Dentistry
9.1 This chapter differs in character from the other chapters in our report. In it we deal with a full range of issues relating to NHS dentistry and look at the subject in greater technical detail than is the case with most of the other We felt it appropriate to treat the issues about dentistry in this way mainly because dental health and dental diseases are fairly readily measurable and because there is an obvious prospect of making significant improvements in dental health. We are conscious also that while other aspects of health services have been examined from time to time, often in considerable detail since the NHS was set up, there has been no general review of NHS dental services in the last 20 years.
9.2 In this chapter, we review the development of NHS dental services, assess ways in which NHS dental care can be improved and comment on possible future changes in the pattern of treatment. We have not dealt with education to any degree because of the work being done by the Nuffield Committee of Inquiry into Dental Education which is expected to report in 1980. We welcome this inquiry because of the importance which the changes we recommend will have for dental education.
9.3 There is good evidence that dental diseases have increased considerably in the past two centuries although it is only since 1968 that national surveys have provided any reliable information about their occurrence in the UK. Until 1859 there was no formal qualification for the providers of dental treatment and it was only in 1921 that the practice of dentistry was limited to those who were professionally qualified. There are now more than twice as many registered dentists per 10,000 population in the UK than there were in 1921.
9.4 As with general medical practice, publicly funded dental services predate the NHS. However, by 1948 only two thirds of those who were entitled to sickness benefit were eligible for dental benefits, and of these only six per cent claimed them.
9.5 School dental services provided by local authorities developed slowly after the first service of this kind was set up in Cambridge in 1907. However, since 1953 local authorities have had a statutory duty to make comprehensive dental treatment available to pupils, but undermanning has prevented the school dental service from fulfilling this requirement.
9.6 NHS dentistry is provided by the general dental service, the hospital service and the community dental service. Initially NHS dentistry was free at the time of use but charges to patients were introduced in 1951 and have remained, being increased from time to time to take account of inflation. The manpower and finance required to provide NHS dentistry was seriously underestimated in 1948. In order to improve the supply of manpower, existing dental schools were expanded and one new one established in Cardiff. Dental auxiliaries have been introduced in the hospital and community service. However, despite the visionary concept of a comprehensive national service, the sobering reality is that there has been a continuing failure to match the unmet need for dentistry with the resources required.
The nation’s dental health
9.7 Dental health is part of general health and by any standards the dental health of the nation is poor. This is vividly illustrated by the statistics. Total tooth loss is a good measure of the ultimate breakdown of dental health. In 1968 37% of the population of England and Wales over the age of 16 had no natural teeth. In Scotland in 1972, 44% of the population over 15 had no natural teeth. The prevalence of caries (decaying teeth) and periodontal disease (diseases of the gums, bone and other supporting structures of the teeth) is also high. In 1973, in England and Wales, 31% of children by the age of five had five or more teeth affected by caries and, at the age of 14, five or more permanent teeth of 72% were affected. Of all the general anaesthetics given for dental purposes in the UK in 1976, 56% were given for the extraction of teeth in the 5-14 age-group. Periodontal disease was present in 73% of the 16-34 age-group and in 90% of those over 35 in 1968.
9.8 In spite of these gloomy figures there is a strong impression amongst practising dentists that there has been a continuing improvement in oral health in the last 30 years. There is now much more emphasis on the conservation of teeth. Relatively more money is being spent on periodontal care, orthodontics and more advanced conservation, and relatively less on dentures, routine conservation and surgical treatment. Table 9.1 shows changes in the nature of dental treatment for both adults and children in England and Wales.
9.9 We shall not know with any precision what effect the considerable effort by the dental profession and other factors are having on the control of dental disease until surveys comparable to those of 1968, 1972 and 1973 are repeated. There is some evidence to suggest that edentulousness (toothlessness) may now be proportionately less than it was in 1968. The initial results of the 1978 adult dental health survey indicate a fall in England and Wales in edentulousness in all ages from 37% in 1968 to 29% in 1978 (28% in England: 37% in Wales). The 1978 all ages figure for Scotland was 39%. Table 9.2 shows total tooth loss by age in England and Wales in 1968 and 1978.
