Registration of dentists

As pointed out by Gelbier this month in the BDJ,¹ by the early twentieth century, there were many reasons for seeking a replacement for the 1878 Dentists Act, the first such Act of Parliament. Victorian dentists who were qualified and registered thought that the Act prevented the practice of dentistry by other people but they were proved to be wrong. As long as there was no suggestion that the practitioner was qualified and did not use the term 'dental surgeon' or 'dental surgery', there was no legal comeback. That phraseology alone allowed many people to practise dentistry without registration. Others simply ignored the legislation's wording.

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In the 1919 report of a committee appointed by the Lord President of Council to examine the extent and gravity of the terrible problems associated with the practice of dentistry and dental surgery by people not qualified under the Dentists Act,² it showed some of the titles listed by the British Dental Association (BDA) which had been used by non-qualified practitioners: Dental specialist, Dental consultant, Dental expert, Specialist in operative and prosthetic dentistry, Odontologist, Teeth specialist, Expert in modern dentistry, Expert in the science of teeth treatment, Expert in dental surgery, Dental specialist of Anglo-American reputation, Exponent of modern dentistry, Greatest expert in crown, bridge and barwork, Finished expert, Dental operator, Dental pioneer, Expert adapter of teeth, Dental Institute, English and American dentistry and Modern dentistry.

As a result, the BDA, which represented qualified and registered dentists, brought prosecutions. The first was in 1884 over the complex recognition of overseas qualifications. The second prosecution was against a practitioner for using the title of dentist without qualification.³

It is estimated that between 1884 and 1900, the BDA prosecuted 62 people, 55 successfully for using restricted titles or having posed as being specially qualified.⁴ Unfortunately, prosecutions were costly and cumbersome to the Association.

By the time the government committee began its investigations in 1917, the BDA had ample evidence to present. It cited five important cases from five courts.

Maidstone County Court (25 September 1909): £14 10s damages against G. C. Smith for negligence, inflammation of the mouth and tooth broken off. Smith had already been fined twice for calling himself a dentist. He then turned himself into a limited company and then, when an injunction against the company was obtained by the BDA, he again called himself a dentist. The judge drew attention to the disgraceful state of affairs disclosed by the evidence.

Cardiff County Court (6 January 1910): £11 damages against Templar Malins for negligence and excessive bleeding. Defendant stated he extracted 500 teeth a week.

Clerkenwell County Court (2 December 1910): £20 damages and costs against Williams' Dental Institute, King's Cross. Tooth broken, socket of gum crushed, gum and roof of mouth with wounds.

Hull County Court (BDJ 1912; 33): £15 damages against T. H. Jubb for unskillful treatment. Fourteen teeth were broken by the operator leaving nerves exposed. The operator was 21 years of age and had never attended any hospitals or lectures on dentistry. He had often extracted 14 teeth at a time. The judge stated there was serious negligence.

Glasgow Sheriff's Court (BDJ 1915; 36: 191): A. Murray recovered £50 damages and expenses against R. B. Mackie. Jaw bone broken, septic poisoning and haemorrhage. The defendant displayed the words dental surgery on the stair outside his rooms and dental rooms on the door. The claimant did not know the defender was unqualified. The defender appealed and failed.

The BDA summarised some of the frequent consequences of unqualified and unskilled practice: injuries to the mouth and jaws; teeth broken or snapped off; septic poisoning from neglect or ignorance of antiseptic methods; evidence of unnecessary violence; great discomfort from ill-fitting dentures and the consequent impossibility of adequate mastication of food, with a prejudicial effect on health; sound teeth frequently needlessly extracted and replaced by false ones; frequent cocaine poisoning; and not uncommon death from the unskillful administration of anaesthetics.

Moreover, the practice of injecting local anaesthetics such as cocaine and other dangerous drugs into the gums gave rise to cases of poisoning. This was because instruments were not properly sterilised, leading to the transmission of disease from one patient to another.

