Skip to comments.Dentists and the NHS Toothache
Posted on 06/28/2009 7:43:55 AM PDT by stan_sipple
A DODGY accent and startling false teeth were all that was needed to turn Canadian actor Mike Myers into the British super-spy Austin Powers. In The Simpsons, a television show, Ralph Wiggums dentist scares him into brushing with the decaying snaggle-teeth of the (fictional) Big Book of British Smiles. And there is some truth behind the awful stereotype: the factory workers of Britains Industrial Revolution were fed on sugar from the colonies, and led the known world in dental caries. Early in the 20th century Americans were brushing and flossing while some British dentists still believed that chomping on hard foods kept teeth strong. As recently as 1968, well over a third of British adults had not a single natural tooth in their heads. So it is hardly surprising that, since its founding in 1948, the National Health Service has struggled to cope with the dental needs of the population. During its first two years it supplied 100m false teeth, and the first patient charges it introduced, in 1951, were for dentures. The legacy of bad teeth is still putting NHS budgets under strain. In recent years many dentists have turned to private practice as fees for doing NHS work have been squeezed.
On June 22nd came the latest attempt to fix NHS dentistry: an independent government-commissioned review, the third on the subject in 18 years. Changes in 2006 had been intended to simplify payments for NHS work, and to encourage dentists to concentrate less on drilling and filling and more on prevention. Instead they had unintentionally rewarded dentists for over-treating fewer patients, and forced more than ever to suffer or go private. This weeks review recommends re-complicating rates a bit, and once again paying dentists partly according to the number of NHS patients on their books. It is quite a U-turn.
How could the 2006 reforms have missed the mark so widely? By not being piloted, for one thing: the review team wants its prescriptions tested in a few areas before they are applied nationwide. A less tractable problem is that the evidence about what works is weak. Crowns and fillings are a success only if they last; trials must run for many years, by which time new materials and methods are in use.
That means wide variations in practice, and lots of wiggle-room for dentists to respond to financial incentives, says the reviews lead author, Jimmy Steele, a professor of dentistry at Newcastle University. And respond to the 2006 changes dentists did, doing fewer tricky root canals and more extractions, referring more acute cases to dental hospitals and halving the treatments involving laboratory work.
More generally, the gap between the necessary and the cosmetic is wider in dentistry than other areas of medicine, making it hard to agree on what the state should subsidise. Bridges or implants? How crooked is too crooked? How stained is too stained? The value placed on saving a tooth varies wildly from person to person, the review team found, from nothing at all to as much as £10,000 ($16,500) for a molar. Generations differ, too. Few of Britains heavy metal generationthe 45-75-year-olds with mouths full of amalgamaspire to Hollywood-style teeth, because they look far too similar to their parents and grandparents dentures. Should their taxes go towards capping and bleaching the teeth of youngsters who rather fancy the perfectly even, blue-white look? As for advising on prevention, which is probably the most important part of modern dentistry, there is a problem. Britons who visit the dentist feel cheated if all they get is a quick peer and a reminder to floss. But that may change, and surprisingly quickly. Probably because treatment is easily available to children on the NHS, Britain is one of a handful of OECD countries where 12-year-olds have fewer than one decayed, filled or missing tooth per head. (In Europe, only Danish and German children do as well.) British teeth could soon be dazzling the world.