100 years after the founding of the School Dental Service, something is rotten in the health of children’s teeth. Noel O’Hare recalls an era of painful treatments and exploitation – but universal coverage.
When our national School Dental Service was wound down and finally disintegrated in the closing years of the 20th century, few mourned its demise. But its absence is still reverberating like a treadle drill 30 years later. Each year, thousands of children end up in hospital having rotten teeth extracted under general anaesthetic because, for various reasons, they fall through the cracks in the current system.
Now that the Government is replacing district health boards with a new national health system, should there also be a return to a national school dental service, with clinics attached to schools?
That would make no economic sense, says Dr Martin Lee, a public health researcher and theCanterbury District Health Board’s community dental service clinical director.
School dental clinics were phased out in the 1990s and early 2000s after decades of cost-cutting and restructuring that created a legacy of poorly maintained buildings and outdated equipment.
The “hub and spoke”Community Oral Health Service that replaced them has had its failures. Nevertheless, the days of “drill and fill” are over and the emphasis now is on prevention, says Lee.
“To go back to the nostalgic idea of the old school dental service that was set up to do fillings and extractions is not what is needed now.”
Although children’s oral health is generally good in this country, the same is not true for Māori and Pacific Island children. In Scotland, the Childsmile programme successfully tackled oral-health inequities by targeting early childhood centres in deprived areas. The initiative provided free toothbrushes, fluoride toothpaste and supervised brushing. Would it work here? “We’re trying to get funding to run a pilot programme in Canterbury,” says Lee.
Tenor of the times
This year, as another wave of health-sector restructuring begins, former school dental nurses are marking the centenary of the once-ubiquitous service. They have every right to look back in anger at a service that disrespected them, that caused unnecessary pain and suffering to their patients – not to mention management’s recklessness in exposing the nurses to mercury poisoning.
Not that any of that will be top of mind as the champagne flows. What endures is a quiet pride in having done a difficult public service and the joy in friendships that lasted a lifetime.
As the author of a 2017 book on school dental nurses, I interviewed many. All came across as warm, caring women, proud of the contribution they’d made to the country’s dental health. It’s likely there were a few who were cold, indifferent and even incompetent – but that does not explain the widespread fear and loathing with which former patients recalled their experience in school dental clinics. They were the victims of a policy and a time that had scant regard for children’s rights.
Following an internet call-out for people’s recollections of school dental visits, I received a number of responses. Here is a sample: “Our dental nurse would drill in time to the radio. She drifted off one time and drilled my tongue. I yelped and got slapped and told to toughen up. And then she did it again.”
“The sound of those drills sent shivers up my spine.”
“That smell, the chair of fear, the belt-driven drill that sometimes slowed so much it stopped in your mouth in the massive hole that they had drilled.”
“I remember the first dental nurses who came to our native school. The anaesthetic they used could not have been effective because every extraction was followed by painful howls.”
Silver and mercury
A grievance many patients still hold against school dental nurses is that they practised on children’s teeth, doing unnecessary fillings that later required expensive restorative dentistry. This was never the case. The military-style training that dental nurses went through ensured they were fully proficient when they graduated. However, from the perspective of current dental practice, they certainly did unnecessary fillings.
“These dental nurses were brainwashed into believing that every tiny hole needed enlarging and stuffing with an amalgam of silver and mercury – a potent neurotoxin – to carry in our mouths for the rest of our lives,” said one patient.
Dental nurses were instructed to use prophylactic odontotomy, filling any fissures or holes they found in otherwise healthy teeth to prevent future decay. This, the School Dental Service claimed, resulted in fewer extractions and large fillings, but it also meant that teeth that might never have decayed were also drilled.
“I had all my old fillings removed eight years ago and discovered that the majority should never have been put there in the first place, as there was no decay to begin with,” a patient recalled.
This practice stopped only in 1978, when a review of dental practice decided that fillings should be a last resort, and that any small fissures be treated directly with fluoride.
How representative, though, were these children’s experiences with school dental nurses? It’s hard to gauge, but a 2018 post about school dental nurses on the Facebook page “Nostalgic Kiwi” elicited more than 9000 comments, most of them negative.
Dental anxiety remains common throughout the world. About a third of people experience it and about 10 per cent suffer crippling dental phobia. Some of it undoubtedly stems from the actual profession of dentistry. Until the 20th century, dentistry was a trade practised by anyone with a strong wrist. For example, Dunedin dentist Thomas Hunter, who founded the School Dental Service in 1921, was apprenticed at the age of 14 and had set up his own practice at 17.