The use of bad materials was frequently complained about, particularly in cases brought about against dental corporates.

Mr T. A. Coysh, Chairman of the BDA Penal Cases Committee, gave evidence to the committee on the use of canvassing by unscrupulous operators. This was supported by evidence from Mr Richardson, Chairman of the Northern Counties branch and a surgeon at Newcastle Dental Hospital. As well as giving instances of personal injuries seen in the hospital from malpractice, the latter highlighted the position of canvassing in his area: 'I can cite the names and address of men who were drillers and turners and butchers at the outbreak of war, who today are doing what are tantamount to major operations upon the public. The man I am especially citing employed within two months 20 canvassers. They were drawn from the lowest types of workmen, such as casual labourers and so on. Six of those canvassers in my own area, within two months were going about with a bag full of instruments operating on people in their own homes'.

He said the practice in vogue in the north was for a canvasser to go round with a canvass operator, a man who has been a canvasser previously. They usually travelled together. The canvasser called at the houses to ask whether the tenants needed teeth extracted or supplied. In the meantime, the operator was operating at another house. The canvasser watched the operator and in the course of two or three weeks himself became an operator-canvasser. Usually, they hunted in pairs for the first three months.

The practice of injecting local anaesthetics such as cocaine gave rise to cases of poisoning.

The Association considered these cases as evidence and symptomatic of a very large amount of bodily injury, suffering and pecuniary loss caused by unregistered persons practising dentistry.

It was not only the BDA which gave evidence to the committee. It heard from 27 medical and dental witnesses. The British Medical Association (BMA) presented the results of a survey of its 69 branches and regions and 1,600 medical officers. In response to its first question, 'Is it your opinion that it is the usual practice of unqualified dentists to extract teeth and provide artificial dentures instead of undertaking conservative dentistry?',67 of the 73 respondents said that non-formally qualified practitioners did not undertake conservative dentistry. One said: 'when they attempt conservative dentistry, unqualified men have no knowledge of treating the pulp and frequently the result is alveolar abscess or septic infection. A case of rheumatoid arthritis was quoted where several teeth had been filled by an unqualified man; pulp had necrosed and constituted a septic focus which almost certainly was the determining factor in the production of the arthritis'.

When asked to 'State evils known by you to arise out of the effects of inferior dentistry and the loss of natural dentition',the overwhelming response was the production of chronic gastritis and indigestion with consequent defective nutrition. Also listed were severe sepsis, haemorrhage, necrosis, fracture, dislocation and non-diagnosis of empyema of the antrum. Others highlighted were the loss in economic value of workers with poor oral health, especially women engaged in domestic or factory work and nursing mothers.

The committee summarised the problems and grave evils associated with the illegal practice of dentistry:

• Lowering the social status and public esteem of the dental profession

• A great shortage of registered dentists owing to the unattractiveness of the profession which has intensified since the war

• Inability by the general public to distinguish between a registered and unregistered practitioner

• The dental treatment of the public being largely in the hands of uneducated, untrained and unskilled persons

• Grave personal injury owing to lack of skill and technical knowledge

• Extractions of sound or slightly decayed teeth

• Application of artificial teeth over decayed stumps into septic mouths

• The existence in the public mind that there is no advantage in preserving the natural teeth, and that the correct thing is to let them decay and when trouble arises have all the teeth out and substitute a plate of false ones.

The committee said the state could not afford to allow the health of the workers to be continuously undermined by dental neglect, so immediate steps should be taken to recognise dentistry as one of the chief means for preventing ill health. Every possible means should be employed to enlighten the public about the need for conservative treatment. The dental profession should be treated as outposts of preventive medicine and, as such, encouraged and assisted by the state. Treatment should be made available for all needing it.

The committee recommended an alteration in the law to secure the prohibition of the practice of dentistry by unregistered persons. As a result, a new Dentists Act was passed on 28 July 1921 and registration of all practitioners became compulsory.