DENTISTS (AMENDMENT) BILL

DENTISTS (AMENDMENT) BILL: Order for Second Reading read.

3.15 pm

The Minister of State for Health (Mr Heng Chee How): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

The Dentists (Amendment) Bill seeks to amend the Dentists Act (Chapter 76 of the 2000 Revised Edition). The proposed amendments will ensure that our laws are relevant to the practice of dentistry today. The amendments will also enhance the powers of the Dental Council so that it may perform its regulatory functions more effectively.

Background

Singaporeans enjoy a high standard of dental care that is easily accessible. Today, we have about 1,250 registered dentists working in the public and private sectors providing a wide range of dental care and services to our population.

About 20% of our registered dentists have on their own volition upgraded their skills in specific areas of dentistry such as orthodontics, prosthodontics, oral and maxillofacial surgery, periodontics, endodontics and paediatric dentistry. These "dental specialists" provide a higher level of dental care to patients whose dental conditions require management by a

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dentist with specialised training. Although developed countries such as the USA, UK, Australia, Sweden and Switzerland already have a separate register for dental specialists, our specialists are neither recognised nor regulated under the present Dentists Act, other than as registered dentists.

Oral health therapists, ie, dental therapists and dental hygienists, have been providing basic dental care in developed countries such as the USA, UK, Australia and Germany. In Singapore, such therapists, who have been allowed to be employed by the Health Promotion Board, have been providing basic dental care to our schoolchildren for many years. The registration and regulation of oral health therapists will ensure that these therapists, who would now be able to seek employment in the private sector as well, are adequately trained to provide basic dental care to the public.

We need to update the Act to ensure that our laws continue to be relevant to the practice of dentistry today, by recognising and regulating the work of dental specialists and oral health therapists. The proposed amendments will also enhance the role and processes of the Dental Council to enable it to perform its regulatory functions more effectively, and allow for the introduction of compulsory continuing professional education so that the Council can raise and maintain professional standards of dental practice.

Let me now elaborate on the amendments which I have just highlighted.

Setting up of a Dental Specialists' Register

The amendments proposed under clauses 12 and 25 provide for the setting up of a separate register for dental specialists, and the registration of such specialists.

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Dental specialists are recognised in countries like the USA, UK, Australia, Sweden and Switzerland, as I mentioned earlier. In the USA, a dentist is recognised as a specialist when he obtains his specialist board certification. UK, Australia, Sweden and Switzerland provide for the registration of dental specialists in a register that is separate from that for other dentists.

In Singapore, we have a good number of dentists who have specialised in specific areas of dentistry. They provide a higher level of dental care to our patients. A Dental Specialists’ Register will list these dental specialists and their area of specialty. This will allow patients who require specialised dental treatment to easily identify an appropriate dental specialist. Local and overseas general dental practitioners and medical practitioners will also be able to identify such dental specialists so that they can make referrals when necessary.

By recognising and regulating dental specialists, we would also, firstly, motivate more dentists to aspire towards specialisation; secondly, encourage dental specialists to remain competent in their areas of specialisation; and, thirdly, protect the public by ensuring that only dentists with the appropriate qualifications may hold themselves out to be specialists in the appropriate areas of specialisation.

Registration and regulation of oral health therapists

Under the proposed amendments, a new division will be inserted to provide for the registration of oral health therapists.

In countries such as the USA, UK, Australia, Germany and New Zealand, oral health therapists support a dentist's practice and provide basic dental care. In

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Singapore, oral health therapists have been providing basic dental care to primary school students for many years. Basic dental care includes procedures such as scaling and polishing of teeth. By allowing oral health therapists to provide cost-effective basic dental care, dentists will be motivated to improve on their skills and perform more complex dental procedures. The registration and regulation of oral health therapists will help assure the public that these therapists will be appropriately trained and accredited for the skilled provision of basic dental care.

The registration and regulation of dental specialists and oral health therapists will create a continuum of skilled and affordable dental care that the public can choose from.

Enhanced Dental Council

Sir, let me move on to the amendments to enhance the role and processes of the Dental Council.

Compulsory continuing professional education for dentists

Dental science is constantly improving. Therefore, there is a need for dentists to maintain the currency of their professional knowledge and to stay abreast of developments in dental science and practice. Continuing professional education is a well-accepted mechanism to achieve this.

The amendment proposed under clause 14 will enable the Dental Council to prescribe conditions for the grant and renewal of practising certificates, including mandatory participation in continuing professional education. Only dentists who accumulate the minimum continuing professional education points specified by the Dental Council will be issued with practising certificates, or will have their certificates renewed.

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Continuing professional education for dentists is already a requirement in developed countries, such as the USA and UK. In Singapore, continuing medical education has been linked to the renewal of practising certificates for medical practitioners since 2003. Compulsory continuing professional education for dentists will help ensure that standards of dental care in Singapore remain high.

Compulsory voting

Voting of members for the Dental Council is currently compulsory for all registered dentists. The proposed amendments will make compulsory voting applicable only to registered dentists with current practising certificates.

Registrar of the Dental Council

Since 2001, the Chief Dental Officer, Ministry of Health, has been appointed as the Registrar of the Dental Council. The proposed amendments will formalise this practice.

To enable the Registrar to carry out his duties effectively, he will be empowered to remove from the appropriate Registers the names of persons who have:

(a) not renewed their practising certificates for a continuous period of five years and who cannot be contacted; or

(b) requested and shown sufficient reason for his name to be removed from the register, unless an enquiry or proceedings have commenced against the person.

Conditional and temporary registration

The proposed amendments will allow, in addition to full registration, the conditional and temporary registration of dentists.

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The Dental Council will conditionally register a dentist if it is of the view that the person should work under the supervision of a fully registered dentist for a time. Such persons include those whose qualifications or experience do not allow them to be fully registered in the first instance, such as a foreign-trained graduate. In such cases, the Dental Council will explicitly state the conditions of registration.

Temporary registration will be granted to a person who does not have a local degree and who, for instance, is in Singapore for the purpose of teaching, research or to pursue a postgraduate study in dentistry.

This scheme of full, conditional and temporary registration is similar to that for medical practitioners under the Medical Registration Act.

