doi:10.1038/nindia.2017.27 Published online 17 March 2017
• Dental workforce should compose of different types of care providers
• Appropriate mix of care providers in dental care service system.
• Enhancing dental care service in underserved areas and population groups.
China’s population is more than 1.3 billion and approximately half of it is rural1. Its mainland comprises 31 provinces, autonomous regions and municipalities directly under the central government in Beijing. Basic healthcare is provided according to a three-level network using a primary healthcare approach2. The first of the three-level administrative units in China are the cities (in urban areas) and counties (in rural areas). In the second level are districts (in cities) and townships (in counties). At the lowest level are the streets (in city districts) and villages (under townships).
General and dental healthcare services in China are predominantly provided in the public sector. Most dental clinics are established by the government in general hospitals and larger out-patient clinics in urban areas at the city and district levels, and in rural areas at the county and township levels. Dental clinics at the village level are not common. In the major general hospitals, there is usually a department of stomatology (dentistry) with in-patient facilities. Speciality stomatological (dental) hospitals with in-patient wards may be found in larger cities. Recently, the number of private dental clinics have been increasing, mostly in large cities.
In 2013, there were 137,000 dentists in China, with a dentist to population ratio of approximately 1:10, 0003. Dentistry degree courses are offered by more than 80 universities and graduates can provide the full range of general dental care services independently. They can also specialize after postgraduate clinical training. As well as university-trained dentists, China has an equal number of assistant (mid-level) dentists. Diploma dentistry courses of three to four years are offered at around 100 training schools across the country. Assistant dentists can practise independently, and usually work in government dental clinics at the county and township levels. They can provide a range of services similar to that of university-trained dentists, but rarely perform maxillo-facial surgery. Assistant dentists are also required to register with the local health authority and national licensing examinations are held regularly. China does not have recognized auxiliary dental care operators, such as dental therapists or hygienists.
Fully trained healthcare professionals such as dentists tend to stay in urban areas, especially large cities and this is likely to lead to inequality of access to care between geographic regions and among different socio-economic groups. The establishment of a category of assistant dentist is quite unique in China and was primarily to address demand for staff in the large number of dental clinics, especially in rural areas and at the lower administrative levels. Usually, assistant dentists are not supervised by more senior colleagues, because there are relatively very few dentists working in these clinics. Although they are only trained to provide common general care services, such as prevention, scaling, fillings, tooth extraction, and prosthesis (false teeth), they largely meet the needs of the people. Assistant dentists greatly improve accessibility of services in the disadvantaged areas and populations of China. This also helps reduce the cost of dental care services.
Findings of the third Chinese National Oral Health Survey conducted in 2005 show that although there were differences in the level of dental caries (measured by the number of decayed, missing or filled teeth - DMFT) and proportion of untreated decay (measured by DT/ DMFT) between urban and rural dwellers, the discrepancy was not large (Table 1)4. The proportion of untreated dental caries was 20-40% in adults and over 80% in children, which may indicate that the provision of dental services was inadequate for the population, especially in children.
There is a need in China for more dental care programmes with a strong prevention element and simple treatments for school and preschool children. To reduce access barriers, these dental programmes could be implemented in kindergartens and schools, and should make good use of dental auxiliary personnel and other healthcare providers.
Besides tooth decay, periodontal (gum) diseases are prevalent among Chinese adults. In the 2005 National Oral Health Survey, more than 70% of 35-44 year-olds had bleeding gums and around half of the middle-aged had periodontal pockets4. The periodontal health status in the 65-74 year olds was worse. Whether the two oral diseases prevalent in China — dental caries and periodontal diseases — can be managed by increasing the number of assistant dentists, or whether there is a need for other types of auxiliary personnel (such as therapists and hygienists) should be investigated.
A modern dental workforce should feature various types of care providers and an appropriate mix should be utilized in different situations. Attention should be paid to enhance the provision of dental care service to the underserved areas and population groups, so as to reduce oral health inequality and dental care access.
1Professor, Faculty of Dentistry, University of Hong Kong, Hong Kong (firstname.lastname@example.org).
1. National Bureau of Statistics of China. China Statistical Yearbook 2014. Beijing: China Acad. J. Electronic Publishing House(2015)
2. Hillier, S. & Shen, J. Healthcare systems in transition: People’s Republic of China. Part I: An overview of China’s healthcare system. J. Public Health Med. 18, 258-65 (1996)
3. Zheng, J. W. et al. Current undergraduate and postgraduate dental education in China. J. Dent. Educ. 77, 72-78 (2013)
4. Qi, X. Report of the third national oral health survey in China. Beijing: Publishing House of People’s Health (2008)