HEALTH PROFESSIONS COUNCIL
RECOMMENDATION ON THE
DESIGNATION OF DENTURISM

As is evident from the letters quoted previously, members of the public and the Council of Senior Citizen's Organizations attested to the benefits of the services of denturists. Their letters invariable made reference to the quality of care provided by denturists and the reasonable cost of their services as compared to dentists.

There is a national accreditation system administered by the National Council of Denturists Governing Boards. Vancouver Community College (VCC) offers a two year training course which provides instruction regarding the technical, anatomical, biological and psychological needs of the edentulous patient.

There are currently five Canadian colleges which offer a diploma program in denturism, including Vancouver Community College.

Beginning in the fall of 1993, VCC intends to implement the Canadian Baseline Denturist Competency Profile curriculum which includes training regarding all removable prosthetic appliances.

Because of the risk of harm which accompanies the practice of denturism, it is important that the continuing competence of a practising denturist be monitored.

Within this health profession, there exists recognized leadership which has expressed a commitment to regulate the profession in the public interest. The predominant organization is the Denturist Association of British Columbia. The Pacific Denturist Association also represents denturists in British Columbia. It maintains the same basic objectives as the applicant and fully supports the application.

One of the most important factors affecting the viability of a college is that there is a sufficient number of registrants to support its activities. The applicant stated that there are currently 194 practising denturists in British Columbia, 72% of whom voluntarily belong to the applicant, most of the remainder to the Pacific Denturist Association and the rest having no affiliation. The applicant has represented denturists since 1951.

The applicant appears to have an understanding of the duties and organization of a college established under the Act.

The College of Dental Surgeons of British Columbia opposed designation partly on the basis of the applicant's past record of non-compliance with applicable legislation. It was submitted that the applicant's past record is indicative of the applicant's inability or unwillingness to manage their affairs in a publicly responsible manner.

Comment:

The Council expects that the College which is created under the Health Professions Act will be structured to ensure compliance with the Act, regulations and bylaws.

Denturist services have been regulated under the Dental Technicians and Denturists Act since 1953. Designation under the Health Professions Act, in itself, will not affect their availability.

Based on the foregoing analysis, the Council is of the opinion that designation of the practice of denturism is in the public interest.

Consistent with other colleges regulating health professions in British Columbia, the Council recommends that the College use the name of the practitioners and not the name of the profession.

The Council prefers that the generic title "denturist" be reserved exclusively for registrants of the College of Denturists. This title is generally understood by the public and is reserved by other provinces in Canada. The Council considers that a reserved title for denturists is in the public interest. In this way, the public and other health professionals will be assured that anyone calling themselves a denturist is a registrant of the College and is therefore qualified and subject to disciplinary processes for incompetent, impaired or unethical practice.

In Canada, prior to 1933, only dentists and physicians were permitted to provide and fit a dental prosthesis. In 1933, the Alberta Government amended the Public Health Act to permit a dentist to associate with a denturist when furnishing complete dentures to the public. In 1958, British Columbia allowed denturists to make full dentures directly for the public. The Council reviewed the current scopes of practice for denturism in Canada. In Ontario, when the Denturism Act, 1991 is proclaimed, denturists will be permitted to provide RPDs directly to the public. Apparently DOIs are not considered an issue in Ontario. Denturists in Quebec are also permitted to deliver all forms of RPDs directly to the public without the supervision of, or a prescription from, a dentist. The only restriction is that, with respect to RPDs, a denturist must ask the patient whether he or she has been examined by a dentist and, if not, inform the patient that examination by a dentist is strongly recommended. A 1991 amendment to the Denturologists Act specifically prohibited denturists from taking x-rays and required supervision of a dentist for fitting DOIs. New Brunswick recently amended its governing legislation to permit denturists to provide any RPDs directly to the public as long as the denturist receives an oral certificate from the patient's dentist. DOIs are not permitted. In Saskatchewan, denturists who are specifically licensed as "partial denture technicians" may provide partial dentures, but only in accordance with a written referral from a dentist. Similarly in Manitoba, denturists may provide partial dentures in accordance with a prescription from a dentist. These provinces have not yet considered the issue of DOIs. British Columbia, Alberta, Nova Scotia and Newfoundland appear to limit the scope of practice of denturism to providing complete dentures, although the status of DOIs is unclear. Prince Edward Island does not permit the practice of denturism. The only provinces which appear to have addressed the issue of DOIs are New Brunswick, which sought to prohibit it, and Quebec which permits some delivery of DOIs under the supervision of a dentist.

