Every year has significant anniversaries. 2018 has two of national importance: 100 years since the formation of the Royal Air Force (RAF) and 70 years since the start of the National Health Service (NHS). Just as significant to dental hygienists are two other anniversaries, the completion of the first dental hygienist course in the UK 75 years ago and the 60 year anniversary of permitted duties for the dental hygienist being defined by the General Dental Council (GDC). And the connection between all these anniversaries? It was the RAF which inaugurated the first hygiene training course for a group of dental professionals who have made such a contribution to the RAF, to the health service and to the wider dental team.

Credit: ©Sean Gladwell/Moment/Getty Images Plus

The first dental hygienist course was held at Sidmouth Devon. The dental historian Stanley Gelbier1 has alluded to the impact of war on this development:

‘wars greatly influenced the establishment of children's and hospital dental services, dental hygienists and dentistry in the NHS’.

In the RAF dental fitness was essential.

‘In the service it is essential that everyone should be made dentally fit and that dental fitness if maintained. This is necessary to assure efficiency and accuracy and so avoid the wastage of man hours’. 2

Acute necrotising gingivitis and dental sepsis were major issues for all three services during World War II. In the RAF it became noticeable that many operational flying hours, as well as engineering and administrative support was being lost due to these debilitating conditions.

In 1942, Sir William Kelsey-Fry, civilian consultant to the Royal Air Force, wrote to the Director of Dental Services. He suggested that dental hygienists should be employed to help alleviate the problems of acute necrotising gingivitis and dental sepsis in the neglected mouths of young men who had little knowledge of basic oral hygiene procedures. ‘As through education this type of gross dental disease was preventable.3

Sir William was both a doctor and a dentist, served in World War I and gained a Military Cross for providing care at the front line. Injured during WWI, he returned to England and along with Gillies (an ear, nose and throat surgeon), pioneered plastic and oral surgery. Sir William went on to become the first President of the British Dental Hygienist Association (BDHA) which formed in 1949.4

The concept of dental hygienists was not new. We know from the Nuffield Foundation Report (1993)5 that University College Hospital in London had piloted a scheme in 1928 to train dental ancillaries. It was later abandoned, largely due to pressure from within the dental profession. An amendment to the Dentists Act (1921) in 1932 described the work that could be carried out by a dental ancillary as ‘scaling and polishing tooth surfaces’, a definition that became embedded within our doctrine. The strict definition was to address the training of the Derbyshire dressers (so-called because their role was instigated by Derbyshire local education authority) who worked in a small number of school dental services, carrying out dental health education and simple restorations on children. The employment of such ancillaries would be limited to the public and charitable services with private dental practices excluded.6 Although supported in many areas, the work of the Derbyshire Dressers was finally curtailed by the 1932 amendment to the Dentists Act. It was clear that for the foreseeable future, any ancillary role would be limited to scaling and polishing.7

Bowdler Hendry8 confirmed in the British Medical Journal the importance of dental hygienists and described how he was part of the 1928 experiment that would see dental hygienists only working in civil (charitable) practices. He outlined that for many years he employed a female dental surgeon just to treat gum disease and he went on give credit to the Royal Air Force for taking forward this cost-effective step.

The trial scheme for the training of dental hygienists suggested by Kelsey-Fry was initiated at the RAF Medical Training Establishment at Sidmouth in Devon, based on the training pioneered by Fones in the United States during 1913.9

Credit: Commentative plaque placed at Glenside (a care home) Sidmouth in 1993 celebrating the first UK Dental Hygienist training school. Instigated by Air Commodore Noel James who in 1993 was Principal of the Dental Office Royal Air Force Support Command.

Specially selected dental clerk orderlies (dental nurses) completed sixteen weeks training which enabled them to scale and polish teeth and most importantly, they were trained to educate patients to prevent dental disease.10

Squadron Leader James Smith was largely responsible for the training along with a young RAF volunteer reserve dentist, Flight Lieutenant Gerald Leatherman, who led the move of the school of dental hygienist training to the RAF Dental Training Establishment Halton in 1945 and was to become the second president of British Dental Hygienists Association (BDHA). He went on to champion the role of the Dental Hygienists in the United Kingdom, well into the 1980s. In 1994 BDHA in recognition of his life time commitment to the dental hygienist profession introduced the Doctor Leatherman award11 which recognizes the outstanding commitment to the dental hygienist (and now dental hygienist / therapist) profession.

In the post war years, tremendous interest was shown by the dental profession and the Ministry of Health into the introduction of dental hygienists into the RAF dental team. As the initial training was governed by the RAF, students qualified with the title dental hygienist as a trade indicator. No formal qualification was awarded by an educational or dental board. It was not until 1961 that RAF (and Army) dental hygienists undertook final examinations that permitted them to register with the GDC. This aligned them with those who trained at the small number of dental hospitals now providing dental hygienist training funded by the Ministry of Health.12

Credit: Derbyshire dressers

A review of the correspondence between the military and the GDC reveals the reason for the delay in the development of the dental hygienist between 1958 and 1961: the GDC had concerns over male dental hygienists being enrolled on the GDC register, questioning whether it was an appropriate profession for a man!

By the late forties the RAF training had developed into a nine-month programme, which was to be adopted by the General Dental Council when it was set up in 1956.13 This training programme formed the basis of the permitted duties that would be defined in 1958.

Meanwhile, military interest and pressure from dentists in the field of dental health led the government to sponsor a trial training scheme at the Eastman Dental Hospital in London between 1949 and 195414. Although in line with the recommendations made in the Dentists Act 1921 their employment was still restricted to the public sector, and not privately-owned practices, even though they would provide treatment on behalf of the emerging National Health Service.