Enhanced disciplinary processes

To enable the Dental Council to carry out its regulatory duties effectively, the proposed amendments will grant the Council and its committees enhanced powers in respect of disciplinary matters. In summary:

(a) The Dental Council will be empowered to direct that an inquiry be continued even if the complainant withdraws his complaint before it is referred to a Complaints Committee, a Health Committee, a Disciplinary Committee or before the conclusion of the inquiry of the above-mentioned committees.

(b) A Complaints Committee will be empowered to decide on its own motion to inquire into a matter when it receives information regarding the conduct or physical or mental fitness of a dentist or an oral health therapist which may give rise to proceedings against the dentist or the oral health therapist under the Act.

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(c) A Disciplinary Committee will be empowered to refer information to the relevant authorities for further investigation if there are reasons for the committee to believe that a criminal offence(s) has been committed.

Furthermore:

(a) The Chairmen of Disciplinary Committees will be selected from a panel of senior, well-respected dentists appointed by the Minister for Health. A disciplinary committee will also include non-Council members as well as a lay observer.

(b) The maximum penalty that may be imposed by a Disciplinary Committee will be increased from $5,000 to $50,000. This increase in the maximum penalty will give a Disciplinary Committee the flexibility to impose a monetary penalty that is commensurate with the professional misconduct in question.

Appointment of Interim Orders Committee

Inquiries into disciplinary matters may take up to 24 months to complete and, presently, a dentist who is under investigation is still able to practise. This may not be entirely satisfactory in some situations as there may be compelling reasons to suspend such a dentist from practising, even before the outcome of his disciplinary inquiry, in the interest of public safety.

We have therefore proposed a provision to allow the Dental Council to appoint an Interim Orders Committee with the power to suspend or restrict the practice of a registered dentist or a registered oral health therapist for the protection of members of the public or in the public interest, pending the completion of disciplinary proceedings against him.

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To safeguard the rights of dental professionals, however, provisions have been inserted:

(a) to restrict a member of a Complaints Committee or Disciplinary Committee from participating as a member of an Interim Orders Committee inquiring into the same matter;

(b) to provide that no interim order shall be made unless the dental professional in question has been given an opportunity to appear before the Interim Orders Committee and present his case (either in person or by a legal representative);

(c) to grant a dental professional a right of appeal to the High Court;

(d) to require the review of an interim order by an Interim Orders Committee after six months to determine if it should be revoked or amended and, following this first review, a further review every three months until the matter is settled, or until an Interim Orders Committee decides that the order is no longer necessary, or eighteen months after the initial issue of the order. An extension beyond eighteen months will require approval by the High Court.

These enhancements to the disciplinary processes, including the amendments to allow the appointment of Interim Orders Committees, are modelled on the provisions in the Medical Registration Act.

Composition of offences

Amendments have also been proposed to allow the Dental Council, with the approval of the Minister, to prescribe offences which may be compounded and, where appropriate, compound such offences.

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Change in name of the Dentists Act

To reflect the extension of the Act to cover dental specialists and oral health therapists, we further propose to change the name of the Act to the 'Dental Registration Act'.

Conclusion

In conclusion, Mr Speaker, Sir, Singapore has, over the years, seen quantum improvements in the provision of dental care and services. Our dental professionals' standards of competency and commitment have led to a general state of good dental health and treatment in Singapore.

The proposed amendments will ensure that Singaporeans continue to enjoy access to dental care which is affordable and of consistently high standards.

Sir, I beg to move.

Question proposed.

Mdm Halimah Yacob (Jurong): Mr Speaker, Sir, I rise in support of the Dentists (Amendment) Bill. This Bill is necessary and timely. It will enhance the standards of professionalism in the practice of dentistry and further raise the quality of dental care services that are provided in Singapore. Improvements, such as the Continuing Professional Development Programmes and the Dental Specialists' Register, will also bring the practice of dentistry in line with that applicable to the medical doctors and also the practice found in many developed countries, a plus point for Singapore in our efforts to build up Singapore's reputation as a medical hub and to attract more foreign patients under Singapore Medicine.

Sir, Singapore has a good standard of dental care comparable to international standards. Among the population,

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especially younger Singaporeans, there is a high level of awareness about dental hygiene. Research done in 2003 showed that 45% of Singaporeans visited their dentists once every six months. Singapore's key approach in maintaining dental health is through prevention. Our school dental programme provides a very useful service. Every day, in our primary schools, all the kids will line up and be made to brush their teeth after recess. I was told that this is still the practice done in some schools, although some schools have discarded that practice. This is a good practice as it certainly helps to increase awareness and instil the habits of good dental hygiene among young children in the early days when such habits are not yet well established among our population. As a result of such initiatives, a 1994 survey showed that a child at the age of 12 had only one decayed, missing, or filled tooth and that 97% of Singapore's population at age 18 did not lose any permanent teeth as a result of tooth decay.

Despite our good progress, one area that I feel deserves closer attention is how to better provide for the dental care needs of a rapidly ageing population, a point that I will revisit later.

Sir, let me now touch on some of the specific areas covered under the Act. I support the various measures instituted under the Bill to tighten control over discipline in the practice of dentistry, that is, increasing the fine to $50,000 and establishing an Interim Orders Committee. Although some dentists have expressed concern over the higher fine, this must be looked at in its proper context. Dentists who are honest and exercise their professional duty of care need not worry. But tighter discipline would generate greater public confidence and act as a better deterrent for errant dentists.

Sir, for the first time, the Bill proposes the setting up of a Dental Specialists'

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Register which is already in place for the medical doctors. About 25% of the 1,250 registered dentists have undergone some form of specialised training. But there is no formal system of accessing and recognising those who have the qualifications and expertise to function as specialists. The register will thus help Singapore to develop and grow specialised dental practice which is required for the management of complex dental cases. It will also provide patients and the public with the proper level of care appropriate to their needs as they can more easily identify dentists who have specialised skills and expertise in specific areas of dentistry.

Sir, however, there are two issues that we need to address. First, there is a concern that the establishment of the Dental Specialists' Register and the registration of specialists would result in higher fees for patients. As dental care services in Singapore are primarily provided by private practitioners, this is a genuine concern that needs to be addressed. Without a Dental Specialists' Register, it is more difficult for specialists to charge higher fees because, to the patient, he is just like any other dentist. But with the register and a clear recognition of their status as specialists, the fear is that specialists will push up their fees.

