This introductory chapter gives an overview of the changing nature of the practice of dentistry, highlighting current and anticipated future issues and challenges.

Big Picture

Dentistry is a fast developing biomedical healthcare science which should be viewed as an integral element of mainstream healthcare – oral health having been recognised to be important to general health and wellbeing. Moving on from the long‐established, experienced‐based, mechanistic approach to treating different forms of oral and dental pain, discomfort and disease, dentistry is evolving into a patient‐centred, evidence‐based, preventatively orientated, minimum intervention system of care to establish and maintain oral health – a health‐ rather than a disease‐management service. This, however, only holds true for dentistry in forward‐looking, typically well‐developed countries of the world. In other countries, where there are provisions for oral healthcare, dentistry may be found to be caught, to different degrees, in a twentieth century time warp, with treatment focusing on pain relief, often by means of traditional, interventive restorative procedures and the extraction of teeth, with or without prosthetic replacement. Elsewhere in our diverse, unequal world, billions of people have no, or at best very limited access to any form of dental care.

This chapter, in common with the rest of the manual, considers arrangements, procedures and techniques for patient‐centred, evidence‐based, preventatively orientated approaches to oral healthcare provision – best practice.

Oral and Dental Disease

The social determinants of oral and dental disease are largely universal: exposure to an unhealthy diet, tobacco use, excessive consumption of alcohol, and poor oral hygiene all contribute to poor oral health. In addition, many adults do not help themselves limit their exposure to oral and dental disease, by, for example, indulging in the frequent consumption of sugar, forgetting to brush their teeth, not bothering with interdental cleaning, and only seeking dental care when in pain or experiencing a problem.

In most developed countries overall levels of dental disease, in particular amongst children, have shown improvements in recent years, but behind such encouraging statistics there tend to be widening health inequalities, with levels of oral and dental disease increasing amongst the children of the poorest members of society. At the other end of the age spectrum, there is increasing longevity, with many more teeth being retained into old age; however, oral health among older people is generally poor, with levels of xerostomia and advanced periodontal disease being a particular cause for concern. In adolescents and young adults pathological tooth wear is now relatively common, and oral mucosal disease, notably the incidence of oral cancer, is increasing. So, while much has been achieved through the application of advances in the prevention of oral and dental disease, much remains to be done, and new forms of disease such as peri‐implantitis, albeit limited to those who have been fortunate enough to access implant dentistry, are generally considered to be a ‘ticking time bomb’. Overall, it may be concluded that there continues to be widespread exposure to the determinants of oral and dental disease, the most prevalent forms of which – caries and periodontal disease – are opportunistic and given the chance will affect patients of all ages. Furthermore, as discussed in detail in Chapter 2, it may be concluded that oral and dental diseases continue to be a major public health problem, in large part because of the failure of individuals to practise the most basic of preventative measures.

In helping to address oral and dental disease issues, dental teams should seek to find ways, in the community in which they operate, to help reduce oral health inequalities and increase public awareness of the importance of oral health and how it may be achieved and maintained. Such a service to society, if undertaken by all dental teams, would make an enormous difference to oral health in general.

The Dental Team

Modern oral healthcare is best provided by a dental team. The day of the single‐handed general dental practitioner, attempting to meet most, if not all of the many different dental needs of a diverse population of patients of all ages, is widely considered to be a thing of the past. For maximum efficiency and effectiveness, the dental team, led by one or more dentists and supported by a network of specialists in different, distinct branches of dentistry, should comprise:

• Oral health therapists, which may comprise (dental) therapists with skills and expertise in oral hygiene, or therapists together with dental hygienists.
• Dental nurses, trained together with other members of the dental team, with roles and responsibilities, over and above chairside participation in the provision of treatment, ranging from the recording of simple intraoral radiographic images to the application of preventive measures (e.g. fluoride varnishes) and oral health education. Dental nurses in modern practice environments must have well‐developed skills in running, or at least overseeing, state of the art decontamination and sterilisation procedures.
• Dental technologists, including clinical dental technologists, to work with the chairside team in the provision of indirect restorations, removable prostheses and other appliances. Increasingly, dental technologists are critical to developments in digital dentistry, including, for example, the production of restorations from digital images and CAD CAM (computer assisted design–computer assisted milling). It is anticipated that dental technologists of the future may have as many information technology (IT) skills as traditional manual skills.
• Practice managers with wide‐ranging roles and responsibilities to ensure the safe, efficient running of the practice or dental health centre. Practice managers’ skills and expertise may usefully include, by way of example, business development and marketing, practice accounting, consumables logistics and the management of human resources within the practice or centre.
• Dental receptionists as the patient’s first and most common point of contact with the dental team. In this role, receptionists require excellent human relationship and communication skills, together with skills in diary management, aimed at the best use of the time and skills of the various members of the dental team. Dental receptionists, in addition to requiring good telephone and face to face communication skills, are extending their roles to include multimedia communications with patients. Receptionists may also pay crucial roles in patient satisfaction surveys and the initial response to concerns and complaints.

As leaders of dental teams, dentists, amongst the many other challenges they face, must develop the necessary leadership skills during their formative years in clinical practice. Leadership courses are anticipated to become an important element of postgraduate dental education.

The Practice Environment