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Putting the bite on 'traditional' dentists

Following HIV cross-contamination in Battambang, ‘traditional’ dentistry practices are under increased scrutiny

A sign featuring a large tooth hangs outside the shophouse where, for the past eight years, Lim Kim Hout has been practising dentistry – but no university degrees hang on his walls.

“I didn’t go to school; I just learned dentistry from my teacher,” Hout reluctantly admitted this week at his small, grimy clinic near Koralanh Market, a few kilometres from Siem Reap. “I took all his lessons and then started my own practice.”

Dr Hong Someth’s father was a traditional dentist for 40 years.
Dr Hong Someth’s father was a traditional dentist for 40 years. Charlotte Pert

Hout sees one or two patients a day, he said, and cleans his instruments after each, but when asked to reveal what sterilisation method he used, he refused – “No, no, no” – and would not say why.

Patients risk much more than botched tooth extractions by going to these so-called “traditional dentists”: If instruments contaminated with blood and saliva are not properly sterilised, health experts warn they could pass on infectious and possibly life-threatening diseases.

And traditional dentists are surprisingly common in the Kingdom. Some believe they far outnumber properly trained dentists, especially in the provinces.

However, in the wake of the HIV outbreak in Battambang province’s Roka commune discovered late last year – in which 277 people allegedly contracted the virus after being treated by an unlicensed doctor who re-used syringes – there are signs the government might be about to act.

According Dr Callum Durward, head of the dentistry department at Puthisastra University, traditional dentists were once ubiquitous across Southeast Asia.

“Most countries phased them out 20 or 30 years ago,” Dr Durward said. “They registered them as sort of auxiliary dentists and restricted their practice, and then when they retired, no more were allowed.

“Whereas here in Cambodia, they’ve been allowed to continue to practise and train their sons and daughters to continue the tradition.”

University-trained dentists tended to stay in Phnom Penh, while in some areas of Cambodia, traditional dentists are the only option, he added.

Traditional dentists usually only performed simple procedures – tooth extractions, bridges and crowns - and were popular because they were cheaper and had long-standing relationships with their patients, he said.

“Unfortunately, the traditional dentists have never had a chance to learn good cross-infection control procedures, so they’re just doing what they always did: wiping instruments with alcohol perhaps, or steaming them – methods that aren’t reliable in killing viruses,” he said.

Used instruments should be cleaned then soaked in antiseptic over night.
Used instruments should be cleaned then soaked in antiseptic over night. Charlotte Pert

The “gold standard” method of sterilising dental instruments uses a machine known as an autoclave, a kind of pressure cooker that looks like a cross between a microwave and a safe, and which subjects equipment to high-pressure steam at a temperature of about 121 degrees.

“It kills viruses and bacteria and fungus very efficiently,” said Dr Durward.

Other methods, including boiling or steaming instruments, soaking them in disinfectant and wiping them with alcohol, were largely ineffective, he said. Heating them in dry ovens works, but the instruments need to be heated to the correct temperature for a long period of time.

Dr Reiko Tsuyuoka, World Health Organization team leader in emerging disease surveillance and response, agreed that the possible transfer of blood-borne diseases – such as HIV and hepatitis B and C – if traditional dentists re-used unsterile instruments was a concern.

“There has been intensive discussion to improve quality care and regulations of unofficial facilities,” Dr Tsuyuoka said.

Dr Hong Someth, whose Standard Dental Clinic is located on Street 57 (next to the Blue Pumpkin), was one of the first Cambodian dentists to graduate after the Khmer Rouge era and is himself the son of a traditional dentist who practised for more than 40 years.

“It was very helpful for Cambodian people [to have the traditional dentists] because we didn’t have much qualified dentists at all,” he said. “After the Khmer Rouge there were only about 30 left, and they were all auxiliary [trainee or assistant] dentists.”

However, he agreed that they now needed to be replaced.

“The government should register the dentists so we know the number first, and then grade them, because some of them are quite modern, while some are of a very low standard. Some are mobile: they go from village to village only with a bag of instruments on a bicycle or moto and go extract teeth in the village.”

Dentistry involves bodily fluids and precautions are necessary to prevent cross-infection.
Dentistry involves bodily fluids and precautions are necessary to prevent cross-infection. Charlotte Pert

Dr Someth said the risk of disease transmission if instruments were not properly sterilised was “high”.

“People who have got infected won’t know from which source, because most people don’t do their blood test regularly,” he said.

No one knows exactly how many traditional dentists are operating in the Kingdom. Dr Durward and Dr Someth said there might be several hundred in Phnom Penh and many more in the provinces.

