John Appleby in the BMJ opines on whether “Dentistry: should it be in the NHS at all?” (BMJ 2016;355:i5986 ) and comments “…continued inequalities in dental health (partly exacerbated by patient charges) suggest the NHS should perhaps be doing more—not less—to fulfil its fundamental mission on equal access for equal need.” So if dentistry is to be excluded for the majority it is still important for the NEETs. it could reasonably be rationed out of the local Health Service provision for those paying tax….
When the NHS opened for business in 1948 two of its biggest product lines quickly became the supply of spectacles and dentures. According to the British Dental Association, in the first nine months of the NHS, dentists provided over 33 million artificial teeth, 4.5 million extractions, and 4.5 million fillings. Dental surgeries were overwhelmed by the demand for treatment.1 Since then dentistry has moved on from drilling, filling, and extraction—but so too has the public’s dental demands. Are we approaching a point where it will become increasingly hard to justify tax funding for dentistry? Is the perfect smile a medical necessity worthy of public subsidy?
There is no doubt that the nation’s gnashers have improved tremendously over time. In 1968 a staggering 37% of the adult population of England and Wales had no teeth.2 A decade later, in England, this proportion had fallen to 28%, and by 2009 it was just 6%.3 Over the 30 years to 2009, the proportion of people with 21 or more teeth increased substantially; among people aged over 55, for example, it more than doubled from 30% to 63%.3
The improvement in the number and quality of people’s natural teeth reflects general improvements in living standards and diet, but also reductions in smoking, greater use of fluoride toothpaste, and the efforts of the dental profession. The number of dentists has increased—by 20% in the past decade—and they are doing more work, although this has flattened out over the past few years (fig 1⇓).4
Fig 1 Numbers of dentists with NHS activity and courses of dental treatment relative to 2006-07 (value 100) in England for financial years 2006-07 to 2015-16 4
But although the epidemiological trends in dental health have been going in the right direction, we still have not only a substantial burden of dental disease but also considerable variation—across regions and socioeconomic conditions. The national 2013 children’s dental survey, for example, found that around one in seven children had severe or extensive tooth decay, or both.5 The factors associated with an increased risk of severe dental problems included living in Wales or Northern Ireland, eligibility for free school meals, only attending the dentist when they had tooth trouble, and the consumption of sugary drinks.5 Variation in line with levels of deprivation more generally is also evident in adults’ use of dental treatment. For example, figure 2⇓ shows a positive observed relation (correlation coefficient +0.73) between deprivation and the rate of teeth extractions across local authority areas in England in 2015-16 and a negative relation of a similar magnitude between deprivation and fitting of crowns.6
Fig 2 Number of extractions and crowns per 100 courses of dental treatment in England by local authority based measure of socioeconomic deprivation for financial year 2015-16 (author’s calculations)6
One reason for the different direction of relations may be that in 2015-16 the patient charge for an extraction was £51.30 (€58; $64) compared with £222.50 for a crown. As the findings from the children’s survey indicate, variation in use of different types of dental treatment is influenced not only by lifestyle behaviours related to dental health but by the financial barriers to accessing dental care and how much patients are charged for a treatment.
For a health system based on the separation of treatment and ability to pay, the negative impact of dental charges—even substantially ameliorated by exclusions—is shocking. In 2009, for example, around a quarter of adults surveyed across England, Wales, and Northern Ireland said that their dental treatment had been influenced by cost. For those with very poor dental health this figure reached 50%.7 Nearly a fifth of people had delayed treatment because of cost, and a partially overlapping group of around one in seven said treatment had been both affected and delayed because of cost 7 (fig 3⇓).
Fig 3 Influence of cost on choice and timing of dental treatment in England, Wales, Northern Ireland, 20097
Dentists may not have the same denture workload as they grappled with in the early days of the NHS (fig 4⇓), but despite improvements in people’s general dental health, many people still require the services that dentists provide. And continued inequalities in dental health (partly exacerbated by patient charges) suggest the NHS should perhaps be doing more—not less—to fulfil its fundamental mission on equal access for equal need.
Fig 4 What do dentists do all day? Total number of clinical treatments for adults and children, England, 2015-16