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Dental hygiene and dental therapy in New Zealand.

I moved to New Zealand right before my 30th birthday to experience living and working abroad. Little did I realize how significantly my world would change as I began work in a country where dental therapy was born almost 100 years ago, and dental hygiene is a relatively new and exciting developement. Coming from the United States where the exact opposite is true, you can probably imagine my culture shock.

Back in the early 1900s, New Zealand made a name for itself on the dental map for its very bold dental therapy initiative. At the time, about 90 percent of New Zealand's children were in desperate need of dental care, some of whom had so much decay that they needed dentures until their adult teeth erupted. (1) With no dental insurance or much awareness of oral health, something had to be done.

In 1921, the "dental nurse" was created (renamed "dental therapist" in 1991), a dental professional who worked within the elementary schools throughout the country to bring much-needed dental care and education to the young ones and their families. (2) This marked the beginning of a whole new oral health movement and has made a massive impact on how dental care is delivered around the globe. Today, over 98 percent of [New Zealand's children receive care, making the development of the dental therapist a huge success. (3)

The New Zealand Dental Council (NZDC) defines a dental therapist as one who "provide(s) oral health assessment, treatment, management and prevention services for children and adolescents up to age 18. Disease prevention and oral health promotion and maintenance are core activities." This treatment includes but is not limited to preparation of cavities and restoration of primary and permanent teeth, extracting primary teeth, preparing teeth and placing stainless steel crowns, performing pulpotomies on primary teeth, and performing preventive care such as prophylaxes and fluoride applications. Dental therapists may also work on adult patients over the age of 18 should they hold specific qualifications. This would be done under direct clinical supervision. (4)

Dental therapists often work outside of the traditional dental practice, normally holding employment through the government, or "School Dental Service," at schools and mobile units that operate between the schools, regardless of the family's or community's economic status. They have a "consultative working relationship" with the dentists, and refer out treatment that exceeds their scope of practice. (4)

Dental hygienists in New Zealand are a relatively new phenomenon. From the 1970s until 1992, when the first dental hygiene training began at a technical school, dental hygienists were only trained and utilized within the army. It wasn't until 2001 that the University of Otago School of Dentistry offered a two-year certificate in dental hygiene. (2)

Until then--and still today, although it is less common--many Kiwis were accustomed to receiving the dental prophylaxis from their local dentist, typically involving a 10-15 minute supragingival scaling. Any patient diagnosed with periodontal disease was referred to a dental hygienist. (5) The larger cities are now seeing an exponentially greater demand for routine dental hygiene services, with many Kiwis requesting to be seen by a dental hygienist as a direct result of changing attitudes and rapidly spreading oral health awareness. Even still, when seeing a patient for the first time, I've learned to ask not when, but if they have been seen by a dental hygienist.

The NZDC states that a dental hygienist's role is to provide "oral health education and the prevention of oral disease to promote healthy oral behaviors" and that the "primary task is in prevention and non-surgical treatment of periodontal diseases. They are to practice in a team situation with clinical guidance provided by a practicing dentist ... though some aspects of the scope of practice are provided under direct clinical supervision." These aspects include but are not limited to applying prescription preventive agents, administering local anesthetic and performing various orthodontic procedures including removing fixed orthodontic attachments by using burs and slow speed hand pieces. (6)

The history of education for therapists and hygienists in New Zealand has been one of constant growth and change. Since its birth in the 1920s, dental therapy has been a two-year certificate provided at technical schools outside of the universities, but as of 2007 has been combined with dental hygiene as a three-year, Bachelor of Oral Health (BOH) degree. Unlike the United States, the three-year education is a combination of both dental hygiene and dental therapy. Today, any dental hygienist trained in New Zealand after 2007 also holds a degree as a dental therapist. Although, being dually licensed is not required--one may chose to register in one or both professions. (7)

As of October 2014, there were 811 dental therapists and 576 dental hygienists within a total population of 4.5 million (NZDC). (8) Because dental therapists and dental hygienists work in different clinical settings, they often do not share responsibilities or patients; a dental therapist's treatment is typically of children 18 and under, while dental hygienists work in a private clinical setting seeing mostly adults. Since the degrees were combined, many BOH holders chose to split their work week between dental hygiene in the private office setting and dental therapy in the public schools in order to maintain their skills. Most practitioners I've spoken to have expressed a great appreciation for being dually licensed, often commenting on how much they enjoy the different work environments.

