HEALTH PROFESSIONS COUNCIL
REVISED RECOMMENDATION FIVE ON THE
DESIGNATION OF DENTURISM

I. BACKGROUND

In October 1993 the Health Professions Council ("the Council") submitted its Report on Denturism ("1993 Report") to the Minister of Health. In August 1995, the Minister requested that the Council revise Recommendation Five of its 1993 Report to include more detail about the prescription process for removable partial dentures ("RPDs") and removable dentures over implants ("RDOIs") when provided by a denturist. As part of this special reference to the Council, the Minister submitted eight questions which addressed the prescription process and its implementation.

The Council wishes to point out that this supplemental report does not represent a departure from the rationale of the original Recommendation Five contained in the 1993 Report. Rather, in this report, the Council has elaborated further on the prescription process which it recommended. The public interest criteria analysis addressed in the original 1993 Report following a public consultation process has not changed with this revision of Recommendation Five.

At a meeting in September 1996, the Minister's eight questions were discussed with representatives of all three professions involved in the provision of RPDs and RDOIs. The Commercial Dental Laboratory Association of BC and the BC Registered Dental Technicians Association represented the profession of dental technology. Because the College of Dental Technicians was not presented at that meeting, the Council invited them to make submissions stating their position on the preliminary report. The College of Dental Technicians subsequently submitted a response to the Council. The Council considered their response and the College of Dental Technicians participated in the most recent meeting, held January 9, 1997, with the Council and the other stakeholders.

The College of Dental Technicians have asked to be on the record as stating they do not support Recommendation Five as they are not convinced the benefits outweigh the risks to the public with respect to RPDs and RDOIs when provided by a denturist. However the College states they will work with any recommendation finally approved and will comply with and facilitate the protocols established.

II. EXECUTIVE SUMMARY

The Council has concluded, after carefully weighing the responses to the Minister's eight questions provided by representatives of the three professions involved, that denturists can safely provide RPDs and RDOIs within the limitations specified in the 1993 Report and the clarification of the prescription process and the revision of Recommendation Five provided in this report.

All parties have agreed that denturists providing these services must have appropriate training, as set out in Recommendation 5(i).

The College of Dental Surgeons and the College of Dental Technicians have expressed reservations about the training of denturists to provide RPDs and RDOIs; the Council must operate on the assumption that the College of Denturists will fulfil its legislated requirement under s.15.1 of the Health Professions Act and will establish standards of education and requirements for continuing education for registrants.

Although the three professions involved have not always reached agreement they have displayed a considerable degree of interprofessional cooperation and have expressed general commitment to work toward implementation of the prescription process. The Council is confident that all members of the dental team will fulfil their respective roles and responsibilities within the professional parameters set out by their colleges.

III. MINISTER'S QUESTIONS

The eight questions specified below were submitted by the Minister of Health to clarify the prescription process.

It is the Council's recommendation that the Ministry of Health implement regulations that reflect the following answers to the questions posed by the Minister:

Clinical Examination:

1. What level of clinical examination would be required before a dentist could provide a prescription for an RPD or RDOI?

A full examination must be made by a dentist according to the standards of the College of Dental Surgeons before a dentist could provide a prescription for an RPD or RDOI.

Technical Instructions:

2. a) What technical instructions or directions for fabrication and fitting must be included in a written prescription from a dentist for RPDs or RDOIs?

The dentist's written prescription for RPDs or RDOIs must include a full description and design of the appliance to be used, and a warning as to any parts of the oral environment or tooth structures with which the denturist must not interfere.

Limitations to the Prescription:

b) In what circumstances, if any, could a dentist attach limitations to the filling of a prescription?

A dentist must attach limitations to the filling of a prescription in accordance with generally accepted dental practice.

Types of Limits:

c) What types of limits would this include?

Such limits would include any medical or dental contraindications. A prosthetic must not be supplied where contraindicated.

Alteration of Technical Directions:

3. In what circumstances, if any, would it be appropriate for a denturist to alter any technical directions from a dentist with respect to RPDs or RDOIs?