TABLE 9.1
Changes in the Nature of Dental Treatment: Adults and Children: England and Wales 1935-1976
| Adults | Ratio permanent teeth filled to permanent teeth extracted | Ratio permanent teeth filled to full dentures provided |
| 1935 | 1:6 | 2:1 |
| 1976 | 6:1 | 50:1 |
| Children | Ratio permanent teeth filled to permanent teeth extracted | Ratio of first teeth filled to first teeth extracted |
| 1938 | 2:1 | 1:22 |
| 19761 | 7:1 | 1:1 |
Source: unpublished research by Dr J S Bulman.
Notes: ‘ England only.
‘OPCS, Adult Dental Health for the UK: 1978 (to be published in 1980).
TABLE 9.2
Proportion of People with no Natural Teeth by Age: England and Wales 1968 and 1978
percentage
| Age | 1968 | 1978 |
| 16-24 | 1 | — |
| 25-34 | 7 | 3 |
| 35—44 | 22 | 12 |
| 45-54 | 41 | 29 |
| 55-64 | 64 | 48 |
| 65-74 | 79 | 74 |
| 75 and over | 88 | 87 |
| All ages | 37 | 29 |
Sources: Gray P G et al Adult Dental Health in England and Wales in 1968, London, HMSO, page 27. OPCS, Adult Dental Health in the UK: 1978 (to be published in 1980).
TABLE 9.3 Child Dental Health: England and Wales 1973
| Children with untreated dental disease 1973 | Age in years | ||
| 5 | 9 | 14 | |
| Caries | 63 | 76 | 62 |
| Periodontal disease | 47 | 78 | 74 |
| Malocclusion (irregularities | |||
| of the teeth) | 17 | 55 | 28 |
| Needing some dental attention | 79 | 96 | 90 |
Source: Todd J E, Children’s Dental Health in England and Wales 1973, London, HMSO, pages 23, 48, 63, 74.
9.10 The five yearly surveys of the Department of Education and Science indicate an improvement of the dental health of five year olds in England but Table 9.3, taken from the 1973 Children’s Dental Survey, gives an indication of the daunting amount of untreated dental disease still present in various age groups.
The present provision of dental treatment General dental service
9.11 Most of the dental treatment carried out in the UK is provided by general dental practitioners under contract to family practitioner committees (FPCs) in England and Wales, and directly to the health authorities in Scotland and Northern Ireland. Like general medical practitioners, they are free to carry out private as well as NHS work. Unlike general medical practitioners, however, they do not have a list of patients but enter into a contract with the patient to render him “dentally fit”. Once the necessary work has been done, the dentist’s responsibilities to that particular patient end and a new contract is entered into the next time the patient visits the dentist. Most dentists work on a continuing family practice basis. They may choose whether or not to accept the patient for treatment under the NHS, but having done so, must not charge him privately for any treatment necessary for dental fitness. A very small number of general dental practitioners are salaried. A few have a salary plus bonus type of remuneration but the vast majority operate independently receiving payments authorised by the Dental Estimates Boards (DEBs) for their NHS patients on a fee for item of service basis or directly from the private patients.
Allegations of failure
9.12 Some of the evidence we have received alleges that in addition to its other difficulties the general dental service is seriously failing the patient. The main complaints made to us by Citizens Advice Bureaux, the Patients’ Association and also by some dental practitioners were:
- the difficulty of finding a dentist who takes NHS patients;
- the unwillingness of some dentists to provide certain kinds of treatment which depend on laboratory support, eg. bridges, crowns, dentures;
- the difficulty of obtaining out-of-hours emergency treatment;
- unavailability of preventive items on the NHS;
- confusion amongst patients about what is available under the NHS and about the level of charges;
- high charges to patients for NHS treatment; and
- decline in the quality of treatment (this complaint has come from some members of the dental profession).
