History of Dentistry In Malaysia

THE EARLY DAYS

The earliest record of dentistry in Malaya dates back to 1869 to the island of Singapore, which was then part of Malaya. The first practitioner was a dentist from Hong Kong by the name of Cheong Chun Tin, who started a private practice after obtaining his qualification in San Francisco. He never thought to formally train his own children. On his demise, his two sons continued their father's practice. They had no formal qualifications and their practice was reflective of the times when unqualified dentists thrived.

Subsequently, a James Logan was recorded as having established his practice in Penang in 1899. In 1912, a Mr. Frank Moffat was recorded as the first dentist in Kuala Lumpur, describing himself as a 'surgical and mechanical dentist'. In the period of World War I (1914-1918), a Japanese dentist was reported to have arrived on the scene in 1916. Henceforth began the migration of dentists into Malaya.

REGULATING THE PROFESSION

The above scenario led to the need to regulate the profession. The latter half of the 1920s saw greater focus in regulating the practice of dentistry. The first Registration of Dentists' Ordinance of the Straits Settlement was enacted in 1924, while the Federated Malay States had a separate Registration of Dentist Enactment in 1931. However, the 1924 Ordinance was deficient in many aspects that it was subsequently repealed in 1933 and a second law called the Ordinance for Registration of Dentists 1933 was passed. This legislation prohibited the practice of dentistry by unqualified practitioners and proved the death knell for the 'roadside dentists'.

Following the end of World War II (1941-1945) in Malaya, legislation was further strengthened by the enactment of the Registration of Dentists' Ordinance in 1948. This legislation only allowed qualified persons to be admitted to the Dental Register. Qualified dental practitioners in public and private sectors were registered under the category of Division I Dentists. However, there was a clause that allowed for admission of unqualified dentists already in practice under a separate section as Division II Registered Dentists. The condition set was that they should successfully complete an examination conducted by the then Dental Board that was set up in the same year.

At that time, there were only 50 qualified dentists in the Register and 166 unqualified dentists. There are now 3,165 qualified private and public dental practitioners and 45 Division II dentists who are registered with the Malaysian Dental Council as of 31 July 2008.

The enactment of the Dental Act 1971 by parliament ultimately gave the much-awaited recognition to the profession and signalled the era of contemporary dentistry in Malaysia. The Malaysian Dental Council (MDC) was established under this Act as the executive body to regulate the profession. The Act elucidates features pertaining to the registration and issuance of practising certificates, maintenance of professional standards, enforcement against illegal dentistry and enabling powers to the profession to discipline its own members. The registration of Division II dentists was subsequently closed in 1972.

The Dental Act 1971 has since undergone some amendments. One was to enlarge the Malaysian Dental Council membership in 1997 from 20 to 24 members, and to strengthen penalties for offences under the Act. Another amendment was to address the acute shortage of dentists in the public sector. This led to the mandated three-year national service for new registrants with effect from 29 June 2001 .

BRINGING ORAL HEALTHCARE TO THE COMMUNITY

It was also in the latter half of the 1920s that the British administrators began to seriously plan for organised dentistry. In 1929, a building in the Pudu area of Kuala Lumpur, formerly housing the poor, was converted into the first government dental clinic. It was demolished 43 years later in 1972, and replaced by the Cahaya Suria building owned by the Urban Development Authority (UDA). Two floors of this 16-floor building have been allocated to house the headquarters of the Dental Department of the Federal Territory of Kuala Lumpur.

In 1946, a Dental Division was established in the Medical Department and a professional man was appointed to head the dental services in Malaya. Mr. Charles F. Mummery was appointed Chief Dental Officer of the Federation of Malaya and the Straits Settlement and was instrumental in charting the course of the public dental services.

The public dental health services began with British dentists (officially Government Dental Officers) employed in the main hospitals and assisted by locally qualified dentists. These dentists visited districts or towns to undertake emergency dental care for one or two days a week. These part-time dental care centres later became full-time government dental clinics manned by qualified dentists.

In 1947, there were 20 dental officers in the public sector. The bulk of services continued to be provided by the private sector then consisting of 50 private practitioners and approximately 400 registered dentists.