Also, what we need in Singapore is to promote right siting of dental services. If there is no need for the patient to engage the services of a dental specialist, then it is a waste of resources and an over-consumption if patients start visiting specialists, instead of dentists, even for less complicated treatments, not to mention that this will also drive up cost. One way is for the Ministry of Health to publish the list of specialists as well as their fees for the various dental treatments. I hope that the specialists would also do the same by putting up the schedule of fees in their clinics as well. In

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this way, the public can compare prices and can also decide whether they want to seek the services of a specialist or a dentist with the clear understanding on the different fees that they may be charged.

Sir, the second issue is one of awareness and education. Public awareness of the existence of different types of specialties and the field of dentistry is extremely limited. To them, a dentist is someone who is medically trained to deal with all problems associated with the gums and teeth. In the old days, they used to be just pulling out your teeth. But now, it is a lot more sophisticated. They are not able to differentiate between the different types of specialists, whether it is orthodontists or periodontists, or whatever, that you may have. How to prevent confusion and ensure that people are able to make informed choices as to the level of care that they need? It is necessary to educate the public on the Dental Specialists' Register. I would like to urge the Ministry to look into this and come up with an appropriate education programme for the public.

Sir, I also support the proposal to register and regulate oral health therapists, such as dental hygienists and dental therapists, who usually help the dentists but can also on their own do the routine chores associated with the practice of dentistry. I feel that the use of oral health therapists, subject to the various conditions stated in the Act, would help to reduce the costs to patients as there are some tasks that do not require the intervention of the dentist. As this is already done in other countries and as oral health therapists have already been widely used in our schools, registering and regulating them is a correct move. It would also help to promote greater professionalism and growth of the profession. However, there

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are two gaps that the Bill does not address.

The Bill does not define the job scope of the oral health therapists. With some ambiguity, will we have a situation where the oral health therapists may even end up doing the work of the qualified dentist although they may not be qualified to do so? I think it is important in the public interest, as well as in the interest of the oral health therapists themselves, to clearly define what would be the scope of work of oral health therapists so that the public is aware and understands what service they can expect from them. Oral health therapists are also now subject to the same discipline and penalties as dentists, stipulated under the Bill. Therefore, Sir, it is in the interest of the oral health therapists also to know what they can or cannot do in order to prepare themselves.

Sir, the other point which the Bill does not address is the problem faced by many oral health therapists who are prohibited from providing treatment to patients above the age of 18 years. Last week, I had the chance to speak to some oral health therapists and they feel that this restriction limits their career development and scope of work as they could only provide service within our schools and they have no market value beyond that. The dentists in private practice will not find it practical to employ them since they cannot assist the dentists to treat patients who are above the age of 18 years. So if the intention of the Act in putting oral health therapists under the Dentists Act is that they can expand their scope and they can also practise in the private sector to help to reduce the cost for patients, then I think if this restriction is not removed, it will have limited application and impact.

Sir, I support the continuing professional development programme. Our dentists must keep pace with rapid changes made in scientific knowledge,

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dental practice and the development of new materials and technologies. The voluntary programme has not worked. Therefore, a compulsory programme has to be put in place in the public interest. I understand that, since September 2005, dentists need to complete 70 hours of continuing development programme over a two-year period and that, by September 2007, annual practising certificates will only be issued to dentists who fulfil this requirement.

Sir, while I support this move, I have received feedback that older dentists who are in semi-retirement and who are not working full-time are worried with this requirement as they find that 70 hours are too long for them, considering that they do not work full-time. I would like to ask whether the Ministry can be more flexible in implementing the continuing professional development programme for such dentists so that their training hours could be shorter, or the 70 hours could be spread over a three-year period, instead of a two-year period, so that they will not lose their practising certificates. In this way, we also do not lose their years of skills and expertise which are valuable.

Sir, next, I wish to touch on the use of Medisave for dentistry services. I have received feedback from both patients and dentists who feel that the current provisions allowing Medisave to be used for approved dental procedures are very restrictive on two counts. First, the type of procedures for which it can be used is restrictive and should be expanded as dental technology has advanced so rapidly. But Medisave use is still restricted to the system in place 25 years ago. Second, the fees should also be revised, as the current table of fees is also 25 years old and may no longer be realistic. For example, with a rapidly ageing population, the need for dentures is more pervasive, especially among elderly patients. But they cannot use their Medisave or that of their children to pay for the cost

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of making dentures, which can be quite costly for the average elderly to pay out of their own pockets. I would like to suggest that MOH update or review the current allowable usage of limits for Medisave use for dental services.

Sir, the population in Singapore is ageing very rapidly. One worry is that the elderly in Singapore tend to give dental care a lower priority than medical care. A study conducted by the Department of Preventive Dentistry of NUS in 1992 on the elderly who were in institutional care supports this finding. There does not seem to be a more recent research, but international research on this in more recent times supports the same finding. The study examined the existing arrangements for financial support of dental and medical care to elderly persons living in 68 long-term care facilities in Singapore. The results showed that a significantly higher number of homes, 93%, assumed responsibility for the provision of medical and dental care. A significantly greater proportion of them offered inhouse medical care, 42%, compared to inhouse dental care, only 5%.

Sir, we all agree that oral health is integral to an elderly person's general health and quality of life, and basic oral health services are an essential component of primary healthcare. There is therefore a need for us to ensure that dental care services are better designed so that there is a geriatric focus, and all students doing dentistry or receiving training as oral health therapists are taught about geriatric care. I hope that the Ministry will pay closer attention to this so that our elderly would also have access to quality dental health services.

Sir, on the whole, this Bill would improve the quality and standard of dental care services in Singapore. And, therefore, I support the Bill.

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3.45 pm

Dr Fatimah Lateef (Marine Parade): Mr Speaker, Sir, dental practice and education are becoming more globalised today.

Greater practitioner and patient mobility, the free flow of information, increasing global standards of care and new enhanced legal and economic frameworks are forcing countries to review dental licensure and specialisation as well as their continuing education programmes. These changes are to be expected and seen as a springboard of the future.

Outdated concepts of regulation and the assumption that the profession alone knows best must be set aside in order to keep in step with the ever-increasing patient expectations and developments in healthcare provision and regulation. Dental care in Singapore is of world-class standard. The number of foreign patients seeking both general as well as specialised dental care here is certainly increasing. In line with all these changes, the introduction of these amendments is indeed timely and appropriate.

