J Dent Educ. 70(11_suppl): 22-26 2006
© 2006 American Dental Education Association
Global Issues in Oral Health |
Dental Workforce Issues: A Global Concern
Hari Parkash, M.D.S., F.I.C.D., F.I.M.F.T. (U.K.), F.A.C.D.;
V.P. Mathur;
R. Duggal;
B. Jhuraney
The workforce is connected to a system of health care. Health care systems depend not only upon infrastructure and resources, but also on the availability of skilled human resources. The changing pattern of oral diseases, their frequency and severity, and the disparity of distribution between developing and developed countries require changes in the strategies of dental education and oral health care delivery systems. Significant differences exist in the type of professionals delivering oral health promotion, prevention, and curative services. Factors relating to geography, quality, training, support, remuneration, and workload influence the recruitment and retention of clinical staff.
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Present Situation
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The current situation features huge unmet treatment needs, striking inequality in delivery systems, and absence of an adequate community-oriented prevention system. People in developing countries are burdened by a significant number of oral diseases, which are further aggravated by poverty, poor living conditions, lack of dental awareness, and the absence of appropriate policies and funding to provide basic oral health care.1 In the wake of changing culture and lifestyle, new dental diseases are emerging. While future patterns of disease and the efficacy of future treatments are difficult to predict, the demand for dentistry is likely to increase.
According to the World Health Organization, oral diseases like dental caries (tooth decay), periodontitis, and oral and pharyngeal cancers are global health problems in both industrialized and developing countries, especially among poorer communities. An estimated 5 billion people worldwide suffer from dental caries. The mean number of decayed, missing, or filled permanent teeth (DMFT) at age twelve is 1.9 in low-income countries, 3.3 in middle-income countries, and 2.1 in high-income countries.2 Despite a low mortality rate associated with dental diseases, such diseases have a considerable impact on self-esteem, eating ability, nutrition, and health throughout people’s lives.
A mismatch exists between oral health professionals and the population they serve. In India, for example, a staggering 202 dental schools graduate about 13,500 students each year.3 A highly energetic community of 100,000 dentists serves a population of one billion. The dentist-to-population ratio, which was 1:300,000 in the 1960s, stands at 1:10,000 today. Like anywhere else in the world, urban bias exists in India, with three-fourths of dentists clustered in urban areas, which house only one-fourth of the country’s population. Government hospitals and establishments treat the dental ailments of only a small part of the population, while the remainder seek treatment through private clinics. The impact of oral diseases on pain, impaired function, and reduced quality of life is extensive and expensive. In Africa, the dentist-to-population ratio is approximately 1:150,000 against about 1:2,000 in most industrialized countries, which further highlights the global difference.
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Oral Health and Systemic Health
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We are entering an age of interdisciplinary practice, where dentistry provides oral health care as an integral part of an individual’s overall health.4 Oral infection can have an adverse impact on other organs of the body. The oral cavity can tell of direct assaults by a broad range of systemic disorders, such as diabetes, AIDS, or Sjögren’s syndrome. Several recent studies have demonstrated a relationship between periodontal disease and infective endocarditis, coronary artery disease, stroke, diabetes, and respiratory tract diseases. Periodontitis appears to share genetically determined risk factors with several other chronic degenerative diseases, such as ulcerative colitis, juvenile arthritis, and systemic lupus erythe-matosus.5 Obviously, these health problems are of concern to all health care professionals, including dentists. From the insight provided by these studies and technologies, we now recognize that periodontal disease may be a potential risk factor for many health problems.6
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Changing Disease Patterns and Treatment Needs
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A definite transition in disease patterns is changing the treatment needs of patients. With increasing awareness about the orodental system, a more informed and affluent population has begun to understand the importance of oral health. An increased demand exists for conservative treatments, including endodontics, dental implants, and cosmetic surgery, while dental extractions have taken a backseat. Prevention should be made the global priority today. Thus, the workforce should be well equipped and able to cope with the changing needs of society in improving the performance of the oral health system.7
In most of the industrialized Western countries, oral health care is available to the population in the form of prevention and curative services based on private or public systems. Prevention based on good oral hygiene habits, use of fluorides, and prudent diet has dramatically reduced the level of these diseases in industrialized countries.8 People in deprived communities, certain ethnic minorities, homebound or disabled individuals, and elderly populations, however, are not sufficiently covered by the oral health care system.9 Dental diseases are a costly burden to health care services, accounting for between 5 and 10 percent of total health care expenditures and exceeding the cost of treating cardiovascular disease, cancer, and osteoporosis in industrialized countries.10
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Importance of Workforce Planning
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Workforce planning is an essential element in planning future health service provisions. Factors of both supply and demand for dental services are changing, which makes it all the more important for workforce planning to prevent future projected shortages or surpluses.11 In a society that steadily increases its consumption of health services, a correspondingly increasing workforce is needed. The following issues are discussed here in relation to effective workforce planning: 1) oral health promotion and prevention, 2) migration of the dental workforce, 3) reform of the existing dental curriculum, and 4) the changing role of women in dentistry.