Complaints about NHS dental services occurred in about a quarter of the 166 evidence submissions we received from community health councils (CHCs). Of these, 26 were about the availability of dentistry under the NHS, 11 about the lack of emergency services and nine about patient confusion over charges for NHS treatment.
9.13 While we have had ample anecdotal evidence to cause us some disquiet, we have found it difficult to quantify the seriousness and extent of these complaints. Also, most of our evidence was prepared at a time when there was a dispute between the dental profession and the government over practice expenses and a consequent move away from NHS provision by some general dental practitioners. Some of the complaints appear to be related to the shortage of dental manpower and its uneven distribution. Others are related to the way dentists are paid and we consider these matters in the following paragraphs. Our views on patients’ charges, emergency care, patient confusion over the availability of NHS treatment and the quality of care are set out in paragraphs 9.24-9.27. We consider in 9.66 the question of the availability of preventive items in NHS dentistry.
9.14 About 14,000 general dental practitioners in the UK in 1977 were contracted to provide services under the NHS. Given the present level of disease and methods of practice, regular dental care can be given to considerably less than half the population. The fact that, in general, demand is much lower than need saves the service from breakdown. In addition to the overall gap between need and provision there are wide regional differences in the distribution of dental resources (see Table 9.4) and even wider intra-regional differences, similar to those found generally in the NHS: for example, the dentist population ratio in 1977 in Sunderland was 1:7317 compared with 1:3522 in Newcastle-on-Tyne.
9.15 There has been some improvement in patient attitudes to dental care. Forty-six per cent of adults with some of their own teeth in England and Wales regularly attended a dentist in 1978 compared with 40% in 1968. The proportion of patients seeking regular dental care varies by region and by social class and with the distribution of dentists. The variations in total tooth loss by social class and region are shown in Table 9.5. This is another illustration of poorer health among the less well-off referred to in Chapter 3. The unequal distribution of dental manpower and the difficulty of recruitment in unattractive areas are problems shared throughout the NHS. There is, however, some evidence that as the number of registered dentists increases recruitment is improving in previously neglected areas.
9.16 On the basis of current estimates of need there is a considerable shortfall in dental manpower and a much smaller and locally variable shortfall on the basis of demand. There is a real prospect that a preventive approach through fluoridation of water supplies and effective dental health education could transform this position. A preventive strategy of this kind would lead to the substantial control of dental diseases and people would keep their teeth longer. The reduction of dental decay following water fluoridation could mean that eventually the same number of dentists would be able to serve more people, although this could be upset by a change in the style and content of dental practice to one providing more comprehensive care for individual patients. On the other hand, the effective use of less highly trained manpower for procedures which do not require the skills of the fully trained dentist, would release them to carry out more complex treatment for a larger number of people. In the short term the dental health education component of a preventive strategy would need careful co-ordination to prevent stimulating a demand which could not be met.
TABLE 9.4 Distribution of Dentists in the General Dental Services: UK 1977
| Total number of dentists | Number of principals | Number of assistants | ‘ Number of persons per dentist | |
| ENGLAND | 11,784 | 11,629 | 155 | 3,914 |
| NW Thames | 1,371 | 1,358 | 13 | 2,494 |
| SW Thames | 1,027 | 1,015 | 12 | 2,773 |
| South Western | 935 | 918 | 17 | 3,367 |
| SE Thames | 1,034 | 1,016 | 18 | 3,434 |
| NE Thames | 1,024 | 1,007 | 17 | 3,604 |
| Wessex | 706 | 699 | 7 | 3,674 |
| Oxford | 555 | 553 | 2 | 3,992 |
| Mersey | 603 | 601 | 2 | 4,104 |
| East Anglia | 397 | 395 | 2 | 4,535 |
| Yorkshire | 111 | 767 | 10 | 4,582 |
| North Western | 856 | 851 | 5 | 4,722 |
| West Midlands | 1,079 | 1,064 | 15 | 4,769 |
| Trent | 848 | 829 | 19 | 5,333 |
| Northern | 572 | 556 | 16 | 5,445 |
| SCOTLAND | 1,204 | 1,163 | 41 | 4,293 |
| WALES | 576 | 567 | 9 | 4,794 |
| N IRELAND | 345 | 306 | 39 | 4,413 |
Source: health departments’ statistics.