On registration, Sir, I fully support the differentiation set out pertaining to full conditional as well as temporary registration. This will make the definition and delineation of roles so much more clearer and, of course, it is also very similar to what the medical practitioners are already practising today which is working very well. Making it comparable for both professions is a positive step. Doctors and dentists, who have been deemed not ready to practise independently, should be given the due supervision they require to mature and excel. It is also important to differentiate between the general dentists and those who are specialised as their scope of practice, the types of equipment, the state-of-art technology and also the risk

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involved are very different. For dentists dealing with medical-related devices, such as dentures, braces, bridges and so on, they should be subjected to the Medical Products Act which has just been recently discussed in Parliament.

The payment of dental practice insurance may also differ from these different groups of dentists, just as we have doctors in the low, medium as well as high-risk disciplines paying different premiums. It is only fair for those performing more invasive and high-risk procedures to be more highly covered and insured as you can certainly say, "Your bite is only as big as your teeth."

I am also very glad to see the introduction of registration and regulation for oral health therapists. This is a profession which has certainly not been given much focus and recognition despite the importance of their role. Many are today being sidelined still, except in the school dental health service where they play a very significant role even up to today. These are the group of people who can help with dental public education and creation of awareness, not just for children, but also for the public, and their knowledge and expertise are to be tapped in certainly a positive way. Sir, this wider range of a more robust regulatory mechanism will also be in the interest of public protection and certainly safety.

On accreditation, the Bill stipulates that the Dental Council is to have one academic representative who is the Dean of the Faculty of Dentistry at NUS (section 3.2(b)) and the academic representative of the Oral Health Therapists Accreditation Board to be one member of the academic staff of the dental hygiene and therapy course offered by Nanyang Polytechnic. This, Sir, may turn out to be very restrictive towards other institutions in future which may become engaged in training and education to serve the growing needs of our population.

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Sir, this new Bill must provide a leeway for future developments without having to propose a new amendment Bill every time to suit changes and evolution. So we hope that could be addressed.

On oral health therapists, just as new fields in dental specialisation develops, the scope of work of oral health therapists should be expansive and not restrictive. The new Bill introduces two groups of oral health therapists, namely, the dental therapists and the dental hygienists, with a very narrow scope of work. Should not the scope of work for oral health therapists be allowed to expand, especially with a formal introduction of dental specialisation? Should not dental therapists be trained to complement, not just general dental works, but also specialised dental works as well? Dental therapists are currently trained in general dental restorative works, such as fillings and basic dentistry for minors up to the age of 18 years in school dental health service. If we are to support that expansion of services, how will they make the transition into practice that involves adult patients? There must, therefore, be some options and avenues for them to develop in order to make the transition and necessary adjustments. It is also unclear from the Bill as to whether dental hygienists and therapists can set up independent practice after a prescribed period of supervised practice with a Division I qualified dentist.

On CME, Sir, revalidation of members of the dental team is a proactive approach to regulation. Revalidation will now require them to demonstrate on a regular basis that they remain fit for continuing registration and thus worthy of their patients' trust. Acquisition of adequate CME activity points over a stipulated period will allow one to renew the professional practising certificate. This new regulation will promote self-motivation and thus compliance, just as it has done for the medical profession.

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Sir, I would like to highlight and suggest the following to be considered in the setting up of the dental continuing professional development programme and system in Singapore. First, a dialogue for the Dental Council, the Ministry of Health and the dentists to attend and discuss as well as finetune, taking into account their feedback and suggestions, as these are the people who work on the ground and they know the practicalities and issues on the ground.

Second, the setting up of a secretariat to help in the management of the system. Third, the use of on-line submission to facilitate the management of the CME points. Fourth, the use of different categories with different point weightages given, something similar to the current medical CME system. And, finally, to have a system to pro-rate and manage those who have to be overseas for an extended period of training or practice.

One word of caution I have is that there must be consideration before starting up a core versus a non-core points accumulating system which is used with the medical system today. Core points pertain to points obtained when attending CME sessions related to their area of specialisation, whereas non-core points or general points are for generic dental-related CME programmes. As the discipline is relatively small in Singapore still, we will have to ensure that there are enough such CME sessions in order that the dentists be given a fair chance and, of course, the choice as well.

On complaints and disciplinary prosecution, with the new Bill, the complaints process is being made clearer with more structures in place and, of course, it is even more fair and effective. It is essential to ensure parties involved get a fair deal and understand early the course of action which is going to be

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involved. This can then ensure that they undertake a series of necessary systematic steps in pursuing the issues concerned. This will certainly contribute towards consistently high quality dental care and practice, aligning with the norms for professionals and perhaps even for everything else in Singapore, which is always to be whiter than white and shinier than shiny.

Sir, I also strongly support the proposed formation of an Interim Orders Committee which will be making the decision whether to suspend or restrict the practice of a practitioner whilst he is still under investigation. Currently, such practitioners are allowed to carry out their work which is creating a bit of a sour feeling with a lot of people. Once again, this is consistent with our call for enhancement of patient and public safety. It is also very heartening to see that various safeguard measures have been in place and are clearly stipulated to preserve the rights of the dental practitioners.

Finally, I concur with the change in name for the Act to the Dental Registration Act, certainly a more appropriate choice and an all-encompassing terminology.

Sir, I support the Bill.

3.53 pm

Mr Zainudin Nordin (Bishan-Toa Payoh): Mr Speaker, Sir, I rise in support of the Dentists (Amendment) Bill.

Sir, Singapore has taken great strides to be the dental hub of the region. Recently, the Singapore Dental Association says that our dental clinics here are seeing more overseas patients than before. These patients seek more than just a quick clean-up or check-up. They

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are here for specialist treatment from prosthodontics to oral surgery.

In another development, next year, Singapore will play host to the International Dental Exhibition and Meeting (IDEM Singapore 2008). This event will be the number one communication platform for the entire dental sector in the Asia-Pacific region.

Continuing this development, in 2009, the Annual World Dental Congress (AWDC) will hold its annual congress also in Singapore. The congress plays an important role in the international advancement of dentistry and will include a Scientific Programme, a World Dental Exhibition and the World Dental Parliament.