Comment:

The Council recognizes that by qualification and training, dentists must be considered the primary care givers with respect to oral health. They are the only ones qualified to perform comprehensive examinations, diagnoses and therapeutic treatment. Current applicable laws reflect this. Further, only dentists are qualified to recognize periodontal disease which may arise from fitting removable prosthetic appliances.

Special Risks Associated with Removable Partial Dentures (RPDs) The Council has identified risks to which the public could be exposed in the fitting and dispensing of RPDs, including:

• the risk of causing or contributing to periodontal disease and infection,

  failure to recognize and diagnose periodontal disease or infection, and

• improper design, fabrication or replacement of the RPD resulting in loss of and damage to remaining teeth, loss of use of the RPD, and general deterioration of oral health.

The RPD presents the most potential for risk of harm and requires a proper and competent assessment of the remaining teeth so as to minimize the possibility of damage placed on these teeth by the RPD. The challenges presented by the RPD were discussed in a recent article on the biological risks associated with the RPD by a faculty member of the Department of Clinical Dental Sciences at the University of British Columbia.

In conclusion, there should be no doubt that the decision to replace teeth using a carefully planned RPD requires a biological appreciation of the consequences of tooth-loss and of the potentially destructive impact of dentures. It requires familiarity also with alternative methods of replacing teeth, and an ability to provide the complete range of fixed and removable prosthodontic treatment following an accurate assessment and diagnosis of the problem. Dental students today place a major emphasis on the development of diagnostic judgment and a critical awareness of treatment options, but it is widely acknowledged by dental educators that prosthodontics present some of the most difficult educational objectives to meet. Consequently, misunderstandings on the benefits and dangers of the RPD abound.

Certainly the therapeutic benefits of the prosthesis, as demonstrated by the studies of Bergman et al. and replicated regularly by dentists in this country, will not be achieved by allowing others with less than an accredited dental education to misuse it as an intimate mechanical appliance around weak teeth supported by unhealthy tissues.

(MI MacEntee, "The Biological Sequelae of Tooth Replacement with Removable Partial Dentures, A Case for Caution", December 1992, p.6)

Special Risks Associated with Dentures over Implants (DOIs) Implants are metallic structures embedded in the jaw bone which protrude through gum tissue and to which the denture is fastened. They are expensive and difficult appliances to place and pose a danger of serious infection from bacteria entering down the attachment between the gum tissue and the metal post. Dentures placed on these implants must be meticulously fabricated and placed so the patient can clean the metal structures where they protrude through the gum tissue. Careful attention is required to the occlusion or biting forces so that the jaw bone is not traumatized by the forces that are transmitted through the metal peg into the jaw bone. The College of Dental Surgeons stated that only a few general practising dentists involve themselves with the placement of removable dentures over implants. The majority choose to refer the patient to a prosthodontist who has special training in removable and fixed prosthodontic appliances. The College is of the opinion that, if many dentists do not feel competent to provide this service, it is inconceivable that denturists are sufficiently qualified to provide this service. Conclusion The Council concludes that denturists are not currently qualified, by education and training, to provide RPDs and DOIs safely to the public without the involvement of a dentist. Consideration has been given, however, to whether denturists should be permitted to provide these services on the prescription of a dentist. This is discussed further in Recommendation 5.

Comment

Nothing in these recommendations prohibits a person from practising a profession, discipline, or other occupation in accordance with another Act (section 14, Health Professions Act).

The issue of RPDs and DOIs has caused a great deal of difficulty for the Council. On the one hand, we tried to ensure that the public interest is served by providing alternatives from which individuals may make choices. On the other hand, we were mindful of the caveat that such choices should be selected from safe options. The Council had a most helpful visit to a denturist clinic in Victoria. We were most impressed with the obvious professionalism of the operation. We were introduced to patients of the clinic who spoke very highly of the services provided (in this case, dentures over implants). So far as the Council was concerned, we had no reservations as to the competency and skill of the practitioners as it related to the construction and emplacement of the prosthesis nor as to their ability to establish a satisfactory rapport with their clientele. Members of the Council have also availed themselves of the opportunity to visit dental offices and discuss these specific issues with dentists on an informal basis. One such meeting with practitioners in a dental clinic in Vancouver was likewise of great help in understanding the problems involved. One particular case clearly demonstrated the importance of radiological evidence in the examination and prescription of partial dentures. All in all, the Council is satisfied denturists who have been properly qualified have the necessary knowledge, skill and expertise to make and fit both removable partial dentures and dentures over implants. We presume the College of Denturists will establish appropriate criteria for determining such qualification. We are not at all satisfied, however, that by training, denturists are qualified to examine and assess the appropriate prosthesis for individual patients. In our opinion, the provision of RPDs and DOIs should only be made on the explicit prescription of a dentist who has examined the patient and determined the appropriate prosthesis to be fitted. The actual construction, fitting and adjustment could very well be left to the denturist. The best to be hoped for would be a conjoined effort with dentists exercising their undoubted qualification to examine, diagnose and prescribe and the denturists exercising their undoubted skill and expertise to manufacture and fit the prosthesis. The College of Dental Surgeons of British Columbia has emphasized the importance of the concept of a team approach to the provision of dental services. The Health Professions Council is encouraged by this position and is equally reassured by similar attitudes expressed during the public hearing by denturists. The professional collaboration recommended by the Health Professions Council will provide additional safe options from which the public may choose in selecting its dental services. This approach echoes the 1981 Ontario study by Professor Bernard Dickens of the University of Toronto, Faculty of Law.