Development planning and the introduction of Five-Year Plans began in the post-war reconstruction of colonial Malaya. Planning for healthcare then was little more than a list of government departmental projects designed to make use of whatever monies were available. Following World War II, the Emergency consumed the major part of government resources and energies and little was done in healthcare planning until the establishment of the First Malaya Plan (1956-1960) and the Second Malaya Plan (1961-1965). These Five-Year Malaya Plans justified the expansion of healthcare and proved the catalysts for expansion of public dental services.

Subsequently, the Malaya Plans became Five-Year Malaysia Plans. These Plans have seen public sector oral health services gaining strength and transforming into the comprehensive, decentralised services of today. In 1970, there were only 398 dental clinics of various types. Today in the Ninth Malaysia Plan, the count was 2,188 dental facilities of various types at the end of 2007.

National Concern for Dental Health

Between the years 1952 to 1963, the organised dental profession began to consolidate its concern for national dental health. Although this period saw more practitioners venturing into private practice, the various states, which had previously been under central control, were now given the mandate to develop their own dental health programmes under the direction of Principal Dental Officers. It was at this stage that mobile clinics were established. Oral health services were extended to rural populations with emphasis on school children and antenatal mothers and dental health education was integrated into dental care. Dental clinics were established for the general public and for specific groups such as police personnel, the armed forces, prisoners, lepers and TB patients.

Oral Healthcare for School Children

With the under-18s then forming 50% of the population and exhibiting oral health, which was described as 'appalling', there was serious consideration to provide dental services specific for school children. In 1948, the school dental service was launched. This was the same year the dental nurses' scheme was introduced, whereby this category of personnel was allowed to provide limited dental services under supervision. The dental nurses' scheme was strongly opposed by the profession but was later accepted when it was proven innovative and advantageous to the country.

By 1952, there were 19 school dental clinics. In the following year, dental components were incorporated in health centres. When the Rural Health Service Scheme was introduced in 1955, dental services extended its coverage to the rural population. By Independence in 1957, there were 55 school dental centres and 40 school dental clinics operated by dental nurses. By year 2009, the numbers have increased more than 23-fold to 937 school dental clinics with 16 school dental centres.

The School Dental Service is now the core business of public sector services. Expansion to cover almost 92% of primary and 60% of secondary school children has been largely through the outreach strategy implemented in the early 1970s. Informally and affectionately known as 'flying squads', these mobile teams utilising portable equipment, ensure expansion of services to all areas. Mobile dental teams increased about 43-fold from 13 in 1970 to 560 (including 20 mobile dental clinics) in 2009.

Oral Healthcare for the Public

Oral healthcare for the public was delivered through main dental clinics. A main dental clinic was officially opened in Kuala Terengganu in 1954 to serve the public, soon to be followed by development of main dental clinics in other states.

An important milestone at this time was expansion into specialities with dental officers being sent overseas in oral surgery, orthodontics and dental public health. Specialist services commenced in 1952 with the establishment of oral surgery centres in Johore Bahru and Penang .

Chronological Development of Dental Specialist Services in the Ministry of Health

Year Specialty Discipline
1950 Oral Surgery
1954 Orthodontics
1967 Oral Medicine and Oral Pathology
1984 Periodontology
1985 Paediatric Dentistry
2005 Restorative Dentistry
1961 saw the first dental officer being sent to for a course in Dental Public Health.

Oral Healthcare for Specific Segments of the Population

Special segments of the population also had dedicated access to oral healthcare. In 1953, the Department of Orang Asli Affairs was established to render services to indigenous groups residing in the interior areas of Malaysia . The Health and Medical Division of the Ministry of Rural Development continues to this day to provide dental services to the 'orang asli'.

In 1955, a dental clinic was opened at Sungai Buloh Leprosy Centre, Selangor to cater to its inmates. Police personnel had two additional clinics in Kuala Lumpur and Ipoh . In the 1960s, service expanded to the Pudu Penitentiary in Kuala Lumpur.