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Oral Health Promotion and Prevention
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The immediate need is an oral health care system that uses existing health care infrastructures and applies an appropriate technology with an emphasis on community-oriented prevention directed to all at an affordable price. This concept of primary health care developed on the World Health Organization pattern should be largely adopted by developing countries to provide maximum benefit to their people.12 The emphasis should be on multidisciplinary work that maximizes the use of clinical skills, facilitates the development of new professional roles, and increases system capacity. In addition, a properly integrated, long-term strategy for the planning, development, and education of the workforce should be developed. The public should be able to access the dental services they require speedily, effectively, and with confidence. Primary health care is a vital means through which not only many preventive, diagnostic, therapeutic, rehabilitative, and support services are provided for individuals, but also, importantly, the means through which many public health services and interventions are provided for local communities.
Even though common dental diseases are preventable, not all community members are informed of or are able to benefit from oral health promotion measures. Moreover, in many countries, oral health care is not fully integrated into national or community health programs. The most important challenge is to offer essential oral health care within the context of primary health programs. Community empowerment, harmonization, and organization techniques need to be applied according to the primary health care concept. This concept is based on the promotion of a self-help and self-care family responsibility for health and community involvement.13 Encouraging the participation of the general population to sensitize the community, developing dental awareness, and training the population for implementation and management of community-based activities should be done.
The concepts of health promotion, self-care, and community participation emerged during the 1970s, primarily out of concerns about the limitation of the professional health care system. These areas are still in infancy in developing countries. In industrialized countries, an oral health promotion program should increase awareness and interest among consumers, thus facilitating the conversion of unmet need to demand. In developing countries, the oral health promotion guidelines demonstrate ways to extend resources to meet a broader base of need.14 Oral health care is virtually nonexistent in rural areas of most developing countries, where more than 80 percent of the population lives. Recently, community-based oral health programs have been initiated in some countries to fill the gap. These programs give more emphasis to oral health promotion and prevention of oral diseases than to treatment of the consequences.15
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Migration of the Dental Workforce
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Another matter of concern is the international mobility of health care professionals. Recent times have seen an increasingly large-scale, targeted, international recruitment approach by many developed countries to address domestic shortages. Most professionals who migrate from developing countries go to the United States, the United Kingdom, and Canada. Several factors promote migration, including unemployment, colonial links, financial incentives and material benefits, pursuit of higher education, improvement of working conditions and facilities, and avoidance of excessive bureaucratic procedures.
The migration of health professionals directly affects health system performance, population health outcomes, and the health workers who remain in the country. Migration can result in serious delays in providing emergency care and long waiting times for scheduled services. Health care in rural areas can suffer due to lack of expertise and trained professionals. Moreover, excessive workloads and long working hours for the remaining staff can lead to demoralization, burnout, and decline in the quality of care. Thus, the challenge is to provide adequate, respectable, and attractive employment opportunities to the workforce while maintaining a balanced geographic distribution.
