125 years of developments in dentistry, 1880–2005 Part 2: Law and the dental profession

Introduction

As Sir Robert Bradlaw said in 1980: “It is fitting at this time that we should remember the fathers that begat us.”¹ In that spirit today's dental profession particularly needs to remember Sir John Tomes whose portrait and bust are displayed in the BDA's headquarters (Figs 1 and 2). We owe him a deep debt of gratitude. The name of Tomes is probably best known to practitioners because of the dentinal fibres named after him but he was an all-rounder: general practitioner, hospital dental surgeon, scientist and dental politician. Before the period under consideration Tomes had been a prime mover in the establishment by the Royal College of Surgeons of England of the Licence in Dental Surgery examinations and diploma. In 1878 he was involved in promoting through Parliament a Dentists Act for the registration of practitioners and establishment in 1879 of a Dentists Register which it was hoped would restrict the type of people able to practise dentistry. He was also a prime mover in the establishment in 1880 of the British Dental Association. Bradlaw said Tomes would be delighted to find a profession “united and self-regulating, with a well-established code of ethics and a strong sense of social purpose”; that the Government had established a National Health Service with the aim of a dental service for the whole population; and that dentistry is now a university discipline resulting in the award of a degree to surpass the royal college diploma for which he fought.

Figure 1

Sir John Tomes

Figure 2

The portrait of Sir John Tomes, displayed at the BDA premises

Dentistry in the Early 19th Century

A small number of people with medical or surgical diplomas from a Royal College of Surgeons or the Worshipful Society of Apothecaries practised dentistry as an appendage to their main professions. Others provided dental treatment as a sideline to their main business: barbers, wig-makers, blacksmiths, silversmiths or apothecaries. With an increased demand for treatment more of both groups began to practise dentistry exclusively. Established practices sometimes were passed from father to son, each generation training the next (Fig. 3). Some opportunists picked up the tricks of the trade as they went along but had little or no skills. Tales of malpractice abounded.

Figure 3

A Victorian dental practice proudly displaying notice of its services

Establishment of the dental profession

For a group to be considered as a profession it requires education, training, a code of ethics, regulation of its members by the control of entry and exit to a restricted list of practitioners and publication of scientific journals. Dentists started to follow that path from the mid-1850s before which there was no profession.² Tensions grew between various factions. By their very background and geography many London surgeons practising dentistry wanted to be associated with the Royal College of Surgeons of England. In 1856 they formed the Odontological Society of London sought for that college to award an LDS diploma and established the [later Royal] Dental Hospital of London in 1858 and its London School of Dental Surgery in the following year.

Others, preferring the profession to develop without the surgical college's influence, formed a College of Dentists of England with its own training programme. They instituted a membership qualification – the MCDE – and founded the Metropolitan School of Dental Science, which opened its doors four days after the Dental Hospital of London commenced its activities. However the College failed to make adequate arrangements for their students to obtain clinical experience until 1861, when the National Dental Hospital was opened in London's Tottenham Court Road.³ Before then some experience was provided at the Westminster Dispensary in Soho. Through the efforts of Tomes and his colleagues the LDS was established by the Royal College of Surgeons, with the first 43 people gaining the diploma in 1860. From then the College of Dentists no longer had a purpose so merged with the Odontological Society in 1863 to form the Odontological Society of Great Britain. It became an important focus for dental science and learning through its meetings and published Transactions but remained aloof from dental politics. In 1907 it joined fourteen other medical and surgical societies to become the Section of Odontology of the Royal Society of Medicine.

The 1878 act and the struggle for registration

In 1872 the Monthly Review of Dental Surgery suggested the need for a British Dental Association similar to the British Medical Association and the organisation for dentists in the USA. It wanted groups set up around the country to act as branches of a new dental association with a London-based coordinating office.

An 1875 meeting with Charles James Fox in the chair set out to unite the profession. There was opposition from the ultra-conservative Association of Surgeons Practising Dentistry which consisted of fellows and members of the English surgical college who wanted to remain separate from other dental practitioners. Nevertheless Fox and his colleagues established what later became the Dental Reform Committee chaired by Samuel Cartwright. Strangely he was also president of the Association of Surgeons Practising Dentistry and of the Odontological Society.