In 1958, the Armed Forces Dental Services (AFDS) was established to provide oral healthcare to military personnel and their families. Initially, dental officers were seconded from the Ministry of Health. A major focus is to attain and maintain combat readiness and fighting fitness of troops. The AFDS of today also undertake outreach programmes as civic duty, and has been actively deployed to other countries where Malaysian troops have been stationed.

The outreach concept of service provision was not confined to merely mobile clinics overland. In 1958, the marine dental clinic became operational, dispensing oral healthcare along the Perak River .

PREVENTION FOR ALL: WATER FLUORIDATION

The people of Johor Bahru had been receiving fluoridated water as early as 1957 followed by Penang in 1959 and Simanggang, in Sarawak in 1961. The Johore state government eventually extended coverage to other areas of the state in 1966. In those days, caries levels were high. In 1963, it was cited that the DMF rate among National Servicemen of average age 21.4 years was 10.181. With a wide disparity between treatment needs and care provided, a Committee on Fluoridation of Public Water Supplies was appointed and mandated by the Minister of Health in 1969 to 'study and report upon the feasibility of introducing fluoridation of public water supplies as a public health measure in all states of West Malaysia'. The recommendations for fluoridation of water were based on extensive scientific literature supporting equity of caries-protective effects, safety, efficiency and cost-effectiveness of water fluoridation. The Cabinet Committee accepted the recommendations in 1972. It is estimated that about 75.5% of the population enjoyed the benefits of fluoridated public water supply in year 2009.

DENTAL MANPOWER

Developing Competency and Proficiency of Dental Professionals

The need for qualified dental practitioners to address prevailing dental needs of the day led to the establishment of a dental school in the King Edward VII College of Medicine in Singapore in 1926. The initial response was disappointing with no applicants. Between 1927 and 1929, seven enrolled for the four-year course only to leave during or after the first year.

Undaunted, the institution reinstated the school with the appointment of the first Professor of Dental Surgery and Head of Dental School, Professor Edgar K. Tratman. A five-year course based on the British syllabus was introduced. The first graduate to receive the Licentiate in Dental Surgery (LDS) was in 1933 followed by other undergraduates in 1934.

Despite the Japanese Occupation of World War II (1941 - 1945), there was further development in dental education. The Japanese administration mandated continued training for medical and dental students. Paradoxically, while supporting efforts for trained professionals, the Japanese authorities also issued licences to all who wished to practise dentistry. This led to a tremendous increase in the number of unqualified dentists during this period. On change to British Military Administration at the end of World War II, these unqualified dentists were allowed to continue plying their trade.

With peace in the country, the King Edward VII College reopened in 1946 and candidates who had earlier been awarded diplomas under Japanese rule were made to re-sit their professional examinations. They were duly awarded the LDS on successful completion. The General Medical Council of the United Kingdom conferred official recognition on the LDS (Singapore) in 1946. With the formation of the University of Malaya ( Singapore ) in 1949, the King Edward VII College was renamed the Faculty of Medicine and the dental school remained a department within the Faculty. The degree of Bachelor in Dental Surgery (BDS) replaced the LDS.

A legislation passed in 1961 resulted in the University of Malaya (Singapore) being redesignated the University of Singapore on 1 January 1962 . This also led to the founding of the University of Malaya ( Kuala Lumpur ) in the same year. However, it was only in 1972 that the Faculty of Dentistry, University of Malaya was established with its first intake of 32 students. Development of the Faculty led to the establishment of postgraduate training in 1994, starting with the Master in Community Dentistry and later into other fields of clinical dentistry. A year later in 1995, the undergraduate programme was revised and the period extended from four years to five years. The course gained recognition by the General Dental Council of Great Britain in 1998.

The second dental school in University Kebangsaan Malaysia was established in 1997 and subsequently a third at Universiti Sains Malaysia Kubang Kerian in 1998 to address the projected target of 1 dentist for every 4,000 population by 2020.

Education of Dental Auxiliaries

Dental Nurses
With shortage of qualified dental professionals to meet the needs of 50% of the population under 18 with 'appalling' dental conditions, the dental nurses' scheme was introduced in the civil service in 1948. This was based on a scheme of New Zealand that had by then utilised dental nurses for 25 years. In the Ministry of Health (MOH) the school dental service was also launched in the same year.