The torturous dentistry of the past has left an indelible mark on our collective memory, argues Joanna Bourke, author of Fear: A cultural history. It’s what scientists now call transgenerational epigenetic inheritance – the transfer of trauma via genes.
Some of those painful “murder house” memories may also be heightened by peer-generated anxiety about what went on in that hut at the edge of the school grounds. In her 2010 thesis, “The Murder House Case Studies: An education in dental anxiety”, dentist Susan Cartwright writes: “Anxiety can cause an individual to be hypersensitive to pain so that their pain threshold is lowered and may even cause stimuli that would normally not be painful to be perceived as such. Conversely, pain increases anxiety and so a vicious cycle is established.”
Nevertheless, there were real reasons for children to feel anxious as they trudged to the clinic. The equipment almost guaranteed that the experience would be unpleasant. Electric drills were introduced in the 1930s, but some dental nurses were still using the foot-operated treadle drill in the 1950s and 60s.
The treadle drill, with its cast-iron pedal base, was state of the art in 1871. It was grindingly slow and the patient experienced unpleasant and noisy jarring through the skull and to the ears. One former patient recalled: “The worst part was getting the dreaded call late in the afternoon when the old girl was running out of energy to keep the treadle going at a decent speed.” Cartwright has observed that former patients’ horror stories often include reference to the treadle drill, even though they were too young to have received treatment with it.
Treadling for hours a day while stooped over a patient was hard work, and back problems seem to have been an occupational hazard. It was said that you could recognise a school dental nurse by the fact that one calf muscle was bigger than the other.
In 1949, New Zealand dentist John Patrick Walsh invented an air-turbine, high-speed drill. It was a game changer, with the potential to eliminate much of the pain associated with dentistry. But the School Dental Service wasn’t having any of it: “The efficiency of the instrument is almost incredible but, like all instruments that are manually operated, it has its dangers. There is always the human element to contend with.” In other words, the nurses were not to be trusted and there were no plans to upskill them.
Despite the treadle being practically an instrument of torture, dental nurses were permitted only to use anaesthesia for extractions, not fillings. Even then, it often did not provide much relief, according to dental nurse Kath Salter: “The anaesthetic supplied was only 1% strength. The department was too scared to issue anything that might cause reactions. It was made up in Wellington and sent out to us.”
By the 1970s, nerve blocks that eliminated pain by anaesthetising the whole lower jaw were in common use by dental nurses in Australia. But again, their New Zealand counterparts were not to be trusted. GH Leslie, director of the division of dental health, defended that decision: “I am still of the same mind that any advantage that might accrue from the introduction of regional anaesthesia would be outweighed by the risks inherent in entrusting the technique to 1400 operators, none of whom have had a sufficient basic education to support our unqualified defence in law should an accident ever occur.”
Animals requiring dental treatment were luckier: nerve blocks were routine at the vet because it was a breach of the veterinarians’ code of practice to cause unnecessary suffering.
Leslie’s ossified management was reflected in every aspect of the service. New Zealand had been the first country in the world to set up a dental service for schools, and it was adopted as a model by 15 countries. But other countries quickly overtook us in providing a modern service.
In her thesis, “From Innovative to Outdated? New Zealand’s school dental service 1921-1989”, Dr Susan Moffat noted that dental nurses were frustrated by the lack of new equipment and outdated procedures. “Eileen Jenkin commented that dental nurses were ‘brainwashed’ into thinking their ‘capabilities’ only extended so far. Freda Patterson felt that they could really have used more local anaesthetic and, when working in Canada, observed that they would never have considered doing restorative work there without local anaesthetic or block anaesthesia. Furthermore, Canadian dental professionals would not consider doing ‘quadrant dentistry’ on a child without a high-speed drill. Gill Woods, on returning to work in 1973 after 17 years away from the SDS, described as ‘staggering’ the fact that the service was still using the same dental materials as when she had left. The clinics, in terms of materials and equipment, were always ‘way behind’ those of dentists.”
Nelson writer and former patient Angela Fitchett offers this perspective: “Looking back at mid-20th-century school dental treatment from the careful present, where reassurance and comfort is an expected part of any dental or medical treatment a child receives, it’s easy to be horrified. But in defence of the treatment, it was free, it was regular and we children couldn’t avoid it because it was compulsory.
“Despite the fear and the pain, I really am truly grateful to those dedicated young women in their crisply starched white uniforms who cared for the teeth of New Zealand’s schoolchildren.”
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