Sunday, 28 August 2016

A Tale of Teeth: The Death of Dentistry

Dentistry is dying. To be more precise, it's been murdered.

This may seem a strange statement to make, but I’ll explain.

Twenty years ago, dentistry was the up and coming profession in India, to the extent that the magazine Outlook even published a puff piece on it in circa 1997 (titled Dentists: The New Buccaneers, if I recall correctly).  The article was full of mistakes and idiotic statements, such as the claim that a root canal treatment is “normally” completed in three sessions (and if it isn’t, your dentist is a “mercenary molar mechanic”, a bit of alliteration that must have warmed the cockles of some sub-editor’s heart). But it did make the very important observation that dentistry, once a profession held in contempt and filled with those who couldn’t make it as physicians, was now an increasingly respected, lucrative, and sought after line of work.

And that is exactly what killed it.

Until the late 1970s, there weren’t that many dentists. Indians, back then, didn’t really give a damn about teeth. The attitude was that as soon as your teeth started giving trouble, you’d get them all taken out and replaced with dentures. Obviously this didn’t exactly require dentists with a lot of expertise in the job. Not surprisingly, the average dentist then was a quack who learnt his “skills” as an apprentice with another quack.

I recall being taken by my father to one of these quacks, one “Dr” Prabhat Bhattacharya, while I was a schoolboy. This Bhattacharya was very popular with the Middle Class of the day, which was stingy to the bone, because he was much cheaper than the two qualified dentists this city boasted at the time. He had an old wooden barber’s chair as a “dental chair”, and used a hanging motor – which is actually used for laboratory work like trimming and polishing dentures – to do his “fillings”.

This Bhattacharya looked lugubriously at my teeth, shaking his head mournfully, and declared “The enamel is spoilt, nothing can be done now”. This, I later found, was his standard response to anything that might even need filling, and the way he escaped having to do the incredibly difficult job of removing decayed tooth tissue and replacing it with filling material. Fortunately, my father took me to one of the two real dentists, who filled it with a simple filling, which is still in place to this day, over 30 years later.

Actually, Bhattacharya was absolutely typical of the kind of quack which infested Indian dentistry at the time, and examples of which can still sometimes be found here and there. They can be fairly easily recognised from their signboards. For one thing, they’ll never have a degree after their name (I’ll mention some qualified dentists these days who add an additional “degree” after their names in a moment). For another, their shingles will always proclaim proudly that they’re “specialists” in something, usually dentures. And in a huge majority of these cases, there’s going to be a large, pastel coloured denture on top of the quack’s name – usually, one of the type prevalent seventy or more years ago, with a suction cup on top holding it to the palate.

Since people, as I said, neither cared about their teeth, nor wanted to spend money on them, there was nothing stopping these mountebanks from making a good living.

Their equipment also followed the same standards. The basic dental electric motor, invented in the late 19th Century, only became available to Indian dentists in the early 1970s. Previous to that they’d been using a kind of sewing machine contraption with a treadle. I saw at least two of these still for sale in a dental showroom in the late 1990s and was assured by the dealer that “unqualified doctors” still bought them. As late as the early 1990s, when I was a student, we read about the light-cure unit, which is used to harden filling material after placing it in teeth, in our textbooks – but never saw one, because our dental college did not have a single light cure unit.

This dental college was one of the top in the country then, and even in 2016 is Number Six in the dental college list. Think about that. One of the very topmost dental colleges in the nation didn’t have a basic piece of equipment.

I first saw a light cure unit in 1996 with a private practitioner, in Calcutta. Today, I have no less than two of my own, and can’t imagine surviving without them.

Now, one of the side effects of the “economic liberalisation” of the early 90s was that suddenly people became rather more appearance-conscious, and willing to spend some money on this. Not health-conscious, just appearance-conscious, but as far as dentistry goes, good appearance pretty much implies you have to have good dental health as well. And this, of course, meant in turn that dentistry suddenly began attracting more money than it used to do.

Suddenly, the dental showrooms turned from dingy little holes in the back passages of decaying commercial buildings into swank establishments with plate glass windows proudly exhibiting the latest model dental chairs, rather like car dealerships. Suddenly, they began sponsoring dental conferences, spending money on making themselves known, and, for instance, dentists who’d never even seen a full range of scaling hand instruments were being invited to buy the latest ultrasonic sets. And, like it or not, they had to, because everyone else was doing it.

In fact, I’d call the Dental Revolution of the late 1990s the equivalent of the modernisation of Japan in the Meiji period of the latter half of the 19th Century. Overnight, the material and equipment we’d had to study about in our textbooks, without ever expecting to see or use them, were at our fingertips. Suddenly, the average person discovered that there was much, much more to be done with their teeth than just extract them if they began to hurt.

