Dentists are an important, but an often unrecognised, group of professionals in the field of modern medicine.
The diseases of other organ systems are usually deemed to be more important than a toothache. Dental diseases also require prominence since the medical literature has established oral health can show signs of nutritional deficiencies or systemic conditions, such as diabetes, and oral infections can be risk factors for diseases like cardiovascular diseases. The relationship between oral and general health suggests we should reexamine the role of dental professionals and dentists.
And if we did, we’d see that the dental profession in India is facing multiple issues with regard to education, practice and employment.
India has the second highest number of dentists in the world: 2.7 lakh are registered with the Dental Council of India (DCI). In 2020, the country achieved more than the ideal dentists-to-population ratio of 1:5,000, as against the 1:7,500 recommended by the WHO.
However, the urban-rural distribution of dentists is not even. Each year, 27,000 dentists join the existing workforce after graduating from 313 dental colleges. Of them, 40 government colleges account for 11% of all seats and the remaining are in private colleges. The private sector played a huge role in the growth of dental education. But today, there are many issues in terms of education quality, lack of basic infrastructure and high tuition fees in these private colleges.
Karnataka, Maharashtra and Tamil Nadu have the most colleges, while Jharkhand, Bihar and Uttarakhand each have only three or four. So while India may have achieved the recommended dentist to population ratio, it has come at the cost of a massive privatisation of dental education, uneven distribution of colleges and questionable control over the quality of dental services.
According to data from 2019, only 3% (i.e. 7,337 out of 254,283) of registered dentists are employed in government service. An increased mismatch between the availability of dentists overall and their availability in the public sector and in rural areas has created a supply-demand issue in the profession. The shortfall of dentists in rural public facilities is also because there are few sanctioned positions for dentists and the absence of periodic recruitment to fill vacancies.
Of course, the rise in provision of dental services via the private sector has increased costs.
All these issues, taken together with dentistry’s lower public profile and government underspending on dental health, means dentistry is in crisis in India.
The government enacted the existing Dentists Act in 1948 to regulate dental education and profession in India through the Dental Council of India (DCI) plus local state dental councils. Given the developments in dental education since 1948 and to revive dentistry, the Ministry of Health and Family Welfare proposed the draft National Dental Commission (NDC) Bill in January 2020. This proposed Bill will repeal the existing Dentists Act 1948 and dissolve the Dental Council of India.
The new Bill aims to improve access to good-quality and affordable dental education, availability of dental professionals and their services in all parts of the country, periodic and transparent assessment of dental institutions and facilitate maintenance of a national dental register. It also aims to enforce high ethical standards in all aspects of dental services. It proposes the formation of a new regulatory body, called the National Dental Commission (NDC), to draft policies and maintain quality standards in dental education and the profession.
The Bill also seeks to standardise the procedure for graduates to enrol in the state dental registers, obtain licenses to practice dentistry and to seek admission into graduate programmes through a National Exit Test (Dental).
The preamble of the new Bill envisages a dental education system that improves access to education, dentists and oral healthcare for all and maintains ethical standards. While the Dentists Act 1948 recognises services and procedures related only to restoring or replacing teeth, the new Bill covers the breadth of oral health care services dentists can provide as well as tobacco cessation activities.
As such, the NDC Bill has recognised the scope of dentistry, and this is a positive step.
Autonomous boards and an advisory council
The NDC Bill 2020 proposes to establish four autonomous boards at the national level (section 16), under the supervision of the NDC of education at the graduate and postgraduate levels. The Dental Assessment and Rating Board shall determine the procedures to assess and rate institutions, permit the establishment of new institutions, impose warnings and fines, and/or withdraw an institution’s recognition if necessary.
The Ethics and Registration Board shall maintain online and live state registers of all licensed dentists practising in India, and regulate the professional and ethical conduct of dentists. The proposed Bill also intends to electronically synchronise the state and national dental registers.
To enhance access to dental education across the country, the Bill proposes a Dental Advisory Council (section 11) to put forth the views of the State Dental Councils and advise the NDC on issues of access to dental education.
The Bill also introduces a grievance redressal system. In the case of professional or ethical misconduct reported against a registered dentist, the complaint will be registered first with the State Dental Council. If a dentist is aggrieved by the decision of the state council, she may appeal to the Ethics and Dental Registration Board, and finally the NDC as a last resort.
In the case of grievances regarding the recognition of a dental institution, such institutions may first apply to the Undergraduate or Postgraduate Dental Education Board, as the case may be. If they are aggrieved by the judgement, the institution may appeal to NDC and then the Centre as a last resort.