Once a number of practitioners had gained an LDS the Reform Committee wanted to restrict dental practice to similarly qualified people. They fought to exclude everyone else by pressing members of parliament to introduce restrictive legislation. In November 1876 the committee produced draft legislation which suggested: only qualified people could call themselves 'dental surgeon', 'surgeon dentist' or 'dental practitioner'; others would be fined if they used these titles; a register of the names of qualified dentists would be compiled; only listed dentists would be able to legally recover fees. It meant that practitioners of dentistry with a surgical or medical qualification but not an LDS would be excluded. Not surprisingly the Association of Surgeons was not pleased. In return it used its influence with the surgical college to make it more difficult for people to enter the LDS examination. The Reform Committee stepped up its activities and Tomes became chairman. In 1877 its members learned of action outside London. There were plans to build a dental school in Dublin, proposals for the Royal College of Surgeons in Ireland to establish a new LDS (Fig 4) and petitions to the Edinburgh College. Further qualifications were not welcomed by doctors. In 1882 the Medical Press and Circular referred to the “unrestricted sale of licenses in dental surgery to ignorant persons which is now being carried on by the Colleges of Surgeons of Edinburgh and Dublin and the Faculty of Physicians and Surgeons of Glasgow”.

Figure 4

An early LDS diploma from the Royal College of Ireland

The actions of the Dental Reform Committee resulted in passage of the 1878 Dentists Act (“To amend the Law relating to Dental Practitioners”) and establishment in the following year of the first Dentists Register, (Fig 5) which was held by the General Council of Medical Education and Registration (the GMC). The Dentists Act was “to amend the Law relating to Dental Practitioners”. It stated: “A person shall not be entitled to take the name or title of 'dentist' (alone or in connection with any other word) or of 'dental practitioner' or any name, title, additional description implying he is registered under the Act, or that he is a person specially qualified to practice dentistry, unless he is registered under this Act.” The only exceptions were registered medical practitioners.

Figure 5

An early Dentists Register

Most practitioners listed in the Register were qualified (Table 1). However people who could prove they were already involved in the bona fide practice of dentistry alone or in conjunction with medicine, surgery or pharmacy could also register.

Table 1 Practitioners listed in the 1879 Dentists Register

John Tomes felt that dentistry should be represented on the GMC. In 1882 he sought support from the BDA but its AGM did not support him. It was not until a petition in 1898 from R T Stack, J H Mummery and W B Paterson to the Privy Council that it nominated Charles Tomes as a Crown Nominee to the GMC. He took his seat on 27 May. Tomes had previously acted as the GMC inspector of the dental examinations set by the four bodies awarding qualifications.

The 1878 Act included protection of the titles dentist, dental practitioner or anything else which implied they were registered under the Act or were specifically qualified to practise dentistry. There were many attempts to get round it. 1884 saw the first successful prosecution against someone for unlawful use of the title LDS.

The British Dental Association

Having succeeded in getting a Dentists Register in 1879 the Dental Reform Committee then set its sights on the establishment of a British Dental Association. This happened in the following year when members of the committee became the first representative board, with John Tomes as the first BDA president. However the association remained divisive; only registered dentists could become members. The BDA was to have political, educational and social activities. The first role consumed much time and effort, for example in campaigning against the many unqualified people who continued to practise. Time was also taken up in instituting legal proceedings against such practitioners. To its horror the BDA found the 1878 Act did not preclude actual practice, only the use of the titles dentist and dental practitioner.

The society of extractors and adaptors of teeth

This society was founded in 1892 to represent unregistered practitioners who were not allowed to become members of the BDA. The title was carefully chosen to avoid words forbidden by the Dentists Act. Over the years there were many battles between its members and the BDA. In 1909 the House of Lords confirmed in the case of Bellerby versus Heyworth and Bowen that the actual practice of dentistry by non-registered practitioners was not illegal; nor was use of the word 'dental'. The society immediately changed its name to the Incorporated Dental Society.

When dental treatment became available for some insured people from 1922 under the 1911 National Insurance Scheme any practitioner on a 'panel' list could provide treatment whether qualified or not. It seemed sensible to some dentists that the BDA should admit all registered dentists but the majority of its members wanted only qualified practitioners. In view of the potential for dangerous rivalry it seemed reasonable to some people that a working relationship should be established. As a result a Public Dental Services Association was formed, open to all practitioners.

Unqualified practice and the 1921 act

Over the years there was concern about the dangers arising from dental treatment by unqualified practitioners. In 1917 a committee chaired by Francis Dyke Acland was established to examine the “extent and gravity of the evils connected with the practice of dentistry and dental surgery by persons not qualified under the Dentists Act”. Its report published two years later⁴ indicated a major problem and recommended that unregistered people should be banned from practice. As a result parliament passed a new Dentists Act which made dentistry into a closed profession, restricting practice only to qualified and registered dentists.