There must be no alteration of the prescription without prior consent of the prescribing dentist, and any agreed changes must be properly recorded by the professionals involved.

Prescription Time Limits:

4. What time limits, if any, would be appropriate to attach to a prescription for a RPD or RDOI?

If the filling of the prescription is not commenced within three months of the prescription date it must not be undertaken without consultation with the prescribing dentist. If work on the prescription has not commenced within one year of its date, then re-examination and a new prescription from a dentist is required.

Withholding a Prescription:

5. In what circumstances, if any, would it be appropriate for a dentist to withhold a prescription from a consumer who requirers a RPD or RDOI?

The College of Dental Surgeons acknowledges that it would be unethical to withhold a prescription from a patient where a prescription is indicated. However, where in the dentist's opinion, a prosthesis is contraindicated, the dentist must, in lieu of a prescription, provide the patient with a statement to that effect.

Supervision by a Dentist:

6. In what circumstances, if any, would it be appropriate for a dentist to supervise any aspect of the making or furnishing of RPDs or RDOIs?

Other than as provided in these recommendations, dentists need not be involved in the supervision of the making or furnishing of RPDs or RDOIs.

Follow-up Examinations:

7. In what circumstances, if any, would follow-up examination by a dentist be appropriate?

In every case, after the conclusion of the denturist's fitting of the prosthesis, the patient must be referred back to the prescribing dentist for final evaluation, and the denturist must not continue to treat the patient unless that person has completed the final referral to the dentist. This is an integral part of the prescription process.

Civil Liability/Disciplinary Issues:

8. Are there any civil liability or disciplinary issues which should be addressed prior to implementation of the prescription requirement?

Any problems with civil liability or disciplinary issues have been addressed by the prescription process as outlined. Liability insurance should be mandatory for all disciplines. Any failure to conform with protocols set out should be handled within the disciplinary processes of the respective Colleges.

IV. COUNCIL PROCESS OF REVISION

The 1993 Report concluded that denturists are not currently qualified to provide RPDs and RDOIs and recommended at pages 19, 20, and 21, that any denturist who provided RPDs or RDOIs was required to have special qualifications and training. The Council reiterates this original recommendation. All parties accept this requirement.

The Council based its revision of Recommendation Five and analysis of the prescription process on two basic assumptions:

a) that the College of Denturists would fulfil its legislated requirement under s.15.1 of the Health Professions Act and establish, monitor and enforce standards of education and qualifications for registration of registrants, and establish and maintain a continuing competency program; and

b) that the team approach to dental services with regard to the provision of RPDs and RDOIs by denturists is a viable option.

The Council approached its revisions to Recommendation Five by requesting each of the three professions involved to provide answers to the Minister's questions. In September 1996, after written responses to the questions were received, the Council met with the three professions. Dental technology was represented by the Commercial Dental Laboratory Association of BC and the BC Registered Dental Technicians Association. The Council engaged the three stakeholders in a discussion of the questions. The intent of this meeting was to reach a consensus as the basis for the Council's revision of Recommendation Five and clarification of the prescription process. The Council then issued a preliminary report which the Council felt represented such consensus.

In October after the September meeting, the College of Dental Surgeons responded to the Council's preliminary report and raised an issue which, in the College's view, had not been addressed and on which, therefore, there was no consensus:

• RPDs and RDOIs pose a risk of harm when provided by a denturist in opposition to a dentate arch (one which contains natural teeth) because the denturist is not qualified or trained to adjust (cut or grind) natural teeth or crowns to accommodate the fitting of a dental appliance.

As a solution to this issue, the College of Dental Surgeons suggested further limitations on denturists when providing RPDs and RDOIs. The proposed additional limitations:

• No removable dentures over implants or removable partial dentures shall be provided except opposite an edentulous arch; and

• Denturists must not cut or grind natural teeth or crowns in order to accommodate the necessary occlusal relationship and fit demanded by the placement of a removable complete or partial denture or denture over an implant.

The College of Denturists accepted only the second limitation.

