Focus on Denturism

By Duffy Malherbe
Abstract

having one-and-the-same person doing both the clinical and technical procedures involved and for that purpose deal directly with the person for whom the denture is being made.

Efficiency is simply doing things in the most economical way (good input to output ratio). Efficiency generally describes the extent to which time or effort is well used for the intended task or purpose. It relays the capability of a specific application of effort to produce a specific outcome effectively with a minimum amount of waste, expense, or unnecessary effort1. Effectiveness means the capability of producing a specific, desired effect; it relates to getting the right things done. Effectiveness is an important discipline, which can be learned and must be earned2. Economic efficiency - refers to a situation where there is no way to do a better job, given the available resources and technology. Introduction An Ophthalmic Surgeon specializes in the medical and surgical treatment of eye-diseases, yet Optometrists provide primary vision care, sight testing and dispense spectacles and eye ware. Conversely, Dental Surgeons are mandated to provide the whole spectrum of oral health care services. In the case of dentures, the most efficient and economical provision of removable prosthetics globally is by Denturists, who are specifically trained denture-experts3. Denturists are Dental Technicians who expanded their education, adding clinical skills to qualify as expert public denture practitioners - as their dedicated calling4. They are personally responsible for both clinical and technical procedures as well as direct communication with the consumer. They are purpose-effective and create individualized, optimally constructed functional dentures to meet the consumers preferences, well being and affordability. In some countries, including South Africa, the customary fragmented procedure remains, whereby a Dental Surgeon go-between facilitates the clinical measurement procedures and the Dental Technician makes the appliance in isolation from the consumer/patient5. Patients are often not given fully disclosed treatment-options and have to accept what they get6, often complaining about unsuitable aesthetic appearance. Dental Technicians make dentures blindly and too often have to remake (free of charge) due to the communication-barrier with the consumer and deficiencies of the fragmented go-between system. This underscores the desire for direct provision of dentures7. In some parts of the world the view still propagated by the Dental profession is that only Dentists can competently provide safe denture care8. In contrast, proven tests of clinical competency of Denturists and widespread consumer satisfaction of Denturists services are proof to the contrary, both in the legal market in Canada9 and the illegal market in the USA10. This applies equally to all regions of the world where the profession has been established. Globally Dentists often argue for supervision of Denturists3. In whose interests do they really speak? What freedom of choice does the Consumer have? Basic needs of denture wearers The profile of denture wearers is typically the elderly and underprivileged from humble socio-economic circumstances11. The Denturism-drive concerns providing equitable rehabilitation-services to the edentulous (teeth-impaired), which includes large numbers of the often-neglected categories of the poor and the old12. In South Africa, they are currently often left with no other alternative than the unsavory and unhygienic services of unregulated amateur quacks, and exposure to communicable diseases5. The Denturism-initiative aims to provide a vital service to those already excluded by the high overhead costs from the market serviced by Dentists. Besides, competition with Dentists creates downward pressure on the price of dentures, thus enhancing affordability! Due to the training pathways and the expenses of the wide spectrum of services they provide, Dentists fees will always be higher than Denturists13. Only 16% of the South African population is covered by Medical Schemes. Consequently, the huge majority cant afford any dental treatment14. The State Health Budget focuses on essential health priorities and containing life-threatening communicable diseases including HIV/ Aids, TB, cholera, malaria, etc. Justifiably, there will always be a lack of resources for a substantial denture service through the State 15. Yet, denture provision is the most basic of all oral health services. Functional dentures, or the lack thereof, affects all aspects of human functioning, nutritional health and general health14. It concerns the rehabilitation of oral function, speech, aesthetic appearance and human dignity. Research links the inability to chew with premature aging and infirmity. Denture provision is therefore a much-needed essential service and should be recognized as a basic human right16. The Conventional Procedure Dental Surgeons do not make dentures, but have monopolized the sale of dentures as a go-between retailer. Expertly trained dental technicians construct dentures in a roundabout fragmented system that prohibits communication of the manufacturer with the consumer.