Reading the amendments proposed to the Dentists Bill, I can see that there are efforts to streamline common issues between the Singapore Medical Act and the Singapore Dentists Act. And this also includes the functions and roles of the Singapore Medical Council and the Singapore Dental Council.

Dental Specialists Register

The setting up of a Dental Specialists Register is one of the steps taken to assist in the growth and development of specialised dental practice. The registry will also provide patients access to up-to-date and specialised dental care. It will improve the general awareness of the public with regard to general dental practitioners and dental specialists, and help the provision of appropriate dental care at the right level. For example, patients who require preventive dental care, such as professional cleaning, need only to go to a dental hygienist, and patients requiring root canal treatment will go to an endodontist. The registry will also assist referral cases for those who need specific or extensive dental procedures.

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Sir, as protection to the consumers, only those with the qualifications and expertise can be registered and claim themselves as dental specialists. This is where the Dental Specialist Accreditation Board comes in to define the qualifications, experience and other conditions for registration as specialists.

For the patients to derive maximum value from the creation of the Specialists Register, there need to be public education programmes to promote the use and benefits of the registry. The programme can help patients better understand the dentistry field so that they can make educated decisions regarding all available dentistry treatments. This includes information focused on the subject of general dentistry practices in addition to the growing cosmetic dentistry practice. Consumers will find information related to who makes the best candidates for each dentistry procedure, the recovery time after completion of their dental work, and the appropriate expectations.

Sir, on the other hand, the Ministry of Health must also ensure dental fee transparency to mitigate unwarranted and arbitrary revisions to the guidelines of fees established by the Singapore Dental Association. Just to echo the same concern of Mdm Halimah, I hope that the specialist title should not be used as a licence to charge exorbitant fees.

Continuing professional education (CPE)

The field of dentistry has evolved from dentists being known as drillers and extractors to masters of the art and science of dental practice. I remember the times when a visit to the dentist was like being sent to the dungeons for torture. In fact, I used to think they were paid based on the amount of pain and suffering inflicted onto the patient. Nowadays, going to the dentist is as pleasant and relaxing as a trip to the spa. With soothing music, aromatic candles, cable

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television, plush seats and the magic of anaesthesia, you do not feel the dentist "lasering" your teeth away. After a couple of visits, you come out with a set of pearly whites that glow in the dark!

As with any professional operation, dental professionals would also need to keep up-to-date by continuing their professional development. Through knowledge expansion, these dental professionals will be able to provide better quality dental care to their patients. Patients would benefit from new developments in dental procedures, new materials and technologies. They can be assured that their dental professional is competent to give advice on treatment options, and provide sound recommendations.

By raising their skills, expertise and professionalism, Singapore dentists and dental professionals will further enhance our position as a regional medical and dental hub.

Registration and regulation of dental care professionals

Let me touch on the registration and regulation of dental care professionals. Dental care professionals, such as dental hygienist and dental therapist, play an important role in promoting dental health. They provide affordable and quality oral healthcare to those who do not need the full spectrum of services provided by a general dental practitioner. However, Sir, to safeguard the interest of the patients, I support the move to register and regulate these professionals and that they are also governed by the Dentists Act.

Dental Council related amendments

There were also other proposals that were made to allow the Dental Council to function more effectively as a regulatory body. I believe that the proposed

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amendments will enable the Dental Council to effectively monitor, regulate and make recommendations for the advancement of quality dental practice in Singapore. With these revisions, the public will be assured of a regulatory body with more teeth and a council with the authority to bite. Meanwhile, the Council will also protect and uphold the good name of professional dental practitioners in Singapore and ensure that any enquiries and complaints against them will be dealt with in a professional, consistent and just manner.

Mr Speaker, Sir, I trust that these amendments will benefit both Singaporeans as patients and the dental professionals too. It will ensure that patients receive oral healthcare of the highest standard, maintain the integrity of the profession and help thrust Singapore as a centre of excellence for dental medicine.

4.00 pm

Dr Lily Neo (Jalan Besar): Mr Speaker, Sir, I support the provision for the registration of dental specialists in the Dentists (Amendment) Bill. There have been many sub-specialties in dentistry, such as orthodontry, prosthodontry, pediatric dentistry and so on, over the years. In fact, there are nine recognised specialisations mentioned in the American Dental Association. This Bill provides the registration of dental specialists and this registration will allow the discerning patients to differentiate one dentist from another if they so wish to ascertain.

My concern is on the registration of oral health therapists. The Bill spelled out the criteria for the registration of oral health therapists but there is no mention on the practising scope of these oral health therapists. For example, are they allowed to practise on their own? Is

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registration synonymous with the permit to operate their own clinics?

Oral health therapists are Nanyang Polytechnic graduates and trained in limited skills, such as scaling, polishing and filling of teeth after a three-year course, but not trained in the diagnosis and treatment of dental problems. If they are allowed to practise and open their own clinics, their scope of dental care is very limited for patients, but non-discerning patients may not know that. This will lead to dire outcomes, such as misdiagnosis and under-diagnosis of dental problems, to the detriment of patients. But if these oral health therapists are to work under dentists or to the prescription of dentists, then many dentists and specialists can be freed from simple routine work in scaling, polishing and filling of teeth and to concentrate on more difficult jobs, such as dental extraction, root canal treatment, dental prosthesis, and so on. This will thus save time and cost for patients.

The Minister of State said earlier that in Singapore, oral health therapists who have been allowed to be employed by the Health Promotion Board have been providing basic dental care to our school children for many years. In the past, school dental nurses (or the predecessors of oral health therapists) were trained by the Ministry of Health under the School Dental Services. The Ministry gave up training these nurses some years ago and transferred the responsibility to the Nanyang Polytechnic. Traditionally, the school dental nurses were allowed to diagnose, plan and carry out treatment for school children due to a shortage of dentists. Singapore has progressed economically over the years to become a First-World country. Singapore now can claim to have one of the best healthcare systems in the world and aspire to be the regional medical hub. And, yet, when it comes to dental care for our school children, MOH is prepared to digress in

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reverse tandem to our progress as a country by engaging oral health therapists to treat our school children, instead of dentists who are qualified dentists in dentistry.