There seems to be mutual recognition, among the dental health professions and also among analysts and educators observing practices within the Province, that a team approach to all aspects of dental health services is to be favoured. The composition, leadership and individual status of team members are matters to be determined by developments on a number of fronts. Legal and institutional barriers to achieving team participation should be removed, however, where compatible with the health protection, economy and convenience enjoyed by consumers. The hope of this Report is that its recommendations may contribute to the forces which encourage a team approach, and which demonstrate to each profession how it may collaborate flexibility with the other in service to the public.

(Dickens, "Report of a Review of Denture Services Related to The Denture Therapists Act, 1974", January 1981, p.5)

A radiographic examination and a skilled diagnosis based on the interpretation of those x-rays are necessary to determine which teeth can sustain the added stress of having a RPD attached to them and in which direction the pressure should be applied. The strain of a partial denture can cause a loss of teeth if the pressures are incorrectly applied. An RPD which is designed incorrectly can destroy the remaining natural dentition. Because denturists do not have any training or education regarding the taking or interpretation of x-ray photographs, this aspect of practice should not be included within the scope of practice of denturism.

Article 12.02 of the Rules of the College of Dental Surgeons reads as follows:

Prosthetic appliances. A member who takes impressions, extracts teeth, or performs other professional services, preparatory or incidental, to the insertion of a prosthetic appliance must strongly advise the patient, and must use all possible efforts to ensure that the requirements set forth in this Article 12.02 are complied with, and must not directly or indirectly in any way condone any breach of such requirements. The requirements are that:

1. the prosthetic appliance must be fitted by a duly licensed member except if the mouth is completely edentulous, and a complete denture, that is, an appliance which replaces all the natural teeth and associated structures of either the upper or lower jaw, and is not supported, wholly or in part, by natural teeth, roots or implants, is to be fitted;

This Rule would prohibit a dentist from giving a prescription to a patient to have a removable partial denture or a denture over implants furnished by a denturist. In the view of the Council, this provision is contrary to the public interest because it limits consumer choice and impedes the development of a collaborative working relationship between denturists and dentists in the provision of services.

. . . exclusive scopes of practice should be narrowed to focus on preventing harm, as has been initiated recently in Ontario. We believe that more appropriate, cost-effective and timely health care could be provided to more patients if B.C. were to follow the Ontario initiative.

(Closer to Home, Volume 2, 1991, p. D-33)

Restricting professional monopolies (or exclusive scopes of practice) in favour of consumer choice was also recommended in an earlier study, the Foulkes Report (1974), commissioned by the British Columbia Minister of Health. In discussing the conflicts which may arise between the professional college and the public interest, the area of exclusive scopes of practice was raised.

It must be emphasized that any professional legislation which unduly restricts the scope of practice of skilled personnel may be contrary to the public interest in greater supply and accessibility of service through the development of team practice. Therefore, it is urged that: Professional legislation should not contain narrow restrictions or rigid definitions of scope of practice which are excessively exclusive; that measures should be taken (as indicated below) to reduce the area of interprofessional strain and conflict; and that no prosecutions for violations of scope of practice legislation should be undertaken without the prior consent of the appropriate public authority. Insofar as may be possible with due regard for public safety, professional law should not place rigid restrictions on the scope of practice of allied health personnel, and greater flexibility should be encouraged in the allocation of roles between the health disciplines.