After the patient has lost their natural teeth, the clinician takes impressions of the mouth and registers the bite-relationship, simple measurement-procedures calling for no greater skill or precision than is required for the actual making of the denture 17. The finished restoration is placed in the patients mouth and such minor adjustments that are required are carried out. Again, the procedure is of technical nature and does not call for surgical skill 17. Any

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adjustments required throughout the process have to be communicated by the go-between to the dental technician. Such instructions are often vague, incomplete or absent, and since contact with the patient is strictly prohibited, this leaves the dental technician to depend on own initiative or ESP to custom-make the denture14. Circumventing the go-between and providing the service directly by a Denturist can eliminate much of the confusion. All the transportation of materials to and from the dental surgery and back to the dental laboratory for the technical procedures before and after every visit of the patient can also be eliminated. (See table 1) Despite careful handling and precaution, the materials can get damaged or distorted during all the backwards and forwards transportation11. Throughout the various procedures human error remains a factor and as the process becomes more fragmented, so does communication, increasing the chances of misinterpretation of instructions11. The cost of this transportation and the preventable cost of repeating some procedures and even remaking completed dentures resulting from the clumsy process and communication barriers add to the production-cost and all-round frustration often experienced by the stakeholders. Much of the retry and remake inefficiency is avoidable. Is the Dentists monopoly justifiable in terms of the cost of the inefficiency and waste caused by the clumsy fragmented procedures? Communication through a Go-between Communication from the go-between is generally limited to the information captured on the work-order that accompanies the material (impression, bite and try-in) to the dental technician. Incomplete work-orders often provide barely the surname of the patient and the contracting dentist without specified information regarding gender, shade, mould or size of teeth or treatment-plan14. Dental Technicians often have to phone dental surgeries to verify crucial information12. The accuracy of an impression impacts the fitting of the denture and determines the comfort or discomfort in the mouth. Some Dentists are notorious for poor impressions and Dental Technicians often have to improvise successive excuses to request repeat impressions, doing an egg-dance around the Dentists professional reputation and/or ego. All too often a tried-in wax-denture have to be stripped and redone, typically due to non-communication of the patients preferences related to appearance of the anterior teeth or the amount of labial support. This type of unproductive repetition due to the prescribed communication barrier often frustrates the working relationship between Dentist and Dental Technician4. The complicated nature of communication via a go-between conveying the required adjustments of a trial denture to a denture-maker can be illustrated by the analogy of an artist commissioned to paint a specific scene. There are two ways of doing it: You can explain the scene to him and he can then paint it, or you can take him personally to the actual scene18. Consumers are often clear about what they want or do not want, but ultimately have to accept the denture they get regardless6. The Dental Technician often misinterprets the go-betweens limited attempt (or neglect) to convey the patients requests, dislikes or various other crucial technical indicators14. This applies to aesthetical appearance, vertical height and factors that impact functional efficiency. Many dissatisfied denture-patients move on and travel from one Dentist to another, gathering many unsuitable dentures in a frustrating quest for a satisfactory result14 prescribed inefficient squander! Direct services can evade much of this inefficiency and complete the process in far less time by avoiding wasteful and preventable procedures. Reduced training in Prosthodontics By the 1940s a South African specialist pleaded in an international Dental Journal17: the highly trained dentist of the future, who must be qualified to advise on all matters of health in any way connected with the oral tissues, should not focus their valuable time and commercialise themselves by the manufacture and sale of dentures. Fragmentation of the denture delivery system through a go-between is