Sir, as I said earlier, oral health therapists are Nanyang Polytechnic graduates and trained in limited skills and not trained in diagnosis and treatment of dental problems. Nanyang Polytechnic began offering its Diploma in Dental Therapy and Hygiene from 2004. It is in its fourth year since inception. The first batch of 20 has just graduated. In the past, dental nurses had been employed to treat our school children as there was a shortage of dentists. Currently, there is one dentist for every 2,500 Singaporeans. This ratio is comparable or better than some of the developed countries like Australia, New Zealand and the UK. Almost one in four of them works in the public sector. Now that we are not short of dentists, is it cost that MOH is trying to save by employing oral health therapists, instead of dentists, to treat our school children? If it is, then I feel that it is a sorry state indeed for the following reasons:

Oral diseases can exert a multi-faceted impact on an individual with a wide range of effects, including pain, discomfort and inability to eat. The two most common oral diseases - tooth decay and gum disease - are largely preventable if positive oral hygiene practices are inculcated and adopted by individuals. The adage "Prevention is better than cure" is most apt here in the dental care of young Singaporeans by maintaining good oral health while they are still in school. It is therefore important to ensure that children in school get the best of care by competent providers. This will ensure these children have deep foundation and a good set of teeth to last their lifetime.

Many Singaporean parents do not bring their children for dental check-up,

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thinking that their children's dental health has already been seen to in schools. They may, in fact, be under a false sense of security with regard to the dental health of their children if MOH continues to employ oral health therapists to do the job. I feel that our school students should deserve the best of dental care and, therefore, HPB should now deploy dentists and not oral health therapists to provide the dental care for all our school children.

The Dental Specialists Accreditation Board consists of not less than eight registered dentists appointed by the Minister, but there is no mention of who the members should be. There are two providers of specialisation courses in dentistry in Singapore and they are NUS and National Dental Centre. Therefore, the members of this Board should at least have one member of the academic staff of the specialist courses in NUS and another one from National Dental Centre. This is so that it is consistent with the other provision of the same on this Bill, that is in new section 21C(2)(b) of this Bill, which spells out that one member of the academic staff of the dental hygiene and therapy course offered by the Nanyang Polytechnic be a member of the Oral Health Therapists Accreditation Committee.

Section 3 of the Dentists Act is amended to include at least one but not more than three registered oral health therapists in the Council. This is a maximum of three out of a total of only nine dentists in the Council apart from the Chief Dental Officer and the Dean of the Faculty of Dentistry of NUS. Is this not a lop-sided representation of oral health therapists? The oral health therapist course is new in Singapore and currently only 15 to 20 are trained per year, and it will take a long time for their numbers to rise to even approximate those of dentists. Moreover, given the limited extent of their work compared to the whole

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dentistry fraternity, there should be a fairer representation of dentistry practitioners in the Council.

The last issue on fairer representation in the Council is that there should be provision to ensure the Council consists of representation from as many sectors of the dental profession as possible, such as the varied public dental sector and private dental sector. Therefore, there should not be double representation from any sector. One such example is that the Dental Faculty should not have another dentist seeking election to the Council since the Dental Faculty already has a mandated representative.

I hope that the Minister of State can address these issues raised.

Mr Heng Chee How: Mr Speaker, Sir, I thank the Members for speaking in support of the Bill. As pointed out, this Bill will raise the standards of dental care and dental professional practice in Singapore. Allow me now to respond to the Members' specific comments and concerns.

Mdm Halimah wondered if our primary school children are still continuing with the after-recess toothbrushing drills which, as she correctly remembered, had increased dental awareness and instilled in school children good dental hygiene habits. What happened was that that practice actually continued right up to where SARS struck us. At that point, to minimise cross-contamination and possible transmission of unknown infections amongst students, that was scaled down. But, instead, the School Dental Service under the Health Promotion Board moved towards an individualised and enhanced oral health promotion programme which, by their indicator, has proven to be more effective. What happened is that all school children are now instructed, at the chair side during the free dental treatment

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visits, on how to brush their teeth effectively and regularly. In addition, the dental therapists in the schools have also increased the frequency of oral health promotion talks. Dental health education has also been incorporated into the health education curriculum in the primary schools.

Currently, these measures continue to instil good dental hygiene habits amongst our school children. A 2003 survey has found that amongst 12-year-olds, there is 0.54 of decayed, missing or filled teeth. That is an internationally recognised comparable indicator. This number in 2003 of 0.54 was a decrease from the number of one (1) in the year 1994. In other words, there have been fewer decayed, missing or filled teeth in our children. This actually puts us as one of the lowest in the world. So, it is a good result. It suggests that the education programme and the promotion of good habits, in terms of toothbrushing and so on, have yielded results.

Mdm Halimah was also concerned about the job scope of the oral health therapists - and I think Dr Fatimah as well as Dr Lily Neo - and asked us to have some clarity about their job scope. Dr Neo was of the view that registered oral health therapists should not be allowed to work independently, but work under the supervision or fulfil the prescription of qualified dentists.

The amended Dentists Regulations, pursuant to the Act, would clearly state the job scope of all oral health therapists as well as that they will work in collaboration with registered dentists. Specifically, they will only be allowed to perform dental procedures that they are qualified to do and will work under the direct supervision of dentists for at least five years. The five years that they spend under the direct supervision of dentists will help them gain sufficient clinical experience. After the five years, they may

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choose to work under a dentist in the same premises or provide the services in their own premises to patients referred to them by any dentist. They may not prescribe treatment or provide dental treatment independently. They may only treat patients referred to them by dentists and may only provide treatment which is prescribed by dentists.

On Dr Lily Neo's concern that oral health therapists are not sufficiently qualified to perform dental screening of students on their own, I wish to inform the House that oral health therapists go through a 3-year diploma programme at Nanyang Polytechnic. The programme, among other things, trains them to screen school children and provide the necessary basic dental care. Currently, all primary school children and half of the secondary school children are screened and treated by qualified oral health therapists. Some secondary school children are being screened and treated by dental officers due to the shortage of oral health therapists who are fully qualified to do the screening. Once there are sufficient numbers of oral health therapists, all secondary school children will be screened and treated by oral health therapists for the basic care for which they have been trained and qualified to do. Oral health therapists are well qualified to carry out these screenings and provide basic dental care, eg, in scaling, polishing, filling and the extraction of milk or primary teeth.