(Professor J. T. McLeod, "Public Regulation of the Professions" in Health Security for British Columbians, Special Report: Consumer Participation, Regulation of the Professions, and Decentralization (1974, The Report of Richard G. Foulkes, B.A., M.D., F.A.P.H.A. to the Minister of Health, Province of British Columbia, Tome Three, p.145)

Professor Bernard Dickens, in his report on denture services for the Government of Ontario, also put forward a perspective emphasizing individual choice and responsibility.

Individuals are seen as responsible for their own dental care. As consumers of dental services, individuals are perceived to require access to relevant information for their exercise of choice between alternative services and, where they exist, alternative sources of services. Information includes details of services, and of fee scales. Responsibility for dependent persons is shared in due proportion by their guardians. The role of Government, acting through The Royal College of Dental Surgeons and the Governing Board of Denture Therapists, is to ensure that practitioners achieve and maintain competence to discharge the functions they are licensed to undertake, and act in other ways to serve the public, and not inconsistently with the public interest.

(Dickens, op. Cit., p.2)

The 1964 Report of the Royal Commission on Health Services stressed the importance of the individual's responsibility to make appropriate choices.

The individual must assume responsibility for wise and prudent use of health services, for periodic health examinations, including regular dental examinations, for assuring that the mother receives complete pre- and post-natal care, for seeing that children are properly immunized, and at the first sign of symptoms for consulting a physician or dentist. The wise use of available health services cannot be over-stressed.

(Royal Commission on Health Services, Vol. 1, 1964, p.4)

A regulatory framework of overlapping scopes of practice and narrow exclusive scopes of practice creates a system which offers greater choice and accessibility to health care services and at lower costs. It also imputes a greater responsibility to individuals to inform themselves about the choices available, the implications of those choices, and reduces the paternalism of Government and the professions themselves. The Council believes that the recommendations in this Report on denturism reflect this philosophy and maximize freedom of choice for consumers of denturist services to the extent possible, given overriding concerns with respect to public safety. The recommendations also enhance the development of the dental team and encourage greater cooperation and collaboration between dentists and denturists.

Appendix B

Consultation Process

1. ASSOCIATIONS

Alberta Denturist Society
British Columbia Registered Dental Technicians Association
British Columbia Dental Hygienists' Association
The Canadian Academy of Denturism
Canadian Dental Association
Commercial Dental Laboratory Association of British Columbia
Council of Senior Citizens Organizations
Denturist Association of Canada
International Federation of Denturists
Pacific Denturist Association
United States National Denturist Association
Western Society of Dental Technicians and Auxiliaries

2. HEALTH PROFESSIONS

College of Dental Surgeons of British Columbia

3. EDUCATIONAL PROGRAMS

International Denturist Education Centre
Faculty of Dentistry, University of British Columbia
Vancouver Community College

4. OTHER PROVINCES

Alberta Health
Alberta Professions and Occupations Bureau
Manitoba Health Services Commission
New Brunswick Department of Health and Community Services
Newfoundland Department of Health
Northwest Territories Department of Health
Nova Scotia Department of Health and Fitness
Ontario Ministry of Health
Office des Professions du Quebec
Prince Edward Island Department of Health and Social
Services Saskatchewan Health
Yukon Department of Health and Human Resources

1. ASSOCIATIONS

British Columbia Registered Dental Technicians Association

Denturists do not have the expertise to deliver services other than full dentures. Expanded scope of practice would have detrimental effect on the industry as a whole and will result in downgraded quality of dental prosthesis. Commercial Dental Laboratory Association of BC Opposed to expanded scope of practice -- denturists should not be allowed to fabricate partial dentures or appliances for implants because they do not have the education necessary to make adjustments to natural teeth. Council of Senior Citizen's Organization of BC Supported designation of increased scope of practice. Seniors are main consumers of denturist services and denturists have earned their support and confidence because of their dedication and commitment to reasonable cost. Pacific Denturist Association Supported expanded scope of practice because of public demand for the services and the health of the public is not at risk. Wish to cooperate with dentists. 2. HEALTH PROFESSIONS College of Dental Surgeons of British Columbia Opposed designation and expanded scope of practice. The history of denturism in BC demonstrates a lack of appreciation and understanding of the responsibilities of self-governance and the responsibilities of delivering and being responsible for dental health care to the public. Services in expanded scope require a high level of sophistication in education and treatment planning far beyond that obtained in denturists' training. 3. EDUCATIONAL PROGRAMS Vancouver Community College Utilization of Canadian Denturist Baseline Competency Profile should be useful in defining the scope of practice, with limitations established to ensure patient safety is not compromised. Limitations should not restrict direct access to denturist's care. Conflicting relationship between denturists and dentists should not cloud determination of regulation.