TABLE 9.5
Proportion of People with No Natural Teeth by Social Class, Region and Country: Great Britain 1978
percentage
| Social Class | |||
| I, II, IIIa | IIIb | IV, V | |
| non-manual | manual | ||
| North | 24 | 35 | 38 |
| Midlands and East Anglia | 23 | 30 | 37 |
| South West | 22 | 22 | 40 |
| South East | 15 | 17 | 33 |
| Scotland | 32 | 38 | 45 |
| Wales | 29 | 38 | 40 |
Source: OPCS, Adult Dental Health in the UK: 1978, (to be published in 1980.)
9.17 Nevertheless, in no other area of health is the way forward so clearly signposted as in the handling of the two major dental diseases. Wholehearted application of known preventive measures would bring treatment needs to manageable proportions. The control of dental caries in children could be a reality in twenty years time and the full effects felt in a generation. Although it is a more difficult area, much can also be done to control periodontal disease.
9.18 Whilst we have no doubt that this approach to the control of dental diseases is the proper way forward, it nevertheless has serious manpower and educational implications. A general strategy for preventive, curative and restorative services should be worked out as part of the review of dental policy which we recommend in paragraph 9.74. Only then can the tasks to be performed and the types of manpower necessary to undertake them be identified, their numbers assessed and educational requirements logically Continuing evaluation is an essential corrective feature of any strategy of this kind. Until the implications of such a shift in policy have been identified we recommend that the dental student entry numbers are not altered but that flexibility in meeting demand is achieved through the increased use of dental ancillary workers.
Remuneration
9.19 At this point we discuss how dentists are paid. Although a secondary issue, it is nevertheless at the root of some of the problems we referred to above. The present system of remuneration for the vast majority of general dental practitioners consists of payment of a fee for each item of service. After completing a course of treatment the dentist claims reimbursement from the DEBs and is paid according to a scale of fees determined annually by representatives of the health departments and the dental profession who meet under independent chairmanship in the Dental Rates Study Group. The scale of fees is designed to provide “the average dentist” with the target net income recommended by the Doctors and Dentists Review Body, plus an amount for practice expenses based on average expenses.
9.20 We received complaints both about the method of payment and its amount. We are concerned here only with the method and, while we do not regard it as our business to offer views on levels of remuneration, it is clear to us that the willingness of dentists to provide treatment under the NHS depends largely on their NHS earnings. It is alleged that a relatively poorly funded piece-work system encourages quantity at the expense of quality. In addition, charges made for work done by the private dental laboratories for such items as the construction of crowns or dentures have been increasing faster than dentists’ NHS fees. A dentist is not obliged to offer treatment under the NHS to a patient who needs an “unprofitable” course of treatment. Any substantial imbalance between the fee scale and laboratory costs will tend to result in people having difficulty in finding a dentist prepared to carry out such This can be particularly noticeable when dentists’ fees are being squeezed by an incomes policy and laboratory costs are rising disproportionately.
9.21 There are other complaints about pay arrangements. These include the suggestion that the fee structure could be considerably simplified and the numbers of items in which the prior approval of the DEBs is required be further reduced; that new forms of treatment are discouraged because of the time it takes for these to appear in the scale of fees; and that the reimbursement of dentists who attend post-graduate courses is inadequate. The system has been condemned by many of those concerned and the British Dental Association’s (BDA) Tattersall Committee took the view as long ago as 1964 that:
“there is no future for the profession, or indeed for general dental practice as an art and a science, in the system of remuneration as presently operated.”