And, of course, the market for dentists then exploded. From being a neglected sideline, it became a sought after qualification. Instead of young people settling for dentistry as a consolation prize if they didn’t get to study medicine, they went into dentistry as a first choice. Dental colleges suddenly no longer found it necessary to disguise themselves as annexes to older, more prestigious, medical colleges. And the Dental Council of India (DCI), the governing body of the dental profession, saw a golden opportunity.

I should take a moment to speak of the DCI and its equivalent in the medicine line, the Medical Council of India (MCI). Both organisations, at the top level, are rotten with corruption. A couple of years ago, the MCI’s President was even arrested for massive corruption, but of course nothing ever happened to him.

One of the ways this corruption worked is this: remember the bonanza for the dental companies I mentioned? It’s an open secret that the MCI and DCI take kickbacks from the dental and pharmaceutical companies, and do all they can to ensure these companies become richer. And with the sudden growth of dentistry in the late 90s, the DCI got into the business of private colleges.

It was extremely simple – anyone with the right connections would start a private dental college, and charge enormous fees from students to attend it. Many of these “colleges” had hardly any equipment, or patients, or even teachers. If a “surprise” inspection from the DCI was ever scheduled, the college would be tipped off well in time, and the owner would hire dentists to turn up and pose as “teachers” while random people from the streets would be bribed to pose as patients. Everyone, including the inspectors, knew what was going on, of course, but nobody cared as long as the money kept flowing in.

You can well imagine the standard of the “graduates” turned out of these colleges. Now, as I said, my college was primitive in terms of equipment, and some of the teachers were, let’s say, not particularly interested in teaching...but I’m willing to bet a fair amount that I, and any of my colleagues, are highly competent professionals at least as good or better than the best of the West. This is not a boast. It’s based on my observations of the standard of work I, and my colleagues, are capable of...and what I’ve seen of the handiwork of American and British dentists. But these private college degree-shoppers are nothing like that.

I recall more than one of these worthies turning up at my clinic begging rather pathetically for a job. Hardly any of them had even performed a root canal on a molar tooth in their lives. Not one of them had ever extracted an impacted wisdom tooth. And as for doing such surgeries as an apicoectomy, something I did several times as an intern? They’d have a heart attack if anyone had even suggested it.

Not that the DCI people were ignorant of this. Now, to them, dentistry was a lucrative business, and they were intent on pushing their children into it as well. Most of their children didn’t have the intellectual power to get through the rather tough selection exams of the government dental colleges, though...and the government dental colleges had the only real degrees going.

So they found a solution. They’d pay for their kids to enter a private college, and then transfer to a government college. At the time when they first did this – 1992 – it was still totally illegal. So their further solution was to go to the Supreme Court to get it legalised. With money to pay top lawyers, and nobody opposing them, it was easy.

I remember the first set of these transfers who appeared in our college. In 1992, they entered the class immediately junior to us – the “90 Batch”, which started its course in late 1990. Several of them were teachers’ children, and others were the kids of sundry politicians and other bigshots. By then, they’d all already completed a year or more in various private colleges – but you never saw such an incompetent bunch in your life. I remember one, the daughter of a police chief if memory serves, who was asked to adapt a baseplate (a sheet of hard wax) on a plaster cast of the jaw. A beginner normally breaks several baseplates before first succeeding.

Not this young lady. She didn’t break the baseplate. She broke the cast instead.

Now, there was a problem. These transfers, as I said, joined in 1992, about halfway through the academic year as I recall. In order to appear for the year ending examinations, the Second Professional as it’s known (there are four, one at the end of each year), they needed a certain minimum attendance. And of course they didn’t have it. They could not, legally, appear for the exam.

This, of course was not a state of affairs that could be tolerated. The teachers and bigshots hadn’t spent all the money and effort getting their kids into the college to have them balked in this fashion. They tried a trick as transparent as it was guaranteed to succeed.

What they did was claim that the attendance records of most of the class had gone missing. Not all the class – that would have raised questions – but most, something like 75%. So only 25% of the 90 Batch could appear in the Second Professional Examinations unless...

...unless, of course, they were all allowed to appear. And so it was done. And – you’ll be totally astonished to hear – the teachers’ kids all got medals and certificates for their performances.

You’re astonished, right? I thought so.

This was the kind of thing that happened in a government dental college, a good one. In the private colleges, of course, even the minimal checks and balances were dispensed with, and incompetent nincompoops began pouring out by the tens of thousands, with the exact same degree we’d sweated blood to earn.

Can you imagine what this did to the dental profession?

Suddenly, starting in the late 2010s, dentistry was no longer a star-spangled profession. Suddenly, new dental graduates could no longer get a job to save their lives. Suddenly, more than half of them, with a dental degree – even a proper degree, from a government college – found it so impossible to get a job that they ended up looking for work as a call centre operator or a salesperson. And still the number of dental colleges grew, and grew, and grew.

