Oral health is critical to people’s overall health, but a dire shortage of oral health practitioners in the public health sector means that many people are not getting the oral healthcare services they need.
Some dental practitioners such as Dr Bulela Vava says these chronic shortages, especially in provinces like the Eastern Cape, force dentists in the public health system to operate as “dental butcheries as opposed to oral healthcare centres”.Vava is the founder and national chairperson of the Public Oral Health Forum.
Oral healthcare is integrated into the primary health care package provided in the public health sector. As the rural and poor province that it is, the focus of the Eastern Cape should be on prevention, but it does not have more than 50 oral hygienists, says Vava. The Eastern Cape health sector is under immense pressure when it comes to oral and dental healthcare.
Owing to the lack of qualified staff, the provinces’ dentists have no time for restoration services or sophisticated processes other than pulling teeth, according to Vava.
But this situation is not limited to the Eastern Cape.Vava tells Spotlight that oral health patients across the country do not have access to the requisite services.
“With more than 6 000 registered dentists in the country, [fewer] than 2 000 of these practice in the public service, though the public healthcare system has the majority of the population. Even the 2 000 is not evenly distributed across the provinces. As usual, urban areas have the better share of dentists,” says Vava.
“The poor population in rural and peri-urban areas depend on a strained and under-resourced public health service for most of their oral healthcare needs. It becomes worse in the rural areas, as patients do not have access to the oral health services that they should have.
"The government is pushing for the National Health Insurance programme that will focus on providing primary healthcare to the citizens, but the current service delivery model focuses on curative as opposed to preventative and educational efforts.”
According to Vava, the challenges to access oral healthcare highlights the need for the successful implementation of primary oral healthcare, but with the shortage of oral hygienists and dental therapists, this becomes a challenge.
The shortage of qualified personnel can easily be felt both in rural and urban areas, as patients are struggling to access the most basic services such as preventative support. Without the required oral and dental health education, many people find themselves dealing with unpleasant consequences like tooth decay and gum diseases.
According to the Health Professions Council of South Africa’s (HPCSA) 2018/19 annual report, there are 6 374 dentists in South Africa serving a population of 59.6 million people. This translates into 9 350 people per dentist. The report states that the country has 4 325 dental assistants and 1 257 dental therapists.
According to the report the country has only 740 oral hygienists. A dental assistant is registered with the Professional Board for Dental Therapy and Oral Hygiene of the HPCSA and often works in dental practices, clinics, or hospitals where they help prepare patients and “assist in dentistry with regard to infection control, practice management and the education of patients, the public and the community regarding basic oral health”.
The Regulations relating to the scope of practice of the profession of oral hygiene gazetted in 2017, refers to an oral hygienist as a practitioner who can develop and implement oral health promotion programmes; assess and clinically examine patients’ oral health, take x-rays and make diagnoses on oral hygiene, and advise and educate patients about oral self-care.
The Regulations defining the scope of the profession of dentistry gazetted in 2009, defines a dentist as a practitioner who, among others, can physically examine, make diagnoses of oral diseases and injuries, perform dental procedures, and prescribing medicine to manage the oral health of a patient.
Health Department spokesperson Popo Maja tells Spotlight that there is indeed a shortage of dental practitioners for the entire public health sector, and the challenge is worse in rural areas.
"The shortage [resulted from] 80% of oral and dental health practitioners who prefer the private sector, making it difficult for the majority of citizens who are not on medical aid to access services,” he says.
"While there is a dire shortage of dental practitioners in the public sector, all oral and dental health services and specialities are offered at different primary healthcare facilities throughout the country.
"But the waiting list for none emergency services may be long depending on the provinces. It’s best for patients to check with their nearest clinic or hospital if oral health services are offered by the facility, or if you need to be referred to a facility that does.
"In some provinces there are mobile services to accommodate some communities," he says.
Maja could not confirm exactly how many registered dentists, dental assistants, dental therapists, and oral hygienists are available in the country. He referred Spotlight to the HPCSA.
Vava is convinced that patients do not have access to even 50% of the oral health services they are supposed to have access to because government opts for cheaper services.
“At a clinic in a regional hospital where a patient is expected to receive restorative services, it is just extraction every day. Unused dental supplies are expiring on healthcare facilities’ shelves because dentists are busy with extraction,” he said.