A survey conducted by Siem Reap dentist Dr Thim Samphaut last year found there were at least 60 traditional dentists practising in Siem Reap alone compared to just 19 properly trained dentists. Of the traditional dentists, only five had an autoclave.

Forty-four used a steamer.
“I was surprised there were so many more traditional than university trained dentists,” Dr Samphaut said.

All 10 clinics around O’Russey Market and in Stung Meanchey district visited by Post Weekend this week had documents indicating they had a university qualification and licences issued by the Phnom Penh Municipality, and all but one claimed to use an autoclave.

Some said they believed unlicensed dentists were still common in Phnom Penh, others said they only continued to practise in the provinces.

At the Eung Huot Dantal (sic) Clinic (which doubles as a money changer), a dentist who declined to be named said she couldn’t remember what her sterilising machine was called. “It is not necessary to look at the machine that I use, because I use the same thing that most people use,” she said, as a naked toddler slept facedown on a wooden bench nearby. “It’s a Taiwanese machine that you can buy from O’Russey Market.

“It is cheaper and it works fine just like the German one. It has hot and cold water and pressure that can kill bacteria. Most people use this one, even in the big clinics, and they wouldn’t want people to see what they use either.”

The woman said that her qualifications were authentic but claimed that some dentists were able to obtain a licence without going to university.

“They can just buy someone’s name who has the certificate from university to get the licence, and sometimes they offer some bribe money,” she said.

Dr Hong Someth’s clinic has rigorous decontamination procedures.
Dr Hong Someth’s clinic has rigorous decontamination procedures. Charlotte Pert

But it’s not just traditional dentists that have poor sterilisation procedures. Dr Someth, who is vice-president of the Dental Council of Cambodia, conceded that even some university educated and licensed Cambodian dentists were not following best practice sterilisation procedures.

“The quality is not really high … generally not up to standard yet,” he said. “We need to upgrade the knowledge of the private dentists and nurses.”

Even some public health facilities used outdated and inadequate sterilisation equipment, said Dr Chher Tepirou, chief of the Ministry of Health’s Oral Health Bureau.

While the minimum required standard was an autoclave, some places still used dry heat ovens.

“Because the equipment is very old and they don’t have testing equipment to see if it’s enough to kill all the viruses, we are very concerned about that,” she said.

The body responsible for the regulation of unlicensed health practitioners in Cambodia is known as the Committee for Elimination of Counterfeit Drugs and Illegal Health Services, a multi-ministry body headed by the Ministry of Health.

The director of the Department of Hospital Services, Dr Srun Sok, who is on the committee, said a joint Ministry of Health and Ministry of Interior prakas issued two months ago ordered municipal and provincial authorities to collect information about all licensed and unlicensed health services following news of the Roka outbreak.

Autoclaves are considered the ‘gold standard’ of sterilisation.
Autoclaves are considered the ‘gold standard’ of sterilisation. Charlotte Pert

He said the Phnom Penh Municipality had already found at least 312 unqualified traditional dental practitioners and the committee was due to meet again on April 8 to discuss how best to deal with the problem.

When asked why the government had not acted on unlicensed dentists before, Dr Sok said it was a matter of priorities.

“The government’s focus has been on other things, such as reducing mortality rate of mothers and children. Now we have to target this. Maybe this one is not a lower priority [any more]. After Roka commune happened, we are strongly pushing this one to go ahead.

“We will be cracking down on unlicensed dentists along with unlicensed medical practitioners.”

Phnom Penh Municipality spokesman Long Dimanche said he was too busy to answer questions when contacted several times this week.

Even without government action, it appears that traditional dentists are gradually handing over their practices to properly trained dentists – whether bringing qualified dentists into their practices or sending their children to university.

Sok Bopha*, 20, whose father is a traditional dentist trained by his older brother, is now three years into her seven-year dental surgery course at Puthisastra University.

This sign indicates a dental clinic has received a licence from the Phnom Penh Municipality.
This sign indicates a dental clinic has received a licence from the Phnom Penh Municipality. Charlotte Pert

Even though she thought her father was a good dentist, she said he recognised it was important to go to university.

“Because nowadays you need a certificate from university to qualify as a dentist – to get your licence to work or to open your own business and to learn the new techniques,” she said.

She added that her father had bought an autoclave on her advice after she begun studying dentistry.

Dr Durward said the most important thing now was to stop more traditional dentists from being trained informally.

“It seems that it’s just going on and on and on, whereas other countries have stopped it long ago,” he said.

“I’m not saying they need to close down all the clinics, but at least they should register them, train them in good cross-infection control, limit what they do and let them retire later, which is what happened in other countries and is a bit fairer.”

*Some names have been changed to protect identities.

Additional reporting Vann Sreynoch.

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