In 1949, the Dental Training School was established within the premises of the Penang General Hospital with its first Director, Mr. Charles F. Mummery. The initial group of students were selected from among State Registered Nurses and trained in dental operatory procedures. 1950 saw the graduation of the first batch of 14 dental nurses on completion of a one year course.

Since then, the school has expanded to include dental technologists in 1951 and dental surgery assistants in 1981. It now has its own complex, officially opened in 1966 and designated the Children's Dental Treatment Centre and Dental Training School Malaysia. From 2003 henceforth, the institution is officially known as the Dental Training College of Malaysia. The school being a pioneer in the education of dental nurses in the region also became an avenue for training of dental nurses for other countries as Singapore, Brunei, Burma, Hong Kong and Nigeria.
The advent of the dental nurses' scheme paved the way for the training and utilisation of dental nurses in public service. The dental nurses complement the dentists. They provided simple and repetitive clinical tasks to clientele limited at first to those aged 12 years and below. In 1977, the scope was extended to include children up to 17 years of age. Dental nurses also undertake integrated preventive and dental health education activities. As a member of the dental team, the dental nurse remains to this day under the supervision of the dental officer.
Dental nurses are trained and employed in the public sector only and standards and qualifications are established by the government. Within the public sector, practice guidelines, expected productivity, quality improvement initiatives, continuing education, work ethics and disciplinary procedures are well established. Existing policies indicate that the government will continue to train dental nurses according to the need of the public sector. In fact, demand for dental nurses has far exceeded supply due to expansion of public oral healthcare of the MOH. From the first five nurses in 1949, there are now 2,455 dental nurses in service under the MOH in June 2010.
 
Dental Technologists
Dental technologists began as dental mechanics who were trained at the King Edward VII College, Singapore. A course for dental mechanics was started at the Dental Training School in Penang in 1951. The nomenclature dental mechanics evolved to dental technicians in 1959 and to dental technologists in 1996 to reflect the change in role of this category. In the MOH, dental technologists are expected to not only function in the dental laboratory but also to engage in biomedical engineering aspects in the management of dental equipment. Unlike the dental nurses, dental technologists may engage in private sector employment.
 
Dental Surgery Assistants
In 1951, the Assistant Nurse (Dental) Scheme was introduced with the aim of providing clinical support to dental surgeons. This group of auxiliaries had to undergo a two-year in-service course. Subsequently, in 1959 they were re-designated Dental Surgery Assistants (DSA) to this day. However, the formal DSA training programme at the Dental Training School only began in 1982. In 1993, the mode of training incorporated the distance-learning concept.
 

ORAL HEALTHCARE TODAY

The early national concern thus has since been translated into many milestone developments in public oral healthcare of the MOH under the Five-Year Malaysia Plans. Both public and private sectors provide oral healthcare today with the Oral Health Division, MOH assuming the role of lead agency for the profession. The private sector makes a significant contribution although mainly in the well-populated urban areas.

Public-Private Mix

In the early days, public sector dominated oral healthcare. The balance of private-public sector has seen many changes through various economic climates. At the end of 2000, the balance favours the private sector.
The government not only provides healthcare but also ensures dissemination of health education. This policy led to the natural progression of establishment of a Dental Health Education Unit in 1979 at the then Dental Division, Ministry of Health. In 1994, the Unit was re-designated Oral Health Promotion Unit to better reflect its scope of responsibilities in advocating for health with emphasis on oral health. Similarly in 1996, the Dental Division justified a change of nomenclature to the Oral Health Division to reflect the holistic concept of oral health as part of general health.

Professional Organisation

The development of oral healthcare has been greatly facilitated by the establishment of professional organisations, the largest being the Malaysian Dental Association (MDA). The MDA evolved from its precursor, the Malayan Dental Association that was officially inaugurated in 1938. Professor Edgar K. Tratman was its first President. The name change came in 1963 with the official formation of Malaysia.
Dental professionals may choose to be members of the MDA, which today represents about 80% of qualified dental practitioners. The association contributes towards the advancement of the profession in this country. Currently there are many other offshoot dental organisations representing various interest groups and clinical specialities.

