the school dental service is low (0.04 surfaces per child). -The introduction of radiographs into the school dental service would help to determine the timing of the treatment of carious lesions, but would not result in a large reduction of the rate of pulpal involvement. Another important facet of the service is the system of consultation and referral to private dentists. With this type of back-up support, the dental nurse need not attempt complex procedures. Private dentists have close working relationships with the dental nurses in that they treat children who require their higher professional skills. At the same time, they are relieved of the burden of routine pedodontic care. Also, private dentists participate in the government's dental care program through the Adolescent Dental Service. This cooperative program has been so successful that it has achieved complete acceptance by the New Zealand dental profession. Personal observations These on-site observations were made during a three-week visit to New Zealand in March-April 1971. Because so much already had been written on the subject, the objective was to photograph the program in action so that it might be brought more vividly to the attention of the American dental profession. The opportunity to study the organization and administration of the school dental service firsthand was not overlooked. I had read much of the literature on this subject, and, therefore, anticipated favorable impressions; in this regard, there were few disappointments. Some observations were unexpected: in particular, the tight administrative controls and slow process of change in the serviceaspects usually associated with more conservative programs. I visited three dental nurse training schools in addition to many field clinics of primary schools in large and small cities. I was accompanied by either a principal dental officer or a senior dental officer. A schedule had not been preplanned, and selection of schools usually was made on the day of the visit, without prior notification of dental nurses. The dental division of the New Zealand Department of Health provided an opportunity to survey any clinic, with obvious confidence that impressions would be favorable. For example, one visit was to a small school in a poor community without a dental nurse field clinic. Children were examined and their teeth were photographed in the classroom. These youngsters were taken for treatment by bus to another school, five miles away, that had a field clinic. Thus, there were no model clinics to observe, no special success stories to impress foreign visitors. The uniformity of the experience was complete, in terms of the program's accomplishments and limitations. I was immediately impressed with the aura of serenity and beauty surrounding the servicethe orderly calm noted by others. Even more impressive is the conservatism of the service. Although the program represents a radical departure from conventional dental practice, it has changed little since its establishment. Of course, foot-treadle dental drills have been replaced by electric motors. Many intermediate school clinics have hydraulic pump chairs, although most units consist of adjustable wooden chairs. Because compressed air is unavailable, the dental nurses must use bulb syringes to dry teeth. Despite these and other limitations in equipment, the technical quality of treatment, as evidenced by the preservation of natural teeth, is quite high. Many of the silver amalgam restorations in permanent teeth look like textbook illustrations. They are highly polished, properly extended, and smoothly carved. The cavosurface margins are scarcely perceptible and contact points are firm. The unpolished copper amalgam restorations in deciduous teeth are not as pretty; they are flat and lack anatomic carving. But the teeth are there! In fact, no first permanent molars were missing in the 100 children whose mouths were photographed. The only prematurely lost teeth were some second deciduous molars. Because dental nurses do not perform space maintenance, except by preservation of natural teeth, some space loss with resultant blockage of unerupted premolars was noted. The technical quality of restorations prepared by the school dental nurses has been a matter of contention among American dentists. Having seen the product firsthand, I can attest to the adequacy of training in the service. Dunning* summed the matter, comparing the studies of Fulton and Gruebbel": The question of quality of workmanship is an impor tant one to consider and both Fulton and Gruebbel have attempted evaluation of it. Fulton's opinion was Friedman NEW ZEALAND SCHOOL DENTAL SERVICE. 613 generally favorable; Gruebbel's less so in view of certain surface inadequacies noted in the fillings he inspected. Even if we assume that 28 percent of the fillings received by New Zealand children are defective, as Gruebbel does, and if none of the fillings placed by American dentists are considered defective (an almost impossibly optimistic assumption), the New Zealand children in both Fulton's and Gruebbel's surveys still had more good fillings in their mouths than any known comparable group of American children of ages 12-14. In appraising the adequacy of training of the New Zealand dental nurses, it is important to remember how many difficult dental subjects they do not have to learn: endodontics, periodontics, much of oral surgery, and the entire field of dental prosthetics, to name the most important. This allows more time than might at first be imagined for good training in operative dentistry. When a child leaves the care of the dental nurse, he sees a private dentist whose examination includes bitewings. These radiographs are submitted to the district health department's dental division after the dentist's initial examnation. This procedure affords an opportunity to check the quality of restorations performed by the dental nurse with regard to cavity extension and adaptation to the gingival margin. Because many of the radiographs are of children who also have received restorations by dentists (after the initial bitewing series), one can compare the restorations done by dentists and those performed by dental nurses. I found no way to tell the difference. Inadequate cavity extension and minor gingival overhangs were noted in some restorations performed by both dentists and dental nurses. However, the majority of restorations made by both types of operators appeared quite adequate in the radiographs. The concept of wedging of matrixes to prevent gingival overhangs is weak among both dentists and dental nurses. This represents one of the few technical criticisms of the training program. A private dentist, questioned on wedging, replied, "Oh, do you always wedge? We only do it when it is necessary." In contrast to this conceptual laxity, the dental nurse is taught always to apply the rubber dam for the placement of silicate cement restorations. Also, protective cement bases are placed beneath all silicate and most amalgam restorations in permanent teeth. A few basic principles are applied so rigidly that they may astonish an American accustomed