Students who need dental treatments that are beyond the scope of oral health therapists are referred to dental officers for consultation and management. The dental officers also supervise and conduct regular checks on the oral health therapists, not only on how they conduct the screenings but also on how they perform treatment.

Here, I would like to address another issue which was brought up by Dr

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Fatimah as well as Mdm Halimah. This is with regard to the current rule of dealing with the teeth of those who are below 18 years of age by the therapists. This rule currently does not apply to hygienists. So hygienists can practise what they are trained to do in an age neutral way. They are not limited by this rule. As for therapists, this rule in the regulations started because of the way in which they were trained and deployed - in other words, the job that they were employed to do. Because they were dealing within the school system, there was this specification in the regulations. As the scope of the oral health therapists' work is extended and as we consider the fact that they would be able, if they so choose, to practise after the five years on their own, no doubt under the supervision of dentists, one of the measures that has been taken to assist them in enhancing their employability and their job worth is to equip and certify them for the dental hygienist's work. That is step one. So, an oral health therapist, who also qualifies as a hygienist, can do the hygienist's work without limitation on the age.

What about lifting the limitation for therapy work? On this, we would have to look at how things evolve and take concurrent steps. There are a few pieces that we have got to move and adjust in an interdependent way. As I mentioned earlier, the origin of the rule was because of the nature of the work for which they were trained to do. For the adult population beyond the age, that really comes under the realm of the dentists. Dr Lily Neo draws a very strict line as to what dentists can do and what oral health therapists cannot be trusted to do. But Mdm Halimah and Dr Fatimah hold the view that as they upgrade their skills and so on, why is it that we have a limitation of who they can provide services to? So there is an implication on the kind of training that we provide them, what they can be competent in, what kind of supervision they should be put through,

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as we consider whether or not they can then move beyond their current scope, in terms of oral therapy work. This is something that the Ministry will be monitoring and we will have to move in such a way that it balances between not only the interest of the therapists but also those of the dentists, while at every point of time ensuring standards and safety for the people who receive their services and treatment.

Dr Lily Neo was also concerned that oral health therapists may be over represented in the new Dental Council. I just want to explain here that the new Dental Council comprise 11 dentists, of whom up to three may be oral health therapists. These oral health therapist representatives will be appointed by the Minister. The Ministry believes that the oral health therapists have to be sufficiently represented in the Council since they will be working closely with the dentists. The Chief Dental Officer of MOH will recommend to the Minister the actual number to be appointed after considering the total number in proportion to this group of dental professionals in Singapore. So I take Dr Lily Neo's point that we should actually look at the relative sizes in deciding how many oral health therapists ought to be appointed in any one term of the Dental Council, and this is something that the Chief Dental Officer will take into account in making his recommendations to the Minister. Within the amendments proposed, there is a cap of not more than three. Clearly, to have any representation at all, it cannot be less than one. So that is where it stands.

Dr Lily Neo also alluded to why a representative from the NUS Dental Faculty was included in the new Singapore Dental Council but was not mentioned in the other board. She was saying whether or not there should also

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be a representative of the National Dental Centre on the Singapore Dental Council. I would say that there is no dispute over the merits of having a representative from the NUS Dental Faculty on the Council. If we look at the other provisions of appointment, then we are able to utilise the other limbs of the appointment provisions in order to augment the Council or to take suitable representatives to be on board.

Sir, there are various ways of looking at this. Dr Fatimah, in her speech, in fact, cautioned against over specifying. She referred to another provision and said, "Why do you want to specify Nanyang Polytechnic and NUS Dental Faculty? There could be others who might come up." The answer, to balance all these concerns, would be to say that for the obvious ones, we put in and then we have other provisions within the appointment processes to allow us to appoint, because all of them would be registered dentists of various Divisions anyway. That gives us the flexibility to do what is necessary and sensible to achieve the purposes. So we have to strike a balance between not trying to specify every single one in nor to inadvertently over specify and ending up with either creating monopolies or actually restricting our own ability to manoeuvre when circumstances change.

Mdm Halimah and Mr Zainudin highlighted the need for public awareness and education programmes and dental fee transparency, which will help the public make informed choices. Mdm Halimah also wondered if the establishment of the Dental Specialists Register could lead to higher dental fees. Public awareness and education programmes are indeed in the pipeline, and these programmes will focus on the various types of dental specialties as well as on the oral health therapists. The programmes will help improve the public's awareness of the various dental specialties and when and why they should seek treatment from these specialists.

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The Singapore Dental Council's website will include the list of dental specialists and their specialties. The oral health therapists' role in the provision of dental care and the scope of their work will also be highlighted through public awareness and education programmes.

Are dental fees expected to increase because of the establishment of the Dental Specialists Register? I acknowledge that this can be a concern, but I would like to assure the House that the Dental Specialists Register is to formally recognise and make it more transparent to the public which dentists have upgraded and maintained their skills in specific areas of dentistry and who have not. Incidentally, the dentists who will be placed on the Specialists Register, I am told, are already charging appropriate fees for the higher level of specialised dental care that they are providing. So I take it that when they are doing the higher level of dental care, they would explain the difference to their patients and factor that into their charges.

I would like to assure the House that this Register is unlikely to lead to a fee increase. The reverse, however, may be true as general dental practitioners, who had been performing these procedures and who may have called themselves specialists in some way, will now think twice before quoting or charging higher fees. There is also a relatively healthy referral culture amongst our dentists. The specialists will continue to refer the more basic and less complex cases to the general dental practitioners and vice versa; hence, ensuring right-siting, appropriate care and certainly appropriate charging. To promote dental fee transparency, MOH will be publishing the public dental institution fees for selected dental procedures on the MOH website.

Mdm Halimah asked if the continuing professional education requirements to

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renew a practising certificate could be reduced for older or semi-retired dentists. Continuing professional education will be made a condition for the renewal of practising certificate under the regulations to be enacted after this Bill is brought into operation. A practising certificate allows a dentist to perform the full range of dental procedures on their patients. To safeguard the interest of the public, MOH is of the view that the continuing professional education requirements for older or semi-retired dentists should not be reduced.

Incidentally, oral health therapists will also be required to renew their practising certificates biennially and obtain half the number of continuing professional education hours of the dentists, because of their different scope of work. Dentists and oral health therapists will be allowed to accumulate their continuing professional education points through various means, such as attending conferences, lectures, workshops, attempting online education programmes and self-reading of research journals. Seventy hours, which is the requirement, over two years for dentists work out to be about three hours a month. We feel that three hours a month is not excessive. In fact, it is probably conservative.