One difference is reimbursement. Dental therapy services, being government-funded, incur no out-of-pocket expenses for the consumer. As for dental hygiene, dental insurance is not common in New Zealand, so the average Kiwi pays out-of-pocket for their preventive dental services. Because there are no insurance codes, a private-practice prophylaxis is often billed based on time, with the average cost in the country's capital of Wellington being around $150 NZD (about $115 USD) per 45 minutes of treatment time.

I have been in the dental field for 14 years now, eight of them as a dental hygienist. Working in New Zealand has been an eye-opening experience on which I'll always look back with gratitude. With so much exciting change occuring in both New Zealand and the United States, I look forward to the years ahead as our countries continue to learn from each other to deliver the highest standard of global care.

Glossary

Dental Council New Zealand (DCNZ): An authority in New Zealand that develops and regulates standards of oral health care, as well as certifying and registering all practitioners, in order to protect the health and safety of patients and the public. (9)

Clinical Guidance: "The professional support and assistance provided by a practicing dentist.... may be provided at a distance." (6)

Direct Clinical Supervision: The dentist must be present on the premises when treatment is carried out. (6)

Kiwi: Native New Zealander.

Note: This article represents the experience of an individual dental hygienist working in New Zealand. More than 50 other countries have some form of "dental therapist," the definitions and scopes of practice for which vary.

References

(1.) Hoskin S. Open wide--a dental nursing history. Available at: http://pukeariki.com/ Learning- Research/TaranakiResearch-Centre/ Taranaki-Stories/Taranaki-Story/id/602/ title/open-wide-dental-nursinghistory# Accessed Oct. 10,2014.

(2.) Satur J, Dewson B. A history of the dental and oral health therapy profession. The Australian and New Zealand Journal of Dental and Oral Health Therapy. 2012; 1(1): 13-16.

(3.) Nash DA, Friedman JW, Mathu-Muju Kr. A review of the global literature on dental therapists. W.K. Kellogg Foundation, Apr. 2012. Available at: www.wkkf.org/. Accessed Nov. 2014.

(4.) Scopes of practice lor dental therapists. New Zealand Dental Council. Available at: http:// www.dcnz.org.nz/assets/ Uploads/Scopes-of-Practice/ Scope-of-practice-therapists.pdf. Accessed Dec. 2014.

(5.) Code of Practice. Working relationship between Dental Hygienists and Dentist/Dental Specialists. New Zealand Dental Council. Available at: http://www.dcnz.org.nz/ assets/Uploads/Professional-agreements/ Dental-Hygiene-working-relationship.pdf. Accessed Jan. 2015

(6.) Scope of Practice for Dental Hygienists. New Zealand Dental Council. Available at: http://www.dcnz.org.nz/assets/ Uploads/Scopes-of-Practice/ Scope-of-practice-hygienists.pdf. Accessed Dec. 2014.

(7.) Study Oral Health at Otago. University of Otago, New Zealand. Available at: http://www.otago.ac.nz/courses/subjects/deoh.html. Accessed Jan. 2015

(8.) Statistics New Zealand. Available at: http://www.stats. govt.nz/ tools_and_services/ population_clock.aspx. Accessed Jan. 2015

(9.) Roles and Functions. New Zealand Dental Council. Available at: http://www.dcnz. org.nz/about-the-dental-council/ what-we-do/roles-and-functions/ Accessed Jan. 2015)

By Jillian Webster, RDH

Jillian Webster, RDH, is an American dental hygienist living and working in New Zealand. Her memoir, Scared to Life, is out this month. More information and contact details can be found on her website, www.jillianwebster.com
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Title Annotation:SPECIAL FEATURE
Author:Webster, Jillian
Publication:Access
Geographic Code:8NEWZ
Date:Mar 1, 2015
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