Professionalism in dentistry is not guaranteed by simply issuing a graduation degree. That status can only be granted by the public whom it serves. There are three main characteristics that are shared by any profession: delivering the best possible education to its students, giving priority to public service over self interest, and enforcing regulations and codes of ethics through self government (1). The dental profession holds a special position of trust within society which in turn grants certain privileges not available to the public at large (2). In return, the profession makes a commitment to uphold ethical values and principles, including those of justice, integrity and fairness. Upholding those values remains a daunting challenge. Self preservation is ingrained as the foremost principle of human nature. But dentists worldwide expect their peers to uphold an altruistic ideal. This is a professional obligation and a “social contract”, the basis for granting professional status (3).

Dentistry in India is currently being challenged to maintain its professional character according to the standards described above. This is partly a result of pressures applied to the educational system. This paper hopes to highlight those challenges, offer some solutions that have proven to be effective in Canada, and serve as a call to action.

Distribution of dental colleges

The distribution of dental colleges in India is geographically distorted, with most colleges located in southern and western states like Tamil Nadu, Karnataka and Maharashtra. This is an ethical issue, and the government needs to address imbalances in educational access. Colleges need to be opened in under-represented areas like the North-East. There is also a need to limit the mushrooming of colleges (usually for-profit, private institutions) in the more affluent states. Doing so would promote more equal opportunities for students, irrespective of where they hail from.

Private dental colleges

India is a rapidly developing nation of more than one billion people. Public education, for such large numbers of people, has taxed the system tremendously. In order to meet the demand for coveted professional programmes such as dentistry, private dental colleges have sprung up across the country. According to Utpal Borpujari of the Unesco Courier; “most of the private colleges have no infrastructure, offer poor quality education, and charge very high fees that can’t be afforded by the middle class, let alone the poor.” (4) This raises ethical concerns regarding society’s obligations to ensure the competence of providers, as well as to ensure that access to dental schools is based on merit and not entirely on the ability to pay tuition.

The Dental Council of India (DCI) is a statutory body constituted by an Act of Parliament through the Dentists Act (1948). Its main objectives are to regulate dental education, the dental profession and dental ethics in the country and to make recommendations to the Government of India regarding applications to start new dental colleges or higher courses and increase the number of seats (5). It also maintains educational standards with respect to staff/student ratios, curricula, admission and examination. As with any large bureaucracy, it is one thing to have regulations and another thing to ensure compliance with them. In a recent World Bank policy research publication on the public health system in India, Monica Gupta writes; “There are weaknesses in fundamental public health functions such as enforcement of regulations and an inadequate focus on evaluation and on assessing quality of services.” (6)

For prospective dental students, it is caveat emptor (buyer beware), when it comes to choosing their educational institution. In India, there are 191 dental colleges which are listed as offering undergraduate dental courses at the DCI website (7), of which only 30 are government-run. Often, students in private colleges lack the necessary clinical exposure, and hence are not properly trained. They may offer substandard treatment upon graduation, and charge higher fees in order to recover their greater educational costs.

When some states attempted to prohibit (or promote) the opening of private colleges, the Supreme Court of India ruled that the Dental Council of India as an autonomous federal regulatory body could make independent decisions and overrule provincial decisions (8). States have been known to give permission to start dental colleges to private organisations without approval being granted by the DCI or the central government. Students admitted in these colleges unknowingly risk their professional futures as their qualification might not be recognised, or only be recognised within the geographical boundaries of the state where the college is located. Jurisdictional squabbles between states and the central administrative body thus continue to be another stumbling point for ensuring public safety in India (9). In some instances, private dental colleges increase the intake of students without permission, again jeopardising the future of these students. Currently there are colleges that have been derecognised by the Dental Council of India, but are still functional (10).

Ethics education

Ethics education is gradually being recognised by dentists as a solution for many of dentistry’s professional challenges. It is important for every dental school curriculum to inculcate professional ethics into its curriculum. This entails moving beyond didactic lectures that incorporate formal definitions of ethical principles and codes, towards a more introspective orientation of professional life (11). As a result of media reports of fraud and excessive marketing practices, patients are now beginning to openly question the honesty and integrity of their dentists (12). Dental ethics education is an integral aspect in training dentists to uphold the standards of their profession. It is also essential to ensure continued patient confidence in dentistry. This education needs to start early, be reinforced continually throughout students’ graduate training, and continue after they embark upon their professional careers. Although ethics education cannot guarantee that dentists will practice in an ethical manner, it can give students the tools to uphold dentistry’s professional values.

Social inequities

India historically has had caste system customs instilled into every aspect of society. Even today, as the government attempts to protect elements of society from discriminatory practices, higher castes take exception to having seats set aside for the ‘backward classes’ or ‘backward tribes’ in dental schools (13). We are currently in an era of economic globalisation, which is influencing social and environmental conditions worldwide. As a part of this process, India has taken giant leaps forward in the information technology sector with a resultant increase in both jobs and wealth (14). Globalisation has created more risks to certain groups even as it has created opportunities. The uneven distribution of the economic gains of globalisation has generated even greater social inequities (15). Social inequities have been identified as a determinant in health status as well as on health outcomes on a global scale (16).

Access to dental education is an important socio-cultural consideration. If the dental profession does not ensure access to the poor, it risks becoming an elitist profession that is less likely to have empathy for the socially disadvantaged. By ensuring that the rural population and the socio-economically disadvantaged have access to an undergraduate dental education, the dental profession can better champion the rights of disadvantaged patients. It will also be representative of all the cultural and ethnic constituents of the society in which dentists practice. The resultant ethic of care would improve patients’ improved trust in their dentists.

Access solutions in Canada

The government has to ensure that students from disadvantaged sections of society have attractive job opportunities with a supportive infrastructure when they return to their communities after graduation. This can be done by offering financial incentives like subsidised equipment and office set-up costs in under-serviced areas. Similar under-serviced programmes have proven to be extremely successful in Ontario, Canada (17), making the access less difficult for rural Canadians. However, it has been an ongoing challenge to get physicians and dentists to stay in under-serviced areas after fulfilling their contractual obligations (18). The best method for getting doctors and dentists in under-serviced areas to stay after their contracts expire is to recruit students from those areas. Consequently, in 2005, Ontario opened a new medical school in under-serviced Northern Ontario. The University of Western Ontario has developed a rural residency programme, which has convinced doctors to set up practice in rural communities (19). Such programmes in India would help avoid the phenomenon of fresh dentistry graduates flocking to cities, a problem that also plagues the medical profession.

Another solution to the access issue in remote communities in Canada has been to train auxiliaries to provide basic care in under-serviced communities. In medicine, nurse practitioners currently have an important role in alleviating doctor shortages, and enhancing primary care across the province of Ontario (20). In the area of dentistry, dental therapists are being utilised in eight (of 10) provinces and the territories to provide dental care to First Nations Communities (Aboriginal Canadians) who have endured chronic professional dental neglect from society, prior to the implementation of the dental therapy programme (21).

Conclusion

India is undergoing ongoing change as it attempts to shed the ‘Third World’ image that it has traditionally held. As the country’s socio-economic status improves, greater numbers of people will place even greater demands on the dental profession for service. Dentistry must uphold its professional integrity by not compromising on its social obligations, especially as they relate to professionalism, access, and dental education. If the profession instils proper ethical values in students, modelled by the institutions themselves, the future of dentistry in India will be a proud one.