Hansard15 states that the government of the day were so concerned about the recruitment of dentists to the school dental service they advocated the employment of dental hygienists to ensure school children had better access to dental care, working as part of a team under the direction of a dentist. It was felt by some that this was a dilution of the care provided and the employment of the dental hygienist would only be a temporary measure. Baird, the Member of Parliament for Wolverhampton North East outlined:16

As a professional man I agree that it is always doubtful to dilute a profession in any way, but if we limit this dilution to the treatment of school children, under the supervision all the time of qualified dental surgeons, it will not do very much harm. We therefore have to look at the question of dental hygienists in the school dental service very seriously as a help to solving our temporary problem.

During 1952 a new Dental Bill was introduced which included recommendations to regulate the work of ancillaries in dentistry; it was abandoned after its first hearing in the House of Commons. The objections were due to the potential introduction of dental auxiliaries based on the New Zealand dental nurse model (dental therapists of today) who like the dental dressers of the 1920's carried out simple restorative treatment on children.17

Continued debate took place between the Ministry of Health, the Dental Board and dentists both for and against the expansion of the use of dental hygienists. The House of Commons passed a resolution approving draft Ancillary Dental Workers Regulations to be made by the General Dental Council under the Dentists Act.18

For many members of parliament the regulations still did not go far enough: they welcomed the expansion of the employment of dental hygienists into general dental practice, but still felt that their role should include simple fillings.

Further debate took place between the Ministry of Health, the Dental Board and Dentists both for and against the expansion of the use of dental hygienists. It was hoped that the passing of the Dentists Act 1956 would contain reference to the introduction of an expansion of dental hygienist training and their employment outside of the public sector dental services. The Act contained no reference to Dental Ancillary workers. However, it is reported that;

General Dental Council had been asked by central government on Feb 5 to review their draft regulations made in the 1956 Dentists Act, in order that dental hygienists would be enabled to work in general dental practice under proper supervision

British Dental Journal (March 1957) 19

The British Dental Journal further reports that lively debate took place in Parliament for the support of dental hygienists! The speaker outlined that

Dentists would not be allowed to circumvent the Act, as dental hygienists could make a valuable contribution to dental health if they could be used as widely as possible. The minster said that he had asked the General Dental Council to give further consideration to their draft regulations in the light of the known intentions of parliament and he hoped no further difficulty would arise.

British Dental Journal (April 1957) 20

Credit: First hygienist course Sidmouth 1943

This was supported across all divisions of the House. Hansard reported that during the Dentists Shortage debate on 8 March there was overwhelming support for the ‘proper training and employment of ancillary dental workers.21 As highlighted in the British Dental Journal22 on the 10 July the House of Commons passed a resolution approving draft Ancillary Dental Workers Regulations to be made by the General Dental Council under the Dentists Act.

The Dentists Act 1957 was successfully passed and through it the Ancillary Dental Workers Regulations 1957 were introduced. This laid down for the first time in law the role and responsibilities of the Dental Hygienist which were:

Dental Hygienists are permitted to carry out dental work of the following kinds under the direction of a registered dentist who has examined the patient and has indicated the course of treatment to be provided:

  • a. cleaning and polishing teeth

  • b. scaling teeth (that is to say the removal of tarter, deposits. accretions and stains from those parts of the surface of the teeth which are exposed, or which are directly beneath the free margins of the gums, including the application of medicaments appropriate thereto)

  • c. the application to the teeth of solutions of sodium or stannous fluoride or such other similar prophylactic solutions as the Council from time to time may determine

  • d. giving advice within the meaning of subsection (1) of section thirty-three of the Dentists Act 1957 on matters relating to oral hygiene.

Statutory Instrument 1423 23

The direction of a dentist indicated that in general dental practice a registered dentist must be in the premises when the dental hygienist was working. Dental hygienists working in the community dental service and the armed forces were not subjected to this ruling.24

The Dentists Act 1957 lead to the General Dental Council becoming the regulating body for dental hygienists through the Central Examination Body for Dental Hygienists, who then awarded, set and monitor standards for dental hygienists training and examinations. The General Dental Council set up a Role of Dental Hygienists on which all practicing dental hygienists must have their names entered by the 31st January each year.

In May 1958 the General Dental Council issued the first recommendations concerning courses of instruction for dental hygienists.25 Dental hygienists initially trained for a period of no less than nine months and qualified with a Certificate of Proficiency in Oral Hygiene. This entitled them to register with the General Dental Council in order that they may practice as a dental hygienist in accordance with the Dentists Act. In doing so it made the term Dental Hygienist a protected title in law.

The Dentist Act 1957 also laid down the foundations for Dental Auxiliary training to begin in the United Kingdom. Rowbotham et al26 defines how the dental auxiliaries school at New Cross became the only such school in the United Kingdom opening in 1959, training dental auxiliaries specifically for the school and hospital dental school. Hansard (1978)27 defines the change of title of a dental axillary to a dental therapist.

Although it's 75 years since the first dental hygienists in the United Kingdom began to practice as a war time initiative, the debate for their future regulation began 60 years ago, supported by the Ministry of Health, to help meet the treatment needs of the surge of patients now seeking NHS dental care.

While the focus of 100 years of the Royal Air Force its place in aviation and military history we should not lose sight of the fact that it also laid the foundations for the development of the modern dental team. It was the initiative of the RAF to train the first dental hygienists which in turn gave rise to the introduction of dental therapists. We owe much to those early pioneers!

Michael Wheeler is an RAF trained dental hygienist, an honorary senior lecturer at the University of Kent and an HEE programme manager