By comparison, the dentists in the UK are required to chalk up 250 hours over five years, which is 50 hours per year, whereas what we are asking for is 70 hours over two years.

I thank Dr Fatimah for her many suggestions on how to operationalise the system for continuing education. We will certainly take all those ideas and suggestions into account in implementation planning.

On the use of Medisave for dental services, Mdm Halimah suggested that MOH conduct a review of the dental procedures covered and also update the

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Medisave claimable amount. My Ministry is in the course of an internal review. But I would like to say that, as is already the case now, dental inpatient and some surgical procedures performed in day surgery are already Medisave claimable. We will certainly monitor the needs and developments in our population, in particular the ageing demography, and cross check that with respect to Medisave claims for dental procedures and, if necessary, we will make the adjustments when the need arises.

However, I would like to say something about what Medisave is for. As we all know, Medisave is not something that we would want depleted prematurely.

Therefore, for a long time, the Ministry of Health has advocated and stuck by the position that we should keep it for hospitalisation, ie, in-patient care. Only very recently have we made a very conscious and calculated deviation from it, and that is in the case of the Chronic Disease Management Programme. We do that for a purpose, but we have built in very good safeguards to make sure that we do not inadvertently cause this to be a slippery slope through which the Medisave of CPF members would be prematurely depleted and causing them other untold problems later on.

Similarly, in considering whether or not certain scans relating to the treatment of cancer should be included to be Medisave claimable, we also took this into account very seriously. The point is that whatever we do, we must not end up depleting prematurely the member's CPF savings. So, it is a constant monitoring of the developments and to see in what ways can we move that is sensible, and balancing the immediate and longer term needs. We are conscious that obviously when you allow Medisave to be used, then the outlay on the part of the patient could be reduced, and this is attractive to

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the patient. We have to conduct it in a balanced manner.

On ageing population, I think Mdm Halimah mentioned in particular cost of dentures. I am told that, in general, dentures are not prohibitive in cost and at this moment we do not think this is something for which we want to make it claimable. But we will continue to monitor all such developments.

In her speech on the orthodontal care needs of the elderly, Mdm Halimah believes that our dental education institutions should also provide topics on geriatric dental care and planning the curriculum. The NUS Dental Faculty and Nanyang Polytechnic have incorporated teaching modules on the management of geriatric patients. There is an on-going review of the courses with the intention of increasing instruction, contact time and exposure to elderly patients as well as patients with special needs. One of the primary roles of the soon-to-be regulated oral health therapists would indeed be the management of the elderly in the homes and hospices.

We have also not forgotten the need to update and educate dentists on the changes and developments in the management of the elderly patients. In fact, a comprehensive health manpower development programme, or HMDP, on geriatric dentistry as well as the management of patients with special needs, organised by my Ministry, has been tentatively scheduled to be held in the first quarter of 2008. This will be an ongoing programme which should reach out to all dentists, oral health therapists and related healthcare professionals in Singapore.

Mr Speaker, Sir, I would like now to address one final point by Dr Lily Neo with regard to the quality of care that we are providing to our school children and the parents' belief that with screening

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done in the school, they have completely outsourced the need to those school dental services and therefore there is no need to bring their children for regular dental checkups. First of all, on the quality of screening. At the end of it, I think we need not really look at whether or not it is done by a dentist or by what used to be called a dental staff nurse, or now called an oral health therapist. We look at it by way of the training they are provided, the curriculum, and the final test is really in the outcomes. And if you look at the outcomes that we have achieved so far by way of education, practice of oral hygiene and the decay indicators, and so on, I say the results point to one of confidence rather than one of concern. Therefore, I do not think we can say that because our dental staff nurses or oral health therapists have been the ones doing the screening for our children and, therefore, as Singapore develops, we are shortchanging our children or we are subjecting them to third-world care even in first-world Singapore. I disagree with that.

The point about the parents - I would want to take this opportunity to urge parents to remember that it is important that our children have good teeth. I would agree totally with that view and it should be a partnership. Parents should do their part, the school system does its part, the dental health screening service does its part, and together with daily participation of the children themselves, that kind of approach is the best approach, rather than to say that it is to be consigned to any one group to ensure it.

Sir, I believe I have covered most of the points raised by the Members. I thank Members once again for supporting the Bill.

Dr Lily Neo: Could I seek two clarifications, Sir, please?

On my first clarification, the Minister of State did not reply to my earlier

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question on why can we not use dentist instead of oral health therapist. Does he not agree that oral disease in children will cause the permanent teeth to be missing at the end of the day?

Secondly, could I ask him, in the survey done in 1994, it showed that 3% of the cohort of 40,000 of our 18-year-olds had one or more permanent teeth missing. Should we not aim for no young Singaporeans should have their permanent teeth missing? And, therefore, what will happen if we continue now to use new oral health therapists to give care to our school children? Will the dental health of our school children get worse?

Mr Heng Chee How: Mr Speaker, Sir, I agree with Dr Lily Neo that we should continue to do our best for our children's teeth. I propose a multi-pronged approach - many helping hands, so to speak - everybody participating, including the child himself or herself. In this regard, I would say that the quality of the dental screening provided by the School Dental Service is an integral part of that. I agree. So, whether or not that service provided over the years has yielded the intended positive results, improved results, or has that service over the years done harm and caused deteriorating results in the teeth of our children, as measured by internationally comparable indicators? Dr Neo has just quoted a different figure. I am afraid I do not have that particular chart with me. But for the figure that I have quoted in my speech, clearly between 1994 and 2003, that decay index has improved from one down to 0.54. It therefore conveys to us that we are on the right track, that the care that we are giving through that service to our children has led to further improvement in the dental health of our children.

Yes, it also means that there are still teeth decaying in our children and there are still children losing their teeth. We must continue to persist and further

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improve on this. But the answer to a zero missing tooth challenge, I submit, lies in everybody who is involved in it - the child, the parents, the system working together - that will give us the best chance, rather than to say if I have a dentist checking it, the tooth will not be missing. I do not think that is so.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Mr Heng Chee How].

Bill considered in Committee; reported without amendment; read a Third time and passed.