In its 1993 Report on page 21, the Council addressed the denturist's "fitting and adjustment" process. With the concurrence of the College of Denturists and to emphasize that the "fitting and adjustment" is to the prosthesis itself and not to natural teeth or crowns, the Council has added an additional limitation to Recommendation Five, as follows:

(iv) denturists must not cut or grind teeth or crowns in order to accommodate the necessary occlusal relationship and fit demanded by the placement of a removable complete or partial denture or a removable denture over an implant.

The Council agreed to meet a second time with representatives of all three professions for a further discussion of this issue. At this meeting, held January 9, 1997, the three professions, including representatives of the College of Dental Technicians, were present.

The College of Dental Surgeons outlined what it viewed to be the risks of harm involved in the provision of RPDs and RDOIs. They are:

1. Risks to adjacent teeth to which an RPD is attached;

2. Risks to natural teeth in opposition to an RPD or RDOI or other oral structures because of improper occlusal relationship or cutting or grinding necessary to accommodate the occlusal relationship; and

3. Long-term risks to the oral environment inherent in placement of an RPD or RDOI.

After extensive discussion, the positions of the participants were as follows:

The College of Dental Surgeons, the College of Dental Technicians, the Commercial Dental Laboratory Association of BC and the BC Registered Dental Technicians Association: RPDs and RDOIs should only be provided by a denturist when in opposition to an edentulous arch.

The College of Denturists: RPDs and RDOIs can be provided safely, whether in opposition to a dentate or an edentulous arch, within the limitations of the Council's 1993 Report and the requirements of the prescription process.

In the Council's opinion, the risks of harm outlined above are adequately addressed by the revisions to Recommendation Five and the prescription process:

• Risks to adjacent teeth to which an RPD is attached are addressed by the requirement of a dentist's prescription prior to the fabrication and delivery of any RPD and by the further requirement of a final evaluation by the dentist. This allows the dentist, who is the only member of the dental team qualified to read Xrays and to assess the overall health of the patient, to determine the appropriate appliance, if any, for the patient and to specify requirements for its fabrication and placement or attachment within the mouth;

• Risks to natural teeth in opposition to either an RPD or RDOI from either an improper occlusal relationship or from cutting or grinding to accommodate the necessary occlusal relationship are addressed by the prohibition in subclause (iv) which removes the possibility of a denturist cutting or grinding natural teeth and the requirement that the patient return to the dentist for final evaluation; and

• Long-term risks from the placement of an RPD or RDOI are best dealt with by encouraging regular follow-up by a dentist.

All parties agree that the fitting of a prosthesis can have an impact on the natural teeth and overall oral health of the patient, which can only be assessed by follow-up examination by a dentist. Furthermore, since only a dentist can make any necessary surgical (cutting or grinding) adjustments to natural teeth, this would necessitate a final evaluation of the prosthesis by a dentist as he or she is the only member of the dental team responsible for the design and prescription and able to make any such final adjustments to the natural teeth. In addition, the final evaluation by a dentist completes the team approach to the provision of dental services.

Conclusion: The expansion of Recommendation Five and the prescription process outlined in the Council's response to the Minister's eight questions addresses the risks of harm raised by the College of Dental Surgeons.

V. REVISED RECOMMENDATION FIVE

To express fully the original intent of the Health Professions Council's Report on Denturism, Recommendation Five should be amended to read:

VI. IMMEDIATE DENTURES

A second issue was raised by the College of Dental Surgeons in its October 1996 letter to the Council:

• Denturist involvement in the provision of immediate dentures (dentures provided immediately after extraction of live teeth) was not raised as an issue during the 1993 consultation process and therefore was not addressed in the Council's 1993 Report. The College of Dental Surgeons requested that the Council address this issue in this report.

At the January 1997 meeting, after very limited discussion of the above issue, unanimous agreement was reached among the professions that only a dentist may insert immediate dentures and can determine when adequate healing has occurred so that the patient may return to the denturist for fitting of a more permanent removable denture. All parties agreed that there are various bylaws and rules which will be amended or repealed within the respective colleges to implement this acknowledgement.