counter-productive and prohibits communication between the consumer and manufacturer4, sustaining the inefficient status quo. Dentists are expertly trained in oral surgery and the combat of oral disease. As Doctors of the mouth their primary function remains to be the maintenance of general oral health care19! It is confirmed by various training institutions that dental curricula worldwide have slowly but inevitably contained a de-emphasis on the technical component, in favour of the biological basis of dentistry 20. Dental trainees are undoubtedly currently qualifying with fewer technical skills needed to meet the routine requirements of general practice, than in the past20. In denture prosthodontics, technical proficiency and clinical skills can only be acquired after hundreds of hours of laboratory and clinical hands-on time. Internationally the emphasis in dentistry to treat the partially edentulous population has shifted to implants and crown & bridgework4. As a result, there has been a trend in dental schools to reduce and in some instances even consider eliminating removable prosthetic coursework from their curriculum21. With the development of new techniques including CAD/CAM and the introduction of Implantology, etc the South African shortened dental curricula now leaves even less time for training in denture manufacture and denture delivery. The National Oral Health Survey conducted in 1988-89, sited the construction of dentures as the most difficult procedures a Dentist may be called on to perform22. The shortened dental curricula in South Africa now requires dental students to complete only as little as two or three F/F dentures during their training, of which one may be processed by the laboratory. Systems failure Despite the competence of many experienced Dentists, Dental Technicians also have to contend with the other extreme. Frequent complaints manifested in systems failure of clinical procedures, related to inadequate prosthetic training, can be summarized as23: Inconsistency to carry out the measurement procedures of taking accurate impressions or registration of bite relationship. Delegation of clinical procedures in prosthetics to either the chairside assistant or the dental laboratory (task-shifting) Inability to carry out clinical responsibilities to assess certain crucial technical aspects of the try-in of a denture. Inability to indicate clearly to the laboratory the alterations needed to correct the aesthetic requirements of the patient. Inability to give clear instructions to a dental laboratory with regards to plan and execute a successful treatment plan to solve specific prosthetic complications . Failure to comply with providing basic information regarding gender, shade or size of teeth or what type of appliance the patient needs (incomplete work-orders). Dental Technicians often have to guide some Dentists through basic design and treatments options, even clinical procedures23. Dental Technicians, who have the manual dexterity and technical skills and are already professional in making dentures, could successfully do this work directly17. They already receive tuition in anatomy & physiology24. Experience at the laboratory workbench strengthens understanding of the clinical procedures. Having the ability to transfer knowledge acquired in the laboratory to the clinic is the added quality that differentiates Denturists from Dentists25. Dental Technicians only need a modified course in the clinical procedures of denture delivery and oral pathology recognition, so that they can refer, when necessary26. Internationally Denturist-students spend much more time on technical and clinical education than dental students in removable prosthetics27. A course devoted to specializing in denture prosthodontics must therefore lead to a superior clinician in the case of the Denturist (Clinical Dental Technologists) in comparison to the Dentist. In practice, the gradual globalization of Denturism is caused by the improved effectiveness of the profession.

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Dentist (clinical measurement procedures only, as a Go-between)
Dental Technician (contracted out manufacturing
procedures and deliveries) *Materials include work-orders, impressions, plaster models, record-blocks, try-ins.

By taking a patient-centred look at the process of having dentures made, one can more clearly illustrate both the impact on Patients and also the advantages and potential savings via Denturists28. Table 1: Comparison of procedures by a Dentist and Denturist:

Denturist - Clinical Dental Technologist

Combining both clinical and manufacturing procedures and also direct collaboration with the patient/customer = centralized efficiency!

First visit

First visit

Documentation of Patient-history and oral examination by Denturist Treatment options explained and Patient-consent reached for treatment-plan Any oral pathology and tooth-modification referred to appropriate OHP Preliminary impressions made by Denturist and cast in plaster. (If the duplication-method is utilized, impressions are taken in the old Materials* collected by Dental Technician. dentures, models cast and articulated, parameters recorded and dentures Plaster casts and custom impression trays made by Dental Technician. returned. Teeth set up for try-in Skip all other procedure up to 4th visit.) Materials* returned to Dentist by Dental Technician. Construction of custom trays by the Denturist

Documentation of Patient-history and oral examination by Dentist Treatment options explained and Patient-consent reached for treatment-plan Any oral pathology referred to appropriate OHP Preliminary impressions made by Dentist.

Second visit

Second visit

Final impression made by Dentist using custom trays.

Materials* collected by Dental Technician. Master casts and record bases for bite registration constructed by Dental Technician. Materials* returned to Dentist by Dental Technician.

Final impression is made by the Denturist using custom trays. The Denturist constructs master casts and record bases for bite registration.

Third visit

Third visit

Bite-relationship registered by Dentist. Shade chosen by Dentist. Materials* collected by Dental Technician often with incomplete work-orders. Tooth selection determined by Dental Technician in isolation from patient. Mater casts articulated and setting-up teeth done by Dental Technician without communicating with the Patient about personal preferences or needs guided by information or lack thereof on work-order. Potential telephonic enquiry to clear up incomplete or contradicting instructions. Materials* returned to Dentist by Dental Technician

Bite-relationship registered by Denturist. Tooth selection and shade determined by Denturist in cooperation with the Patient. Any specific requirement or personal preferences discussed directly. Technical limitations can be explained. Master casts articulated and setting-up of teeth is done by the Denturist taking into consideration the Patients requested preferences and needs.

Fourth visit

Fourth visit

Wax denture try-in by Dentist (possibly repeated, resulting in additional visits). Evaluation of technical parameters of wax denture in the mouth.

Materials* collected by Dental Technician. Adjustments done according to Dentists written assessment for every additional retry. Potential telephonic enquiry to clear up incomplete or contradicting instructions. Materials* returned to Dentist by Dental Technician.