However, the task of finding a more acceptable system is by no means easy. The dental profession, we were told, has actively and regularly explored alternatives for many years.
9.22 There are a number of possibilities in addition to payment by item of service; grant-in-aid, capitation fees, salary, reimbursement of expenses or a combination of some of these. The Tattersall Committee recommended a part-capitation, part scale of fees system which would consist of a “payment for the maintenance of dental fitness and an additional payment by item-of-service for complex dentistry and dentures”. Some of those giving evidence to us recommended that all dentists should be salaried as they are in the community and hospital dental services. Another suggestion was that the salary plus bonus scheme, such as that in operation in several health centres in Scotland and England, should be introduced more widely. The Court Committee in 1976 recommended experimentation with the capitation system for children using an annual fee for maintaining the dental fitness of a child.
9.23 The drawbacks of each method or combination of methods are well known to both government and profession. It seems likely that no one system could suit every type of practice in every part of the country, and it may therefore be preferable for practitioners to opt for a particular method of It appears to us, however, that any systems considered should:
- be geared to an overall strategy for dental care and encourage a preventive approach rather than one which seeks only to repair the effects of disease;
- provide incentives to patients for self care and regular attendance;
- enable practitioners to earn a reasonable income while at the same time providing a good quality and cost effective service;
- enable practitioners to undergo post-graduate training without personal loss;
- ensure a good standard of premises, equipment and ancillary help and the use of materials of high quality; and
- encourage the development of new techniques and co-operative research by practitioners.
We support the recommendation of the Court Committee for an experimental capitation system for children. We recommend profession and government to experiment with other alternatives to the present system of remuneration for general dental practitioners. A method of payment must be tested and seen to work fairly in the interests of both patients and dentists before being generally implemented.
Charges
9.24 We discuss in Chapter 21 the general question of charges to patients, and note here that they are undoubtedly a disincentive to regular dental care. The OPCS Primary Care study1 suggests that 24% of those with no natural teeth and six per cent of those with some natural teeth found the cost of NHS treatment the main reason why they did not visit the dentist or did not go as often as they thought they should.
Out-of-hours services
9.25 Although some dentists conscientiously look after their own patients requiring emergency “out-of-hours” treatment, many do not. More than half the population have no regular dentist on whom to call when they require attention urgently. The problem of obtaining treatment for acute toothache has been made worse by recent additional Monday bank holidays and the now long Christmas and New Year breaks. In a few towns, for example Glasgow, there are emergency dental services, some run on a voluntary or private basis. The British Dental Association has been negotiating with the health departments about the setting up of four experimental schemes in England, Scotland and Wales. However, these have been prevented from starting by a disagreement over the level of fees. We endorse the recommendation in paragraph 53 of the Eighth Report of the Doctors’ and Dentists’ Review Body that agreement on the appropriate level of remuneration should be reached without delay. There is no doubt that individual suffering can be intense. Robert Burns in his “address to the Toothache” called it “thou Hell o’ a’ disease!” We recommend profession and government to make rapid progress with these experimental schemes with a view to early general provision.
Patient confusion about the availability of NHS treatment
9.26 The National Consumer Council study found that:
“there was widespread ‘leakage’ into the private sector and, in general, considerable confusion over the boundary between private and NHS treatment and fees”.
We also received complaints from a number of CHCs to the same effect. There is a clear ethical responsibility for dentists to make plain to patients the basis on which they propose to treat them and they should fulfil it.
