www.legaltext.ww/failid/findfile. asp?filename60043

International Student’s Guide to Estonia Study in Estonia, Tallinn. 2003.

Ministry of Social Affairs http://www.sm.ee/eng/pages/index.html

Novamed OÜ http://novamed.ee/

Tallinn Health College http://www.ttk.ee

University of Tartu http://www.ut.ee/

Sitemap of Hambaarst.ee http://www.hambaarst.ee

41 Glossary

Adult education - supports the principal of life-long-learning in a variety of different subjects.

Client-centered approach – To meet client’s individual needs

Course system – is a system of teaching and learning, where student passes the subjects in the order determined by the curriculum, whereas preliminary examinations and examinations have to be passed before the next term begins. Students must, before the commencement of the next academic year, gather 100 per cent of the credits in obligatory and elective subjects required for the ofﬁcial standard study period that they have passed

CSP – Individual Care and Service Plan

Holistic approach – Approach covering individual’s physical, social and mental dimensions as a whole

Multidisciplinary team – A work group consisting of professionals with varying training background

Service provision – Refers to organising services that are available for people

Social protection – social protection encompasses all interventions from public or private bodies intended to relieve households and individuals of the burden of a deﬁned set of risks or needs, provided that there is neither a simultaneous reciprocal nor an individual arrangement involved

Orthodontics - about the correction of occlusion

42 Appendix: Dictionary

ENGLISH – ESTONIAN DICTIONARY acrylic plate denture - akrüülplaatprotees aesthetics in prosthodontics – esteetika hambaproteemises attached bugel-denture - lukk-kinnitusega büügelprotees attachment systems – lukusüsteemid braced denture with casted framings - valatud karkassiga tugiprotees bridge-denture – sildprotees bugel-denture - büügelprotees combined dentures - kombineeritud proteesid crown modelling on artiﬁcial root - hambakroonide modelleerimine kunstjuurele denture - hambaprotees determination of teeth – hammaste määratlemine ﬁxed denture - suust mitte-eemaldatavad protees metal-ceramic crown – metallokeraamiline kroon metal-plastic crown – metalloplastika kroon milling technique – freesimistehnika oral bones - suuõõne luulised osad oral cavity diseases – suuõõne haigused oral cavity hygiene – suuõõne hügieen orthodontic treatment – ortodontiline ravi parallelometer milling-cutter - parallelomeeterfrees postprosthetic hygiene – postproteetiline hügieen principles of denture construction - proteesi konstrueerimise põhimõtted removable dentures - suust eemaldatavad proteesid retention forms between metal and plastic crowns - metalli- ja plastivahelised retentsioonivormid root-canal – juurekanal simple crowns – täisvalu protees teeth set – hambaread total-dentures attached with press-stud - trukk-kinnitusega totaalprotees

43 ESTONIAN – ENGLISH DICTIONARY akrüülplaatprotees - acrylic plate denture büügelprotees - bugel-denture esteetika hambaproteesimises - aesthetics in prosthodontics fikseeritud protees - fixed denture freesimistehnika - milling technique hambakroonide modelleerimine kunstjuurele - crown modelling on artificial root hambaprotees - denture hambaread - teeth set hammaste määratlemine - determination of teeth juurekanal - root-canal kombineeritud protees - combined denture lukk-kinnitusega büügelprotees - attached bugel-dentures lukusüsteemid - attachment systems metalli- ja plastivahelised retentsioonivormid - retention forms between metal and plastic crowns metallokeraamiline kroon - metal-ceramic crown metalloplastika kroon - metal-plastic crown ortodontiline ravi - orthodontic treatment parallelomeeterfrees - parallelometer milling-cutter postproteetiline hügieen - postprosthetic hygiene proteesi konstrueerimise põhimõtted - principles of denture construction sildprotees - bridge-denture suust eemaldatav protees - removable denture suust mitte-eemaldatav protees - fixed denture suuõõne haigused - oral cavity diseases suuõõne hügieen - oral cavity hygiene suuõõne luulised osad - oral bones trukk-kinnitusega totaalprotees - total-denture attached with press- stud täisvalu protees - simple crown valatud karkassiga tugiprotees - braced denture with casted framings

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Acknowledgements Estonia

Graphic Design Rhinoceros Ltd for layout Mr. Matti Remsu (co-ordination of the project)