The Dental Board of the United Kingdom was established as a sub-committee of the GMC, with responsibility for maintenance of the Register. Acland was its first chairman.

The 1956 dentists act and self-government

The introduction of NHS dental services in 1948 imposed a need for practitioners providing care to negotiate with government over the terms and conditions, including payment for services. It became obvious that the three major dental organisations had to work together to prevent them from being played off against each other. As a result 1950 saw a merger between the BDA, IDS and PDSA to form an enlarged British Dental Association which at long last represented the whole profession.

In 1943 the government established an inter-departmental committee chaired by Lord Teviot to consider the place of dentistry in a possible national health service. His final report in 1946 recommended, with the support of the Dental Board and the GMC, that it was time for the profession to become self-governing.⁵ There were a number of attempts to take forward that proposal. At the time of discussions in Parliament the BDA stressed that a new Dental Council rather than the Ministry of Health should control the provision of 'minor dental work' by any ancillary workers. From 1950 the BDA strenuously opposed any ideas of extending the role of such personnel.

It took until a new Dentists Act in 1956 before dentistry could be established as a self-governing profession, with a General Dental Council separate from the GMC. It was a major step forward. The first President was Sir Wilfred Fish, the last President of the Dental Board. At the time there was a severe manpower shortage. Because of a lack of dentists treating children one of the first actions imposed on the GDC by the Privy Council was to see what might be done. As a result a group visited New Zealand to report on the work of its school dental nurses. They found their training was deliberately divorced from that of dental undergraduates and made the direct responsibility of the Ministry of Health. They were told the aim was to emphasise that they are auxiliaries and to foster a high esprit de corps. By 1950 there had not been a single complaint of illegal practice. They were convinced the success of the scheme had been demonstrated. It had satisfied a need which probably could not have been met adequately in a “more orthodox way”. Although the Mission refrained from expressing an opinion the BDJ asked “would the NZ scheme, or any modification of it, be equally successful in this country?” And “would the dental profession be prepared to cooperate in putting such a scheme into operation?”

Following the report of the UK Mission⁶ the GDC was mandated to evaluate the use of dental auxiliaries (later renamed therapists) in the treatment of children. It thus established a school to train dental auxiliaries at New Cross Hospital in Lewisham. The New Cross Scheme had a committee of management which related directly to the Department of Health and Social Security and not to a dental school.

Legislation on dentistry was consolidated into a 1957 Dentists Act. A Dentists (Amendment) Act 1973 and the 1957 Act were revoked by the Dentists Act 1984 which modified the constitution and powers of the GDC. The Dental Qualifications (EEC) Recognition Order 1980 took on board the implications for undergraduate and postgraduate education plus specialisation of EEC/EU legislation.

The European union and dentistry

The 1958 Treaty of Rome established the European Economic Community (later the European Union). It allowed the free movement of people, goods and services between the member states. The United Kingdom became a member in 1973. Article 57(1) of the Treaty provides that directives be issued for the mutual recognition of diplomas, certificates and other evidence of formal qualifications. 1976 saw the issue of the first Medical Directives, followed in 1980 by Dental Directives.

Undergraduate training

A 1978 European Council directive 78/687/EEC harmonised the training of students on at least a five year full-time course of theoretical and practical instruction at a university or at a higher education institution recognised as having equivalent status or under the supervision of a university. The subjects are defined. At the same time 78/686 ensured the mutual recognition of diplomas, certificates and other evidence of the formal qualifications of practitioners of dentistry. Together they ensured free movement so dentists could work throughout the EU.

The Eu and specialisation

The 1978 Directive 78/686 recognised oral surgery and orthodontics as European dental specialties. Specialist training must take at least three years. The resultant Certificate of Completion of Specialist Training is recognised in all the countries having that specialty.

In 1988 the General Dental Council (Distinctive Branches of Dentistry) Regulations allowed the GDC to establish a number of specialties: oral surgery, surgical dentistry, orthodontics, paediatric dentistry, restorative dentistry, endodontics, periodontics, prosthodontics, dental public health, oral medicine, oral pathology, oral microbiology, and dental and maxillofacial radiology.

In 1989 oral and maxillofacial surgery was recognised as a joint dental and medical speciality, most medical specialities having been recognised in 1975. It is on a GMC rather than a GDC list.

It was clear to the GDC and the Department of Health that the whole question of specialist recognition and training needed to be examined. It resulted in a report by Brian Mouatt, the Department's chief dental officer.⁷ The Mouatt report has led to many changes.