Interview

Straight from the dentist’s mouth

There may be gnashing of teeth, but is there really a crisis in NHS dentistry? healthmatters spoke to Aubrey Sheiham, professor of community dental health at University College, London

Dentists are in the news for threatening to withdraw from NHS work. There is a conflict between them and the government over pay. What is going on in dentistry, and what are the trends behind the political rhetoric?

Britain has too many dentists. This is the simple truth facing the batch of committees currently debating the future of dentistry, a truth which must somehow find expression in the committee reports soon to be published. The Bloomfield committee will focus on dentists’ pay, an ‘Oral Health of the Nation’ working party will think strategically, the Nuffield report will consider the role of dental ancillaries and, at the summit of all this deliberation, a House of Commons select committee will take an overview.

Most dentists working outside hospitals are over-trained for the majority of their work and under-trained for the complex restorative dentistry that is sometimes needed. New technology - especially new filling materials - mean that treatment of dental caries can be carried out easily by dental ancillaries. And tooth decay is not what it used to be, tending to occur only on the biting surface of the tooth, instead of all over it. This allows simple fillings made of the new plastics to be attached without complex drilling, with the result they last much longer. Not only can ancillaries do much of this work, but servicing of filled teeth is only needed every few years.

No more six-monthly check-ups?

That has not made sense for a long time, and is now clearly unnecessary for most people. Every three years may be more appropriate, unless you have significant dental disease. More complicated dental surgery, like tooth implants, is technically demanding and dentists who have had only brief training in the methods have a low success rate. One consequence of this is that they are subject to increasing litigation. Specialist dentists are well trained to do this work, but are mainly confined to hospitals and are less accessible to the public.

Why have teeth improved? Is it the same story as in medicine - better living conditions, better food and so on?

Exactly. Dental health has improved dramatically over the last 30 years, with much less tooth decay and gum disease in the younger population. Better eating habits, a reduction in smoking, and the use of fluoride in toothpaste have caused this change - dentistry has contributed little to the population change, however much it may have benefited individuals. There are exceptions to this trend, of course, in newly-arrived immigrant populations and among the long-term unemployed, who tend to have a very high sugar consumption.

Let me come back to the original question, about the political conflict. Dentistry has become very expensive to government, and this is one cause of the conflict between the profession and the present administration. The threat to do less NHS dentistry and more private work is real enough, but should be put in perspective. Dentists in contract with the NHS are virtually guaranteed an annual net income of £35,000, and their index-linked NHS pension is tied to part of their gross NHS income, so staying with the NHS is very important financially. One problem that all the expert committees currently thinking about the future of dentistry may have is how to reduce the number of NHS dentists without a major fight with the profession!

If you could influence the government, what would you say?

An ideal dental service for the UK would be much smaller than at present. The WHO recommendation for dentists is one, with four ancillaries, to every 20,000 people. In Britain we have one for every 3,000 and in the richer parts of London one for every 1,200 residents. Rationalising dentistry to achieve a ratio of one to 5,000 would be a helpful first step, I think. We need a low-technology form of dentistry for the young population that needs very little dental care, and a more specialised service for older people and the minority of the young who need complex restorative surgery. Ancillaries could provide the low-tech dentistry and make a useful contribution to educating people about oral health. The specialists could easily be based in the larger health centres and have a population remit.

Dentists working for the NHS should be paid by capitation, like GPs, and should work to a contract that specifies their tasks and insists that, say, 5% of their work should be with NHS patients. Some dentists will opt to go private, and we will have to accept that, but rationalising the NHS dentistry service might allow a reduction in charges to patients.