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Reform of the Existing Dental Curriculum
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With evolutionary advances in oral science during the past few decades, future needs and demands for oral health care are likely to determine the form, function, and size of the dental profession. With the development of an ever-increasing range of new therapies, materials, procedures, and devices, new organizational systems will be needed to support the education and training of dental professionals.16 Reform of the existing dental curriculum is imperative, so that it responds to changes in current and projected disease demographics, advances in science and technology, changing societal culture, the information revolution, increased patient involvement, and greater integration of science and research.17–19
Dental education must emphasize the professional ethics and moral responsibility of graduating professionals to efficiently address community needs. Students should be provided with active learning strategies to inculcate the ability for independent scientific thinking, hence developing reflective and technically competent practitioners.20 A competency-based dental curriculum would provide efficient and effective education for future dentists in both the art and science of dentistry, which would help them serve their community in a more comprehensive and holistic manner.21,22
The twenty-first century is predicted to see the merging of dental and medical education. This will necessitate a broader background of medicine with expanded training in systemic disease pathophysiology in the dental curriculum.23 With health sciences research experiencing dramatic progress, dental students are expected to know about and understand the latest developments in the field. Global networking for mutual information exchange and dedicated funding for research in dental education settings should be encouraged.21 Adequately trained professionals are the lifeblood of dental education, practice, and research. Sustained efforts, new partnerships, and innovative and flexible programs are needed to ensure a competent, diverse, and robust oral health care workforce. Thus, dental education must reflect the changing role of the future dentist.24
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The Changing Role of Women in Dentistry
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Dentistry has become an increasingly popular career option for women. The expansion of the number of women in dentistry has been one of the major dental workforce trends in recent decades.7 The pioneer women in dentistry are worthy of recognition and admiration. They broke the traditional barriers for their gender and set standards for those who followed in their path as dental professionals. As medicine has its Elizabeth Blackwell and nursing its Florence Nightingale, so dentistry has its Lucy Taylor Hobbs and Henriette Hirschfeld.25
Increased numbers of women in the dental profession create an imperative that women be considered as vital intellectual capacity for the future. No educational disparity exists among dentists; female dentists enter the profession on an equal footing with their male colleagues.
Dental student enrollment in the United States is now 42 percent women, and in Finland 75 percent of practicing dentists are women. Women dentists in Russia constitute 48 percent of the dental workforce. Fifty percent of new entrants to dental undergraduate courses in the United Kingdom are female, and by 2020, more than 50 percent of all practicing dentists will be female.26 The United Kingdom has its first woman dental dean, China and Germany have women dental deans, and nine of the fifty-six U.S. dental deans are women. India is also following the trend, and about 15 percent of the deans in dental schools across the country are female. The same trends are occurring among students also, and about 50 to 60 percent of students in all dental schools in India are female.
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Conclusion
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The coming years promise plenty of new opportunities and challenges, and the dental profession should gear up to address the unmet needs of the community in the new millennium. Dental health promotion and prevention strategies should be adequately emphasized as they prove to be more affordable and sustainable. Essential and basic oral health care facilities must be made available to the masses via community-based oral health care programs. An intellectually stimulating environment for professional enrichment, lucrative working conditions, and avenues for career growth should be provided to young dentists to retain them in their country of origin. Presence and implementation of an ethical code of migration, benefiting both the source and the recipient country, should be mandatory for migrating professionals. Adequate reforms in the existing dental curriculum, keeping up with the changing treatment needs, and breakthrough advances in science and technology should be made, thus enabling students to cultivate skills and values that support lifelong learning. Thoughtful steps taken in the right direction will inevitably lead to a better and more efficient use of available resources and will reinforce people’s trust in the dentistry profession.
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Footnotes
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Dr. Parkash is Chief; Dr. Mathur is Senior Research Officer; Dr. Duggal is Associate Professor; and Dr. Jhuraney is Senior Research Fellow—all at the Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India. Direct correspondence to Dr. Hari Parkash, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India; 0091-11-26589304 fax; drhariparkash{at}yahoo.com.
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- India Ministry of Health and Family Welfare and Dental Council of India. Status of dental colleges for admission to BDS course. At: http://mohfw.nic.in/Adental.html. Accessed: July 6, 2005.
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Present situation
Oral health and systemic...
