Dental treatment aims to diagnose and eradicate diseases of teeth and gums, and to repair the damage done, providing better function and improving the patient’s quality of life. All this needs meticulous planning of treatment and its execution. But this can test the patience of both doctors and patients.

There are some 200 dental teaching institutions in India, churning out over thousands of dentists every year. Less than one in five is run by the government and some private colleges are yet to get recognition. Students are not educated in either ethics or in public health.
Further, as newly-graduated dentists set up their practice, they find out that equipment and basic infrastructure costs are high, Indians’ awareness of the need for dental treatment is low, and their spending is unpredictable. People’s priorities and expectations also differ. Some reasons for this could be poor patient education on dental problems, fear of experiencing pain during treatment and the ever-increasing cost of treatment.

The majority of dental problems in India are due to the low importance given to oral hygiene and delays in treatment due to patients’ negligence. Further, because of poor oral hygiene and practices such as chewing tobacco and ‘gutka’ (1), Indians have an increased incidence of gum diseases including oral cancer.

People with dental problems can choose from extremely sophisticated and expensive solutions like implants and the most basic extraction which does nothing more than get rid of pain. The options differ depending on the dentist and the location.

Standards of care
An improved armamentarium with increased delivery costs does not ensure the delivery of a certain standard of care. The choice of treatment is often dictated a patient’s desires and affordability rather than by pure medical need. Materials may be chosen on the basis of manufacturers’ advertising claims, or for other reasons. One example is that of silver amalgam filling.

For some years now, there has been a controversy regarding the appropriateness of silver amalgam fillings. In the West there have lawsuits seeking to ban amalgam for safety reasons. Questions have been asked regarding its safety to patients as well as to staff handling it during its preparation. The American Dental Association (ADA) has fought this campaign aggressively, holding that amalgam is a safe, strong and inexpensive material if used properly.  While there may be different views on this matter, what is important is that the ADA also advises patients to ask their dentists about the options for dental fillings, and discuss the merits of each material before consenting to its use.
The Indian Dental Association (IDA) has not issued any standards for materials, including amalgam filling. Nor, apparently, does it ask dentists to inform their patients of their options on this matter. As a result, we see many Indian dentists doing one of two things. Some use the most expensive options in total disregard of patients’ economic circumstances – and if asked by their patients indicate that amalgam is unsafe, thereby coercing patients into choosing more expensive options. Others use amalgam without informing the patient of the options, presuming that this decision should be taken by the dentist alone.

Records
The management of detailed records -- including charting teeth problems and creating specific long-term dental plans -- is often absent in India. Most dentists treat only those problems presented by the patient. There is a need for proper information and patient education in dental care, explaining the reason for long-term planning and prospective management of problem areas along with a preventive and maintenance regime.  In spite of the amendment to the Consumer Protection Act, 1986, bringing doctors under its purview, many doctors do not maintain records of treatment.

The role of dental councils and governing bodies
Governing health departments and the Dental Council of India are responsible for public health dentistry programmes as well as the certification of dental professionals. Most their awareness drives are organised with the help of manufacturers of dental hygiene products. This only promotes commercial products and creates ‘goodwill’ for local dentists. 

Government bodies and the IDA should work together towards certain goals. They should address the problem of uneven geographic distribution of professionals compared to the need for them; they should promote the continuing education of dental professionals – and the education of the public; they should mandate the use of standards in care; they should promote cost-effective equipment, including indigenous development of consumables and materials complying with standards; and, finally, they should promote better communication between dentists and their patients.

Reference
1. Mehta FS, Hamner JE 3rd, editors. Tobacco related oral mucosal lesions and conditions in India: a guide for dental students, dentists, and physicians. Mumbai: Basic Dental Research Unit, Tata Institute of Fundamental Research;1993.

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BARC dental unit, Anand Bhavan, Breach Candy, Mumbai 400 026 INDIA e-mail: docrdash@rediffmail.com