Try-in of wax denture by the Denturist. Evaluation of technical parameters of wax denture in the mouth. If needed, any corrections can be done instantly due to the in-house laboratory and technical expertise of the Denturist. Retry-ed until satisfaction is reached. Sealing down wax denture on models, investing, boiling out and packing, processing, divesting, trimming and polishing of completed dentures.

Fifth visit

Fifth visit
Can be skipped - generally preventable!

Retry-in by Dentist (possibly repeated, resulting in additional visits).

Materials* collected by Dental Technician. Adjustments done according to Dentists written assessment for every additional retry. Sealing down wax denture on models, investing, boiling out and packing, processing, divesting, trimming and polishing of completed denture by Dental Technician. Completed denture delivered to Dentist by Dental Technician.

Sixth visit

Sixth visit

Insertion of completed denture by Dentist.

Adjustments, errors, misfits collected by Dental Technician, etc. (If necessary, starting over from the beginning) etc. Duplicated admin-costs for invoicing the surgery and the laboratory separately.

Insertion of completed denture by the Denturist. Any adjustments or alterations can be done directly by the Denturist

Direct invoice for a one-stop service, without duplicated or hidden added levies.

The facts speak for themselves from this graphic table28. All the transportation to and from the dental surgery and back to the dental

laboratory can all be eliminated by the implementation of Denturism. Denturists are in the best position to pinpoint and adjust corrections,

Southern African Dental Technology Journal

consider complications and are equipped to do complex modifications simply because they have an in-house laboratory and the training to do both ends of this job, without ado. This ensures optimal fit, correct functioning, maximum comfort and general well being of denture wearers5. The Denturist is personally responsible for both the clinical and technical procedures, as an expert, resulting in an efficient system, meeting individualized needs, properly constructed dentures and results in optimal denture satisfaction. There is simply no argument against this fact28. Delivery fees contribute 10% of additional expenditure on the dental laboratory account. Many of the misinterpretation, confusion and Results of fragmentation

Focus on Denturism

It has been reported that denture wearers experience denturesatisfaction differently than what Dentists evaluate clinically29. It is about comfort of fit, aesthetic natural appearance and balanced function when speaking and eating. Many old-school trained Dentists have acquired sufficient experience to become competent in prosthetics, but what happens when the conventional system fails 14 ? In some practices, Dental Assistants are delegated to take over clinical responsibilities of denture provision and also facilitate the procedures of the crucial try-in stage12. These Assistants are ill equipped for this function and untrained to assess the adjustments required or complications. Due to superficial training in this specialist field, some Dentists are simply not competent in the technical aspects of clinical denture provision to advise the dental laboratory and are quick to refer the patient directly to the dental laboratory to sort out. Many denture wearers seek out these dental technicians themselves and harass them to provide direct services to satisfy their denture needs30. Many Dentists' patients are referred directly to dental laboratories for repairs and other denture procedures (including remakes), which Dentists cannot relay or do themselves. Dental Technicians are prevented from access to clinical training and not mandated clinicians and have to provide these stand-in clinical procedures for free. This is an unfair burden, which Dental Technicians cannot afford to refuse, at risk of losing a client in a restricted prescribed market12. By law dental laboratories may only provide their services to Dentists. The Alternative Direct Process It makes sense to add clinical skills to the work of Dental Technicians and restructure the process of providing dentures by having one-andthe-same person doing both the clinical and technical procedures involved and for that purpose deal directly with the person for whom the denture is being made5. Denture Technicians that so desire, qualifies through clinical training, to provide a specialized direct service31. Deployment of regulated Denturists results in efficiency gains in terms of a reorganized system, more affordable costefficiency and efficient oral health focus with appropriate referrals. Organized dentistry views the emergence of Denturism as professional encroachment on their vested interests. Due to the overpowering monopolization32 and the one-sided anti-denturism propaganda, there is often little awareness of the advantages for Denturism in countries where the category is not yet legislated. Typically, unsubstantiated health scare tactics are used to intimidate the uninformed33. The pattern of delaying tactics is predictably similar globally 30, until the profession eventually becomes instituted and services normalized. The quest for introducing Denturism involves building the Oral Health Team and is pro-denture wearer, not anti-dentistry34. The addition of a denture-dedicated category is essentially not about Dentists having to give up any rights, but simply about an additional choice of service provider to the consumer. In many dental practices, Dentists simply cannot work without a Denturist in the mix of services offered35. It releases them from general Prosthetics and enables them to occupy their time with more financially rewarding procedures, e.g. Preventative Dentistry and Implantology. Defragmented Efficiency