Operationalising Oral Healthcare in The Public Sector

The MOH shoulders the major responsibility for provision of oral healthcare. The large public sector participation gives rise to different modalities of operationalising oral healthcare. The major initiatives in primary oral healthcare of the MOH have been:
The water fluoridation programme officially approved as Cabinet Committee policy in 1972 Integrated oral health promotion with curative care Outreach programmes utilising deployment of oral healthcare outside the confines of the traditional dental clinic Decentralised oral healthcare through various types of dental facilities The establishment of a comprehensive referral system from primary to specialist oral healthcare The establishment of a comprehensive, systematic Incremental Dental Care Programme for schoolchildren.

Improved Oral Health Status

The development of dentistry in Malaysia has seen much improvement in oral health status. To date, 15 dental public health surveys have been undertaken to chart the progress of various oral health status parameters. Data documented since the first schoolchildren dental survey in 1970-19712 and that of a survey in 19973 shows caries decline ranging from 27% in deciduous teeth of 6-year-olds to 57% in permanent teeth of 12-year-olds. DMFX of 12-year-olds has improved three-fold from 3.7 in 1970-71 to 1.6 in Peninsular Malaysia in 1997. Dental caries for the index age of 12 years is now 'low' under the World Health Organisation classification of caries levels.

Planning the Future : The National Oral Health Plan

The government aspires to achieve a developed nation status by 2020. It is from Vision 2020 that the Oral Health Division has taken the lead to formulate a National Oral Health Plan (NOHP) for year 2010. The NOHP documents oral health goals and strategies. Goals are defined for four key oral conditions; dental caries, periodontal conditions, oral malignancies and dental injuries. The Plan also outlines strategies to ensure that all stakeholders will play their respective roles towards improving oral health and quality of life of Malaysians.

CONCLUSION

From humble beginnings as a trade at the turn of the century, dentistry has evolved into a respected biomedical discipline in Malaysia. Reminiscing on the past may seem a futile exercise if there is no distilling of the lessons learnt. In that regard, all the lessons from the past has seen dental health evolve into the holistic agenda of oral health. Progressive developments through the Five-Year Malaysia Plans have resulted in expansion of facilities within the public sector alongside human resource development in dentistry. In tandem with our development, the children of Malaysia show the greatest improvement in oral health status. Discerning Malaysians now enjoy oral health services comparable to that of developed countries. It is envisaged that with the National Oral Health Plan 2010 to chart the course for the future, there will be even greater improvements in oral health to the benefit of Malaysians.

REFERENCES

1. Sundram CJ. A review of dental problems in the Federation of Malaya. J Dent Aux Malaya 1963;1(1):15-24
2. Dental Services Division, Ministry of Health Malaysia. Dental Epidemiological Survey of School Children in West Malaysia 1970-1971. Kuala Lumpur : Government Printers, 1972
3. Oral Health Division, Ministry of Health Malaysia. National Oral Health Survey of School Children 1997 (NOHSS '97). MOH/K/GIG/6.98(RR), 1998

BIBLIOGRAPHY

1. Oral Health Division, Ministry of Health Malaysia. Through the Dental Mirror : A History of Dentistry in Malaysia. Second Edition, 2003
2. Oral Health Division, Ministry of Health Malaysia. Oral Healthcare in Malaysia. MOH/K/GIG/4.2001(BK), August 2001
3. Sundram CJ. The Education of Dental Nurses and Dental Technicians Malaya, Malaysia. J Dent Aux 1963;3(1):28-36
4. Abdul Karim ND. Public Dental Health Services. J Dent Aux 1963;3(1): 4-14
5. Abdul Karim ND. Malaya. In Public Dental Services: World Wide. Ed. Walker RD. ADA-FDI, San Francisco, 1964
6. Oral Health Division, Ministry of Health Malaysia. Notes from the National Archives. Detik Sejarah Pergigian Di Malaysia : 1869-1988
7. Oral Health Division, Ministry of Health Malaysia. Notes from the National Archives. Biography on Health
8. Ministry of Health Singapore. Dentistry in Singapore : 1819-1996. Times Edition Pte Ltd, 1996

 

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