Quality of care
9.27 Questions of quality control are dealt with generally in Chapter 12 but there are a number of specific points about dentistry to be made here. We have received no evidence from individual patients or consumer organisations to suggest that the quality of treatment provided falls below an acceptable standard. The evidence from the British Dental Association on this is illuminating:
“In 1975, for example, the Department’s dental officers in England found that completed treatment was ‘entirely unsatisfactory’ in only 72 out of 17,932 cases examined. The number of complaints or queries of such a nature as to give rise to formal Service Committee investigations is well under 300 annually and in over 50% of these the practitioner is exculpated; viewed against a background of 28 million courses of treatment these figures hardly give cause for disquiet.”
However, individual dentists have told us of their concern that the present system of payment puts the emphasis on quantity rather than quality and militates against the achievement of the highest attainable standards. They have told us that anything less than the best is false economy. High standards require accurate diagnosis and painstaking precision work, using first class materials. The present method and levels of remuneration do not help towards this ideal. Standards also depend on other factors, such as professional education, self-respect, peer judgment, type of patient demand and the inspection of work. In the belief that the NHS should strive for the highest standards we make the following suggestions:
- further work should be undertaken on the difficult area of definitions of the quality of dental care;
- some form of protected educational environment is required, to help the new graduate make the transition to general dental practice; continuing education for the general dental practitioner should be improved (in this context we are pleased to note the stimulus which will be provided by the establishment of a Diploma in General Practice by the Faculty of Dental Surgery of the Royal College of Surgeons of England);
- the development of group practices should be encouraged whether in private accommodation or in health centres: group working brings its own stimulus to improved practice and makes peer review possible; and
- the Regional Dental Officer service which carries out random inspections of patient treatment should be strengthened so that on average four or five patients per dentist could be inspected by the service each year.
Health centres
9.28 Dentistry has played a part in the growth of primary care provision from health centres. As we point out in Chapter 7 there are certain advantages to patients from the increased possibilities for co-operation and team work between health professionals working under the same roof. These apply as much to dentistry as to other professions. When health centres are planned consideration needs to be given to including appropriate accommodation and facilities for dentistry. Too often dental suites in health centres have been added as an afterthought. Without adequate planning and provision health centre dentistry can appear a second class alternative to practice in privately provided accommodation. So far only a small number of dentists work in health centres. The reluctance of general dental practitioners to work in them may stem from conditions imposed by health authorities. Health authorities should also make it possible for part-time dentists to work in health centres.
9.29 We are concerned that dental services are insufficiently developed in areas of social deprivation, although demand may not be very high in these We are pleased to note the announcement of an experimental scheme in four selected areas for participating dentists to work in publicly provided premises and to be paid a basic salary supplemented by payment related to output exceeding a certain level. In addition there is a role for the community dental service to initiate provision on a pump-priming basis with the employment of salaried dental practitioners. Demand for dental services in these areas is likely in time to grow to a point where it becomes attractive for general dental practitioners to provide them. New initiatives are required to improve dental care in areas of social deprivation not only by attracting staff to work in them but also by experiment with different approaches to the provision of care. This field might attract the interest and support of the charitable foundations.
Community dental services
9.30 The community dental service was formed from the former local authority school dental service at the time of reorganisation in 1974. The present service provides dental inspection and treatment to school children, pre-school children and to pregnant women and mothers of infants under one year old. Recently the health departments have allowed discretion to health authorities to provide limited facilities for the dental treatment of handicapped adults who are not hospital in-patients. This extension of service is subject to authorities first meeting their primary responsibilities.
9.31 The community dental service employed the whole-time equivalent of approximately 1,980 dental officers in the UK in 1977. They were assisted in their work by approximately 370 dental auxiliaries, 2,900 dental surgery assistants (DSAs), 70 hygienists and 140 dental technicians. The school dental service was introduced at a time when there was no state funded alternative. Most children are now treated in the NHS general dental service. This development, together with the probability of water fluoridation and a falling child population, calls for a careful review of the future functions of the community dental service. This is an important issue which we deal with later in the chapter in the context of the reorganised dental services. The health departments should include this as part of the review of dental policy which we recommend in paragraph 9.74.