remakes are unnecessary, avoidable and time and materials are wasted12 (10-20% needless ineptitude cautious estimate). Duplication of separate administration costs occurs for the invoicing of the work done at the laboratory and at the surgery. The laboratory invoice gets added to the Dentists invoice for the purpose of medical insurance claims. The Dentist pays the laboratory monthly on statement, although the lab has to carry the cost for all materials upfront. The lab are levied an additional admin-fee by the Dentist to receive their money, unless the lab claims directly from the Dentists patients or their insurance. A Denturist simply invoices patients directly for a one-stop service, without any duplicated or additional hidden levies! Most people would still need a Dentist, for care of their natural teeth, general oral health care and oral-surgical procedures. Delegation of denture-supply away from a multi-disciplined Dentist to an expert with specialized duties must inevitably produce service-efficiency gains for the Dentist and the denture-maker, but in particular for the denture wearer36.

Denturists have an explicitly defined role in terms of construction, fitting, patient aftercare and care of artificial teeth, after patients have already lost their natural teeth4. One and the same person performs both chair-side and dental laboratory work, resulting in a superior end product, simply by bringing all the fragmented procedures of denture provision together11. No information transfer No confusion! Direct consultation between the denture-maker and consumer avoids miscommunication and the clumsy, often-preventable repetition of some extended procedures, commonly associated with the customary system of working through a go-between. The most efficient and economical provision of removable prosthetics globally is by Denturists5. By nature of their training and education, such Clinical Dental Technologists (Denturists) are specialized in discipline-specific removable prosthetic work. They are specially trained to provide oral appliances directly to the consumer and see more denture patients on a daily basis, than Dentists do in a week12! Cost Efficiency In many countries costly investigations were conducted by Restrictive Practice Commissions37 and Competition Boards to reinstate Free Enterprise and to identify and abolish monopolies and cartels created by legislation that were not desirable or in the dental consumers interest38. It was found that such restraints prevent the development of new markets where an unmet demand often exists, causing artificially elevated price-levels39. Globally, the economic crisis has stimulated reforms in all types of services. Simultaneously, public expectations and an increasingly aging population require an efficient and more feasible prosthetic service without compromising standards30. Shortening the fragmented chain of supply with a simplified direct service by the manufacturer provides a more competent service at a better fee36. Denturists fees are better affordable because their services are discipline-specific without cross-subsidies or availability

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fees for other dental services, not applicable to dentures. Denturists provide competition to Dentists for those services they are qualified for, thus putting downward pressure on the prices of prosthetics40. Direct denture provision gives the consumer the freedom of an alternative choice of service provider who reflects the reduced cost of the procedures in their fees to the consumer. Internationally, Denturism is becoming the service provider of choice in both poor and affluent communities41, whether provided in private practice or statesupported, in both urban and rural areas. Prosthetic needs in rural areas create opportunities for partnerships between the public service and privately practicing Denturists through mobile units and district clinics6or in the absence of Dentists, with Dental Therapists. Oral Health Efficiency Dentures are a reversible procedure; if they cause any irritation whatsoever, all the patient needs to do is to remove it from the mouth and return for further adjustment. Dentures are of such a nature that once a patient is satisfied with the aesthetics, function and fit, they cannot harm the oral cavity as such. The biggest risk with regards to dentures is to go without them, or to wear old ill-fitting ones due to unaffordable rates16. There is scientific evidence that the inability to chew efficiently causes premature aging and infirmity42. Being edentulous or partially edentulous is not a disease. It may be the result of oral disease, but is essentially a stable condition or state requiring rehabilitation to replace the lost structures16. The process of denture delivery and all its stages is neither surgical nor medical, but a technical procedure that takes place in a bio-clinical environment16. In contrast to Dentists, Denturists do not perform invasive procedures, they do not administer general anaesthesia and they do not prescribe drugs; therefore their practice does not pose a public health risk41. Denturists professional indemnity insurance in Australia27 and the Conclusion