According to Vava, it is often cheaper to just extract teeth compared to restorative and preventative procedures. “Hence there are elderly people who have never visited a dentist in their lifetime. They are terrified of the dentist and don’t see the need for dental care unless they feel excruciating pain that forces them to consult a dentist.
"Our oral health system needs more dental hygienists to travel to under-serviced [sections of the] population to perform preventative education,” says Vava.
When Spotlight visited the dental clinic in Motherwell, it was Sinazo April’s (42) second visit to the clinic. Four years ago her tooth was extracted, and she developed an infection that made her wary of dental visits. She says pain forced her to return.
“Incessant pain drove me to the clinic though I did not want anything to do with this clinic owing to my previous experience,” she tells Spotlight.
April says she was not informed about whether or not the tooth can be saved, it was just extracted. Gcobisa Magwala (31) also visited the clinic with her eight-year-old son Aphiwe, who was suffering a toothache.
Magwala said the child’s tooth was extracted, and she wanted to have her own teeth cleaned at the same time but was told to make an appointment, which meant a two to three-month waiting time.
Magwala told Spotlight she doubts she will return to have that done. “But my boy was excited about consulting the dentist as it was his first time.
Everything went well. We didn’t experience anything untoward. The dentist was friendly.
A nurse who spoke to Spotlight on condition of anonymity, says that there is a dire need for dentists in areas such as Motherwell in the Nelson Mandela Bay metro. She says these shortages have been a problem for several years.
“Although the number of practising dentists at this clinic increased from two to three in recent years, it still doesn’t meet the demand. Motherwell is one of the fastest-growing townships in Nelson Mandela Bay and services neighbouring townships such as Wells Estate and Ikamvelihle, [all using] the same dental clinic,” she says.
Bring dental care to schools
“Oral health education is the integral component at all primary health care facilities,” says Professor Yusuf Osman of the faculty of dentistry at the University of the Western Cape.
“Employing an oral hygienist in all primary health care facilities will ensure that oral health becomes part of the general health system and that all patients visiting primary health care facilities will be screened for oral health conditions and are informed about how to practice good oral hygiene.”
Osman says the best approach to improve oral health is to bring dental care to schools to ensure that the burden of the disease does not continue into the future. “It is also important to seal the grooves of the first permanent molar soon after it erupts into the mouth.
"This prevents decay from setting in at the base of the groove in the tooth, but more importantly, it is the awareness of the tooth and its health in the mind of the child and the parent,” he says.
"It is critical to maintain optimal oral hygiene practices as a safeguard to general health because everything we eat has to pass through the mouth into our system.
"Therefore, it is critical to brush our teeth at least twice a day with a fluoridated toothpaste to ensure that we do not give the organisms in the mouth the opportunity to create the acidic environment that will result in tooth decay and periodontal disease.”
Osman says it is important to seal all permanent teeth.
“These sealants have proven to be the single most successful strategy internationally to halt the spread of dental decay. Children should be part of a teeth brushing programme at their schools that are managed by oral hygienists. Due to the economic situation, many children in our country do not have toothbrushes at their homes, but at least this way they will have a toothbrush at school.”
Without the required oral and dental health education, many people may find themselves dealing with unpleasant consequences like tooth decay and gum disease.
According to Osman, there are many organisms in a normal healthy mouth. “However, if for some reason the resistance of the person drops or if the organisms increase or change in nature, the consequences can be detrimental for the person.
"This is evident in cases of chronic and highly infectious conditions where the resistance of an individual is compromised, and it also happens in cases where the number and virulence of organisms are increased as in cases of poor oral hygiene, presence of grossly carious teeth, and periodontal disease," he says.
"Both these scenarios can result in debilitating oral lesions. This is further compounded in that everything we eat has to pass through the mouth into our system and this disturbed relationship between the organisms and our immune system passes on into our bodies with possible consequences in our entire body," he said.
Maja could not immediately answer Spotlight’s questions on the country’s oral health policy and oral health programmes in schools. Eastern Cape Department of Health spokesperson Sizwe Kupelo acknowledged receipt of Spotlight’s questions, but provided no further response.
*This article was produced by Spotlight – health journalism in the public interest.