Government needs to brush up its approach to dentistry

Opinion

After 30 years working as a dentist and running dental practices in the north of England I have experienced several dental NHS dental contracts and worked in areas with the poorest child dental health. In the last 15 years I have also carried out research on children’s teeth from ancient populations through to present day Bradford. The current headlines suggest that we are seeing a return to the levels of dental disease seen in Victorian times, and from my perspective, we need to address this urgently.  

If the Government is serious about solving the dental crisis, we need two main actions: as a nation we need to adopt a policy of prevention based on dietary advice (diet, not brushing, being the most important factor in tooth decay). Second, we need a dental contract that rewards continuing care rather than paying for items of treatment.
 
The Victorians were responsible for creating the world-leading dental service that we have come to expect in Britain: the first professional dentists were registered in the 1850s as a response to the rapid increase in dental decay and poor oral health. This in turn came about because of the cheap import of sugar from 1845 onwards, making it available to the working classes: annual sugar consumption per head rose from 20lbs to 90lbs. There is a running joke in my profession in that we sometimes categorise teeth from earlier historical periods by using the abbreviation ‘BC’, which in this case stands for ‘Before Cadbury’. 

Both Labour and Conservative politicians plan to spend resources funding toothbrushing projects, but without also addressing the sugar intake of our children this will not work. Every time we eat sugar, the pH in our mouth becomes acidic and the bacteria in plaque can start to soften our teeth. Our bodies are designed to produce more saliva during mealtimes which can neutralise these acids, so eating sugary foods at mealtimes is preferable. If we consume sugary drinks or snacks outside these times (creating “sugar attacks”), we increase the chances of tooth decay, particularly in the hour before bedtime (so please don’t give your child a sugary drink or cereal just before bed). Brushing will remove food debris from the teeth and introduces fluoride to harden the enamel surfaces but cannot counteract all the “sugar attacks”.
The Smile4Life programme, which has been successful, has been suggested as the method of delivering the improvements in child dental health and includes promoting dietary advice but if it is to be rolled out nationally it needs proper funding.

So, what can the government do to improve accessibility to dental treatment under the NHS and solve the problem of “dental deserts”? 

The first dental clinics for schoolchildren were set up in the early 1900s with one of the earliest in Bradford in 1909. With the advent of the NHS in 1948, dental treatment became available to all, although the discussions between the government and the dentists at the time echo current problems. There was not enough dental manpower, and the cost of moving from a situation where most adult treatment was paid for privately to fully-funded treatment for all was seen as unworkable. 

The reluctance by current NHS dentists to take on new patients has been brought about by political policies that sought to save money. Payments to the dentist are in bands which do not take account of the actual volume of treatment needed and can result in the dentists who own and run their own businesses being out-of-pocket. Who can blame them for wanting to maintain lists of regular, well cared-for patients rather than take on new people who may need much more treatment for the same money? The Government has proposed a new payment of £15 or £50 per course of treamtment to treat around a million people who have not seen an NHS dentist in two years or more. At most this is only equivalent to two of the current Units of Dental Activity and may still not be enough to pay for the treatment a new patient needs.

The Government’s plan to offer dentists £20,000 over three years to cover under-represented areas is well-meaning but short-sighted. The costs of opening a new practice are high: converting premises, specialist clinical equipment, staffing costs and other overheads, particularly in the first years where the profits will be much lower. The risk of starting up in an area of high demand, where the current contract will not reward the dentist for the higher level of treatment those patients need will discourage any business plan. The dentists that I know want to look after their patients to the best of their ability but ultimately need to earn enough to stay in business.

Could we as a nation create a dental contract that would reward dentists who wish to look after the patients on their list (rewarding a mix of prevention and treatment rather than the perverse incentive of paying per filling)?

One of the private models is to create a dental payment plan where each person pays a set amount each month (like a phone contract). Based on their current dental health (and their likely needs in the future) this guarantees check-ups every six months, access to emergency treatment and would include routine treatments such as fillings, cleaning and polishing. Patients have a choice about paying for more extensive or cosmetic treatments. If a scheme like this was funded by the government with contributions from the public according to their ability to pay it would mean patients and dentists would have peace of mind because they could budget based on a fixed cost or income. Dentists would be incentivised to cultivate meaningful relationships with both patient and dentist aiming to maintain good dental health.

If the Government really wants to put a smile on people’s faces, they need a model that encourages patients to take preventive measures for their and their children's dental health, and for dentists to be able to support this in a caring and professional manner.