to rapid change and innovation. Yet, the rigidity-the conservatism-accounts in large mea sure for the success of the program. Since the service embarked on this radical venture, it repeatedly has said, "We train first-rate technicians, not second-rate dentists." Emphasis is placed on technical performance of narrowly defined functions. The dental nurse is not taught to make judgments, but to seek consultation with supervisory dental officers on problems beyond her skills, or to refer patients to private dentists. For example, arrangements can be made for a dental officer to come to a field clinic to extract a child's permanent tooth: for this procedure, the officer brings his own instruments. Patients who require difficult extractions or children with large carious lesions in permanent teeth, which might result in large pulp exposures, may be referred to private dentists for treatment. Emphasis is placed on the principles of standardization, stabilization, and simplification. The field clinics are stylized so that dental nurses may be transferred from one to another, as needed. with minimal adjustment to the new surroundings. Equipment and supplies and their arrangement in each field clinic are almost identical. Change comes about slowly. For example, the service currently is experimenting with the introduction of high-speed, air-rotor drills, but funds are limited. There is no rush to change to more modern operating techniques, and the need to do so is not greatly felt. The lack of ongoing, postgraduate training should be noted. Because of the de-emphasis on teaching dental nurses judgment, they are not encouraged to read journals or to expand their knowledge of dental techniques. However. some of the younger dental officers think that the dental nurses should be trained to perform pulpotomies, simple space maintenance, and mandibular block anesthesia, and that they should be better trained in matrix wedging techniques. The service restricts the position of the dental nurse and does not tempt her to challenge it with newly acquired knowledge. This restriction also applies to dental nurses on the teaching staffs of the training schools (tutor sisters), who only recently have been allowed access to the school's professional library. The close control has been effective in overcoming many of the early fears and objections of the dental profession. The former director of the division of dental health, G. H. Leslie, remembers only one instance in 30 years in which a dental nurse has been found working outside the school dental service, possibly because of a Friedman NEW ZEALAND SCHOOL DENTAL SERVICE. 615 misunderstanding on the part of the dentists who employed her. I interviewed many private practitioners all of whom were enthusiastic about the dental nurse program. In fact, many would be pleased if the government's program were extended to persons up to age 19, as is possible under the general dental benefits scheme. This could be done without appreciable increase in cost to the government. The practitioners made no mention of dental nurses overstepping their prescribed duties or in any way acting like dentists. The government has been successful in maintaining the dental nurse as a first-rate technician, and not a second-rate dentist. School dental nursing, like nursing in general, is largely a woman's vocation, but marriage and child-bearing contribute to a high turnover rate. Many dental nurses retire because of marriage after the three years of mandatory service that follow their training. Those who return after their own children reach school age can work either full or part time. Part-time employment consists not of fewer days, but of shorter hours. A part-time dental nurse works five days a week from 8:40 AM to 3:30 PM, quitting in time to be home for her children. Retraining of the exretiree is minimal. After a 22 week refresher course, she is assigned to a multinurse field clinic to work with a currently experienced nurse. Then she may be assigned to a solo clinic. The average working life of a dental nurse is about eight years, including postretirement service. More nurses are returning to service and an increase in their total working life is anticipated because many younger nurses are not having children so soon after marriage. It is hard to argue with success and this represents one of the difficulties in presenting criticisms of the program. Many of the deficiencies are recognized by the service, particularly those regarding equipment. The criticisms and limitations of the New Zealand School Dental Service must be considered minor in light of the overwhelming accomplishments of the program. The country's small size (about the same area as California, with a population of 2.8 million) and homogeneous population (economically and socially) simplify the problems of introducing a new system. However, those factors do not explain the success and acceptance of the service, even from the beginning. Perhaps it was the unusual circumstance of the application of common sense. 616 JADA Vol 85, September 1972 Extended benefits of the school dental service Many years, perhaps a generation or more, must pass before the ultimate effectiveness of a health program can be assessed. With regard to effectiveness of dental care for children, New Zealand's accomplishments are well documented: loss of permanent teeth has been reduced to almost zero and nearly three fourths of all decayed deciduous and permanent teeth have been restored. Although the school dental service is limited to the care of children, an important measurement of its success is the alteration in the behavior and attitudes of the adult population toward dentistry. In a survey conducted in a major city, more than two thirds of the participants who had natural teeth reported that they visited a dentist at least annually. A study of the dental care patterns of adolescents and young adults found that 71% of the persons between 15 and 21 years of age continued to receive regular dental care at their own expense after they no longer qualified for the government's general dental benefits. Among 20- to 29-year-olds, the number of denture wearers declined in 18 years (1950 to 1968) from 45% to 26%, and among the 30- to 39-year-olds, from 68% to 50%. These achievements reflect a radical change in attitudes and behavior of adults toward dental care. Much of the change must be attributed to the effectiveness of the school dental service program of combined treatment, prevention, and dental health education. Conclusion The immediate advantage of a school-based service for children, staffed by dental nurses, and the long-range benefit to adults has been well documented. Many New Zealand dentists were concerned initially with the effects of a school dental service on their economic and professional status. These same concerns are expressed by dentists in countries that are developing this type of program at present. The experience in New Zealand has demonstrated that the provision of dental care by nurses within the restricted environment of schools does not detract in any way from the dental profession, 34-500 O-74-26 |