International Dental Journal (2008) 58, 61-70 Dental therapists: a global perspective David A. Nash, Jay W. Friedman, Thomas B. Kardos, Rosemary L. Kardos, Eli Schwarz, Julie Satur, Darren G. Berg, Jaafar Nasruddin, Elifuraha G. Mumghamba, Elizabeth S. Davenport and Ron Nagel Kentucky, USA In 1921, New Zealand began training school dental nurses, subsequently deploying them throughout the country in school-based clinics providing basic dental care for children. The concept of training dental nurses, later to be designated dental therapists, was adopted by other countries as a means of improving access to care, particularly for children. This paper profiles six countries that utilise dental therapists, with a description of the training that therapists receive in these countries, and the context in which they practice. Based on available demographic information, it also updates the number of dental therapists practising globally, as well as the countries in which they practice. In several countries, dental therapy is now being integrated with dental hygiene in training and practice to create a new type of professional complementary to a dentist. Increasingly, dental therapists are permitted to treat adults as well as children. The paper also describes the status of a current initiative to introduce dental therapy to the United States. It concludes by suggesting that dental therapists can become valued members of the dental team throughout the world, helping to improve access to care and reducing existing disparities in oral health. Key words: Dental therapist, school dental nurse, global dental workforce Dental caries and periodontal disease, the most preva- previously been a component of the Dutch oral health lent oral diseases, are ubiquitous, preventable, generally care delivery system. Recently, Holland adopted a com- progressive, and without effective treatment result in bined curriculum, expanding dental hygiene to include edentulism. Most nations are faced with a shortage of dental therapy to develop an oral health therapist, and dentists. The introduction of dental therapists to the is now enrolling 300 a year in its training programmes7,8. workforce, then called school dental nurses, began in At the same time, the number of dentists educated is New Zealand in 1921 following the discovery during being reduced by 20%. The Dutch rationale is that in World War I of the poor oral health of potential in- the future significant aspects of basic preventive and ductees into military service1. School dental nurses were restorative care will be provided by these oral health trained in a curriculum of two academic years to provide therapists, with dentists performing more complex pro- basic preventive and restorative dental care for children cedures and treating medically compromised patients. in a School Dental Service, with general oversight by The new Dutch policy is intended to reduce costs and district dental officers. New Zealand’s effectiveness in improve access to care. utilising school dental nurses/therapists has been well- This paper profiles the utilisation of dental therapists documented2-5. By 1978, a number of countries had in six representative countries to illustrate the diversity of developed and deployed dental nurses to improve access approaches to developing and deploying dental therapists. to care6. Since the 1980s, dental nurses have generally It also summarises the recent attempt to introduce dental been referred to as dental therapists. More recently the therapists in the United States. It concludes by suggesting trend has been to integrate dental therapists and dental that access to basic dental care will not be available to a hygienists as oral health therapists. major segment of the world’s population without the The Netherlands serves as an example of how coun- utilisation of dental therapists in the workforce. tries are coming to realise the importance of adding den- Table 1 provides a listing of the countries that have tal therapists to the workforce. Dental therapists had not been identified from the literature, various websites, and © 2008 FDI/World Dental Press doi:10.1922/IDJ_1819-Nash10 0020-6539/08/02061-10 62 Table 1 Oral health workforce in countries utilizing dental therapists, 2007 Country Dentists Population(A) Population per Dental Therapists Dental Hygienists Source(B) Year Dentist Anguilla 2 11,400 5,700 3 1 2000 