Indeed, jurisdictional disagreements between the Centre and states have encouraged the rise of many private colleges. Many of them continue to function despite having been de-recognised by the DCI for not maintaining standards. This way, they jeopardise the professional future of their students, since their qualification may not be recognised or only be recognised within the geographical boundaries of the state.
This is why the new Bill also needs to include regular quality inspections of established dental institutions, along with assessing newer institutions. The Bill may consider regulating the number of colleges within a state as well.
The DCI currently maintains a live register of dentists, students in UG/PG courses, and faculty members of dental colleges, on the DCI website. However, the proposed Ethics and Dental Registration Board omits students and teachers from the list. The Bill may reconsider this point, since a record of students could help generate information on demographics, enrolment by UG/PG courses or by speciality, the drop-out rate and the total annual graduates.
A record of the dental faculty could also help evaluate the number of vacancies against sanctioned positions, both at government and private colleges.
Availability of dental services and professionals
Finally, provisions to regulate dental practice itself have been left out of the NDC Bill – much like the existing 1948 Act.
Only 3% of India’s dentists deliver dental care through government facilities, and most of them work out of private clinics. In addition, various state governments haven’t been proactive – or proactive enough – to regulate these private clinics and monitor their practices. As a result, dental healthcare costs have shot up in the private sector, becoming denied to people in need.
There is also no mention in the new Bill of who will “promote equitable and universal oral healthcare that encourages community health perspective and make services of dental professionals accessible to all the citizens”. So the preamble and the Bill’s provisions are not fully congruent with each other. Similarly, the Bill doesn’t mention who will ensure “availability of adequate and high-quality dental professionals in all parts of the country”.
The overall goal of the new Bill is to develop the dental education system in the country – and it fails to acknowledge ethical dental practice and patient safety as objectives of the profession, much like the 1948 Act.
Dental auxiliaries assist dentists treating patients. The Dentist Act 1948 recognises two types of auxiliaries: dental hygienist and dental mechanic. Currently, only 6,605 dental auxiliaries are available in India – and is one of the more-ignored professional groups of allied health professionals. The proposed Bill overlooks the definition and mention of dental auxiliaries.
Dentists are also supported by dental nurses, and as such India lacks a professional group of and recognised degree for dental nurses. As a result, several independent private institutions offer certificate courses for dental nursing but are not recognised either by the DCI or by the Indian Nursing Council, or in fact any other body.
The government has mooted a separate Bill – called the National Commission for Allied and HealthCare Professions Bill 2020 – to “provide for regulation and maintenance of standards of education and services by allied and healthcare professionals”. Unfortunately, it doesn’t recognise auxiliary workers in the dental profession either. It should.
Concentration of powers at the Centre
There is a provision for the election of DCI members under the Dentists Act 1948. But in the new Bill, members of the commission as well as the autonomous boards will have to be appointed by the Centre, based on the recommendations of a search committee also nominated by the Centre (sections 5 and 18). This will lead to the concentration of powers at the Centre.
Section 53 states that the “Central government [will] supersede the Commission” – which appears to be an effort to bring the NDC under the control of the Central government. So in case of a conflict against the NDC’s decision on a matter, the Centre will supersede the NDC.
This needs to be reconsidered as the Centre could exercise undue influence on the functioning of the regulatory body – which would be against the principle of devolution of powers.
The new Bill’s provisions focus on improving the quality of dental education in India. However, it overlooks some important components of dental practice. Increasing the number of dentists alone is unlikely to resolve the issue of their accessibility.
In addition, the new Bill doesn’t address geographical inequalities in the distribution of dental education as well as its professionals, the quality and cost of dental services, a private sector limited to urban geographies and, of course, patient safety.
We need to urgently resuscitate the dental profession and utilise India’s trained workforce for public welfare. The proposed Bill is an attempt in that direction – but it can be strengthened further by considering the issues highlighted above, especially those related to the practice of dentistry.
The draft National Dental Commission Bill was placed in the public domain in January 2020 for feedback. Since then, no other information has been available.
The author acknowledges the guidance of Dr Rajeev Sadanandan, Ms Pallavi Gupta and Mr Sunil Nandraj for their valuable feedback and comments.
Sonali Randhawa is a dentist by training and currently works as a research associate, Health Systems Governance at the Health Systems Transformation Platform, New Delhi. The views expressed here are personal.