These days, it’s the qualified dentists who, to pretend to be more qualified than they are, have started adding fake “degrees” to their names. One standard one is to call themselves MIDA, which actually stands for Member of the Indian Dental Association. It sounds like some achievement like the British FRCS, but all you need to be an Indian Dental Association member is a dental degree and a couple of thousand rupees annual membership fee. I’m an IDA member myself. There’s nothing special about it. But the shrinking market means qualified dentists now have to pretend to be what they aren’t.

Obviously, nothing of this – nothing at all – was unknown to us dentists. We saw the carnage with our own eyes. But apparently the only ones who didn’t see it, who were wholly oblivious of it, were our masters in the DCI.

Their “reasoning” seemed to go this way: “India has 1300 million people, and x number of dentists. Therefore there are only y dentists per 10000 people, while in other countries there are as many as z dentists for just 1000. Therefore we need more dentists.”

Really? In the first place, and this is something they’d know if they were actual dentists and not simply jacked-up administrators with dental degrees, we need better dentists, not ham-handed incompetents who occupy jobs without the slightest idea of how to do the work. Secondly, almost all Indian dentists are in the cities and towns, and will always remain in the cities and towns, where the market is already saturated. The villages? Well, for one thing, they’re far too poor to afford dental care, and with “economic liberalisation” they’re getting poorer still. Secondly, the villagers of India don’t care about good dental care and never will. To them, a twig is better than a toothbrush, and such newfangled notions as getting your teeth cleaned by a dentist are anathema.

By 2015 the situation had deteriorated to the extent that student composition in dental colleges had changed. Back when I was a student, the law mandated that 50% of the places had to be reserved for women, though the colleges always struggled to make up that number. The average class usually had about 30% females to 70% males. Nowadays, as someone in a position to know assured me, it’s about 80% female to 20% male.

But isn’t that a good thing? Aren’t more women with professional degrees a sign of progress?

Not if you realise that the vast majority of these ladies are never going to land a job in dentistry, and in fact have no intention of landing a job in dentistry. Their only purpose is to add a “Doctor” in front of their names, so as to increase their value in the marriage stakes. That is all it is.

Early this year, one of my former classmates, who’s a teacher in a private college, and is thoroughly disillusioned, informed our alumni WhatsApp group that all private dental colleges in her state have handed the staff a compulsory 40% pay cut. I assume holidays in Hong Kong and Amerikastan are right out in future for her. Quelle horreur.

It was only as late as April 2016 that the DCI finally admitted that something was wrong, and began to take steps. What steps did it take? Did it shut down the useless private degree shops? No. Of course not. All it did was declare that no new dental colleges would be set up.

The golden goose is killed, and they’re still hunting in its beak for teeth. Even though geese don’t have teeth.

But I doubt if private college “graduates” know that anyway.

[Image Source]


  1. Does that mean you got in at a good time or a bad time. It sounds like you started in the very last days of the older era. More money in an industry brings new problems.

    It reminds me of the legal profession here. Someday, maybe on a different account of mine, I'll go into some of that.

    This was fascinating.

    1. I don't know thatthere ever was a good time. Even in the mid 90s I had extreme difficulty finding a job. The dental hospital chains like MyDentist that are ubiquitous in big Indian cities now didn't exist. I recall sitting with a list of hospitals, pathetically calling each of them in turn to ask if there was any job for a dentist going. Not one said there was. After a few very low paying jobs I returned to my hometown and started my own clinic. I suppose it was a good time to do that because I certainly couldn't have done it now. There's too much competition.

  2. I think I've said this, but it's worth repeating:

    I learned all about India (Indjuh) in geography class in school.

    Then I came to the MENA, or Newer Delhi as I call it.

    And every day, I know less and less about India.

    None of what you write was in my geography class that covered everything there was to know about Indjuh.

    But many, many thanks for writing it.


  3. Even though I'm in America, where in my suburb there are probably 30 or more competent dental practices, I'm going to pretend that the situation you describe applies here, to justify my 20-year refusal to have my teeth checked. Thanks for that. #StrangePeopleTouchingMyMouthNoFuckingWay

  4. I am feeling sorry for all those poor people on the end of the teeth the under qualified dentists are working on. Enough to give us all nightmares.


Full comment moderation is enabled on this site, which means that your comment will only be visible after the blog administrator (in other words, yours truly) approves it. The purpose of this is not to censor dissenting viewpoints; in fact, such viewpoints are welcome, though it may lead to challenges to provide sources and/or acerbic replies (I do not tolerate stupidity).

The purpose of this moderation is to eliminate spam, of which this blog attracts an inordinate amount. Spammers, be warned: it takes me less time to delete your garbage than it takes for you to post it.