Australia 8,991 20,155,000 2,242 1,242 577 1, 8 2007 Bahamas 76 727,000 4,250 1 10 5 2004 Bahrain(C) 64 9,755,000 11,359 18 18 3 1993 Barbados 67 277,000 4,134 10 8 1 2006 Belize 35 286,000 8,171 2 1 2006 Benin 54 8,439,000 156,278 8 8 5 2004 Botswana 14 1,765,000 126,071 4 3 1992 Burkina Faso 50 13,228,000 264,560 70 5 2000 Cambodia(E) 335 14,071,000 42,000 88 3 2003 Canada 16,899 32,268,000 1,909 300 14,525 1, 4 2007 Cook Islands 10 18,000 1800 See Note G 1, 3 2001-07 Costa Rica 1,560 4,327,000 2,774 31 2 2000 Estonia 1,076 1,330,000 1,236 20 13 7 2003 Ethiopia 52 77,431,000 1,489,058 32 2 2000 Fiji 32 848,000 26,500 54 1, 3 2004-07 Gabon 42 1,384,000 32,952 55 2 2000 Gambia 18 1,517,000 84,277 1 1 5 2000 Great Britain 32,682 59,800,000 1,830 691(F) 4,722 1, 6, 7 2000-07 Grenada 16 103,000 6,437 5 2 2000 Guyana 34 767,200 38,360 47 2 1 2006 Hong Kong 1,714 6,940,432 4,049 301 60 5 2004 Ireland 1,800 4,148,000 2,304 453 241 6 2000-03 Jamaica 264 2,700,000 10,227 150 10 1 2006 Jordan 982 5,703,000 5,808 120 60 2 2000 Kiribati 2 99,000 49,500 2 2 2000 Lao PDR 367 5,924,000 16,142 11 11 4 1999 Latvia 1,732 2,307,000 1,332 87 177 5 2004 Malaysia 2,550 26,127,700 10,246 2,090 1, 8 2007 Mali 47 13,518,000 287,617 50 2, 3 2000 Marshall Islands 4 60,000 15,000 See Note G 1, 3 2004-07 Mozambique(D) 2 19,792,000 9,896,000 21 3 1996 Myanmar (Burma)(C) 970 50,519,000 52,081 2 2 3 1991 Nepal 100 27,133,000 271,330 7 2 2 2000 Netherlands 8,000 16,408,000 2,051 300 2,000 1 2006 New Zealand 1,836 4,028,000 2,194 660 237 1, 5 2007 Nigeria 2,850 131,530,000 46,151 1,100 400 5 2004 Palau-Belau 2 20,500 10,250 3 1 2006 Paraguay 3,254 6,158,000 1,892 908 1 2006 Seychelles 14 81,000 5,786 28 6 2004 Singapore 987 4,326,000 4,383 183 4 2001 South Africa 4,563 47,432,000 10,395 411 1,000 1 2006 Sri Lanka 1,353 20,743,000 15,331 425 5 2004 Suriname 35 449,000 12,829 70 3 1 2006 Swaziland 11 1,032,000 93,818 2 40 2 2000 Switzerland 4,250 7,300,000 1,717 250 1,400 7 2002 Tanzania 110 38,200,000 347,273 150 1, 3 1985-07 Thailand 6,200 64,233,000 10,360 3,000 70 1, 2 2000 Togo 40 6,145,000 153,625 7 2 2000 Trinidad & Tobago 266 1,305,000 4,906 45 1 2006 U.S.- DT Alaska only 173,500 298,213,000 1,719 11 112,000 1 2007 Viet Nam 1,800 84,238,000 46,799 800 3, 6 2000 Zimbabwe 191 13,010,000 68,115 112 3 5 2004 Total: 281,905 1,158,332,232 4,108 14,441 137,600 ---- ---- A. Updated to 2006 B. Source 1. Personal communication with public health professionals in respective countries 2. Zillén PA & Mindak M. World Dental Demographics, Internat Dent J, 2000; 50: 194-197. 3 WHO/CAPP (WHO Oral Health Country/Area Profile Programme) 4. Governmental agency referenced in WHO/CAPP. 5. Dental association referenced in WHO/CAPP. 6. Publication in dental journal. 7. EU Manual of Dental Practice, 2004 8. Government Report C. Estimated at 50% of combined Dental Therapist/Dental Hygienist figure listed in WHO/CAPP. D. Estimated at 50% of combined Dental Therapist/Dental Assistant figure listed in WHO/CAPP. E. 88 Assistant Dentists trained in ART + 300 Traditional Dentists not counted. F. Includes 363 combined Dental Therapist/Dental Hygienist. G. Dental therapists are deployed in these countries, but an accurate number not available. International Dental Journal (2008) Vol. 58/No.2 63 personal communication with dental health profession- At the end of a school year there is essentially no un- als as employing dental therapists. Currently, 53 coun- treated dental caries in children enrolled in the SDS 3. tries utilise dental therapists, with over 14,000 existing Adolescents, ages 13-18, are also provided with govern- world-wide. As the table indicates, the utilisation occurs ment-financed dental care by private dentists. in both developed economies and developing countries; Until recently, oral health care by dental therapists and in countries with both high and low dentist to was limited to children through the SDS. Legislation and population ratios. registration/licensure now permits them to provide care It should be noted that China has an estimated for adults, following completion of additional training. 25,000 ‘assistant dentists’ who practice independently They can also now work in private dental practices and in rural areas and function in a capacity that could be may also practice independently, but only with a con- considered analogous to dental therapists, according sultative agreement with a dentist12.