Hospital dental services
9.32 Since 1948 there has been a remarkable development of consultant dental services in the UK based mainly on the district general hospitals and plastic and jaw surgery units. The equivalent of approximately 400 consultants are now employed. Appointments are in oral surgery, in orthodontics, and much more recently in restorative dentistry. In general these services are organised and administered in a similar way to hospital medical services. We consider it to be in the patients’ interest that they should remain so. Hospital dentists share with hospital doctors similar problems about their career structure and these are discussed in Chapter 14. The internationally recognised high quality of UK dental consultants has unfortunately not always been matched by NHS provision of staff and facilities.
9.33 Apart from the provision of specialist services, it is the duty of the hospital service to look after the routine dental needs of long-stay patients, such as those in geriatric wards in hospitals. In most areas there has been serious under-staffing of this work, particularly for the mentally handicapped. At the moment it is an area of considerable neglect and is a major gap in the provision of an adequate level of dental care under the NHS. This deficiency must be remedied. We recommend that dental care for long-stay patients should be as readily available as it is for men and woman in the community.
9.34 In addition to the many dental units in district general hospitals, there are 17 undergraduate dental hospitals and one post-graduate institute in the UK. Although they all have important specialist functions, their primary role is to provide clinical facilities for the teaching of students. Most of their patients would otherwise be treated by the general dental service. The dental hospitals have therefore rather a different function from that of general hospitals. It has been suggested to us by the British Dental Association and others that this difference has not been recognised in their funding. The Association, in oral evidence, told us that they thought that as dental hospitals have a national training function, they should be centrally financed, and divorced from the competing claims of district finance. More specific to the dental hospitals is their contention that the service increment for teaching (SIFT) in England and Wales determined by the Resource Allocation Working Party (RAWP) at 25% of the medical equivalent, was wrongly conceived.
9.35 In view of the very different balanced functions and the relatively small component of district services compared with medical teaching hospitals, we recommend that the dental teaching hospitals be directly funded by region or by the health departments. In Scotland dental teaching costs are already allocated directly to those health boards which have dental schools. We also agree with the criticism of SIFT for dental teaching hospitals and are pleased to notice that the DHSS is looking at how to define more accurately the additional costs of dental teaching.
Other dental staff
9.36 Dentists may be assisted by workers of several kinds. They include dental surgery assistants who work closely with dentists much as a theatre nurse works with a surgeon; dental technicians, many of whom are employed in private dental laboratories making dentures and other appliances; dental hygienists, who give advice to patients and carry out preventive procedures; and dental auxiliaries who, in addition, carry out certain operative procedures for children to the diagnosis and prescription of the dentist.
9.37 There is no doubt that increased specialisation and the appropriate delegation of functions by dentists increases the effectiveness of scarce dental manpower. However, increased delegation must be carefully monitored and evaluated to ensure that roles do not become inflexible and that patients do not suffer undue dilution of services. Evaluation must take account also of patients’ preferences: the provision of a personal service like dental care by different people may not prove acceptable to some patients.
Dental surgery assistants
9.38 Dental surgery assistants form the largest group of dental ancillaries. Their numbers are hard to estimate precisely but are in the region of 20,000. If a dentist works with the close support of one or two DSAs, not only does his output increase substantially, but the stresses on him are reduced. There appear to be no problems in recruitment. Through lack of finance, however, undergraduate dental schools are unable to employ DSAs or trainees in sufficient numbers. This results in inadequate training in “close support” dentistry and a substantial waste of undergraduate time.
Dental hygienists
9.39 Dental hygienists undergo a twelve month course of training and work in all branches of the dental service. The number of enrolled hygienists rose from 464 in 1972 to 1,145 in 1978. A much greater increase in their numbers must be an important element in a preventive programme. We support the expansion of training facilities recommended in the report of the Working Party on Dental Services.