US41 is the lowest of any health profession, because they do their job so well that complaints are minimal compared to Dentists. Provision of dentures by Denturists frees the hands of Dentists to use their time and specialized skills more effectively towards prevention and treatment of oral disease and the promotion of oral health4. Denturists have an explicitly defined role in terms of providing removable appliances after the patient have already lost some or all of their teeth, but doesnt include modification of natural teeth or tissue of the mouth14. Their expertise excludes any alterations to living tissue. Appropriate Referral The best possible outcome can be gained for the patient through appropriate liaison between Denturists and Oral Health Team (OHT) members43. When necessary, the denture wearer is referred, affirming the specialized roles of the other OHT members. Typically, standard practice globally is for Denturists to refer partial denture patients to Dentists for occlusal rest preparation and other appropriate procedures Early recognition of serious oral conditions is the most important intervention44. The policy of The Society for CDT has always been to introduce educational programs to improve diagnosis of early lesions for all oral health workers performing clinical intra-oral functions. Denturists are trained to distinguish between normal healthy oral anatomy and histology in order to comfortably recognize the abnormal (pathology) that would require the specialized attention of an Oral Pathologist for treatment4, just as Dentists do. Inter-professional referrals are standard protocol throughout the world and in many professions. The referral chain should always move upwards towards greater expertise45. Around the world Denturists have been recognized to fulfil an important role as gatekeepers of oral health in this regard46.

Denturism

bypasses the customary fragmented procedures through a go-between including the prescribed communication barriers that specifically outlaws communication between the manufacturer and the consumer for his/her custom-made appliance. It makes functioning sense to add clinical/biological skills to the work of Dental Technicians (already specialized in denture-construction) with regards to the defragmentation of the process of providing dentures. One-and-the-same person will then effectively do both the clinical and technical procedures involved and for that purpose deals directly with the person for whom the denture is being made. The expansion of the Oral Health Team to include Denturists is effective Human Resource Development and a productive service efficiency improvement. The introduction of Denturism provides efficient specialization for both the Denturist providing removable prosthetics directly and also for the Dentist to focus primarily on the important role of maintaining oral health and fighting tooth decay.

Globally, the economic crisis has stimulated reforms in all types of services. Simultaneously, public expectations and an increasingly aging population require an efficient and more feasible prosthetic service without compromising standards. By shortening the chain of supply and dealing directly with the manufacturer provides a more proficient service at a better fee. Direct denture provision gives the consumer the freedom of an alternative choice of service provider who reflects the reduced cost of the procedures in the fees payable by the consumer.

Denturists do not perform any invasive procedures and are recognized, or seeking legal recognition, to practice the procedures they are highly

qualified to perform efficiently, through accredited training and conforming to international health and infection control protocols. Most people would still need a dentist, for care of their natural teeth. The provision of dentures by Denturists will free the hands of Dentists to use their time and specialized skills more effectively towards the prevention and treatment of oral disease and the promotion of oral health. This will serve the primary focus of their training and reaffirm the fundamental reason for having Dentists. Exactly as Dentists do, Denturists refer any suspected oral pathology to an Oral Pathologist. Any condition in need of specialist attention is referred accordingly. Similarly any tooth-modification required (e.g. Occlusal rest-preparation for partial denture stability) is referred to a Dentist. Some denture clinics employ Dentists for implantology, tooth-modification and other incidental procedures indirectly related to dentures.

The introduction of Denturism should be supported wherever there is a need for a more satisfactory denture-service, as an expert category, at a basic level, to improve efficiency, and because it is more affordable, especially for lower income categories!

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The bottom-line resulting from introducing Denturism is service-efficiency and happy Denture-wearers!
References

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Deputy Dean and Head of Prosthetic Dentistry, University of Sydney. Director of Clinical Dentistry, University of Sydney. E-mail to The Society- 3/07/2007 www.denturism.co.za/Visitors_Comments 1 Kais K. DDS Dean of Bates Technical College, Tacoma Washington. Member of the Education Committee of the National Denturist Association, USA. E-mail to The Society- 2007-06-25 2 du Plessis JB, Rossouw LM, Smit J, Lichter G. Prosthetic status and treatment needs of the adult population of South Africa. National Oral Health Survey 1988-89. Department of Health 3 Identification of common complaints of dentists clinical ineptness, identified by members of the Society for CDT, formulated in 1998 and updated from time to time. 4 Heydt H. Executive Director of DASA. Circular to all members of DASA advocating clinical access for dental technicians, 11 May 1990 5 Tapealava M. Faculty of Dentistry, University of Otago, New Zealand. Reflection on Clinical Dental Technicians practice. 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