9.40 Dental auxiliaries, soon to be known as dental therapists, take a two year training at the New Cross School. The school was opened in 1960 and has an intake of 60 students a year. The number of enrolled dental auxiliaries has risen from 286 in 1970 to 533 in 1978. Dental auxiliaries are mainly employed in the community service and do not work in the general dental service. The functions of auxiliaries are closest to those of dentists and they carry out much routine treatment. The expansion of this category of staff has been opposed by some dentists who fear, for example, that there might be a tendency to fragmentation of care if this group developed a corporate identity, increased educational requirements and adopted inflexible roles. In our view the risk of the formation of a two-tier profession should be recognised and avoided. We endorse the recommendation of the Court Committee for an expansion of training facilities for dental auxiliaries. We trust that the dental profession will now review this matter most carefully in their own and the national interest.
9.41 The expansion of dentistry which we envisage will require more manpower and in particular an increase in the number of ancillary workers who, in support of the dentists, can improve the service provided for the public. In these professional developments, however, patients’ preferences must not be ignored. To his supporting workers the dentist can delegate simpler duties and procedures; but he must supervise and monitor their work to ensure that it is carried out to a high standard of technical efficiency, and the development of the team must be coherent and balanced. A flexible curriculum is needed which would allow joint training in aspects common to all dental ancillary work and make possible movement between the careers of DSA, hygienist and auxiliary. This would facilitate the flexible development of team roles. The training of ancillaries should take place alongside that of dental students.
Dental technicians
9.42 The dental technician is important in all spheres of dental practice. Against a background of general shortage there is a particular shortage of technicians capable of advanced work in the hospital services. We agree with the BDA that their career prospects should be improved, and we recommend that the present technical college/dental hospital training schemes should be expanded to avoid a breakdown in dental services.
The Reorganised Dental Services
9.43 Before 1974 the general dental service, the community dental service and the hospital dental service were organised separately, but at reorganisation all became the responsibility of the new integrated health authorities. The general dental service is, however, administered in England and Wales by the FPC, the community dental service by the Area Dental Officer and the hospital dental service by the District Management Team, or Area Team of Officers and their equivalents in Scotland and Northern Ireland, and the consultants concerned.
9.44 The introduction of the Area Dental Officer (ADO) at reorganisation was greeted with suspicion by many members of the dental profession. The development and integration of dental services require an appointment of this kind in order to represent and interpret the interests of the profession within the NHS management structure, and the priorities of the NHS to the A wide knowledge of dentistry and the dental services needs to be combined with epidemiological and management skills. At the present time, not all ADOs are equipped for this role and it is doubtful whether a full time appointment is justified in every health authority.
9.45 If our proposals for changes in management structure in Chapter 20 are adopted, there will need to be an examination of the appropriate number of administrative dental officers, taking into account the availability of suitably trained and qualified staff. Rearrangement of responsibilities should be introduced in stages as vacancies occur. Firm decisions need to be made to assist those responsible for the training programme.
9.46 In order to use scarce resources efficiently, it is essential to know the extent of disease and its distribution. It is desirable that such dental epidemiological data are available at operational level and this must be one of the most important tasks of the ADO. To facilitate comparisons of local need and progress, we recommend that data should be collected by community dentists on a nationally agreed basis.
9.47 The present Area Dental Advisory Committee represents all dental interests at area level and, together with the ADO, should shape policy for the best use of local resources. In some areas, this has already begun, but it can be achieved only when all concerned recognise the importance of the job and provide it with the support and co-operation it requires.
9.48 Authorities with different needs and resources will not find their best solutions if confined by rigid national policies. The three arms of the dental service tend, for historical reasons, to overlap. It is important at local level that they should have the flexibility and willingness to complement each other’s services.
9.49 We recommended above a review of the future functions of the community dental service. Added weight is given to this by the present uncertainty over the respective roles of the general dental practitioner and the community dental services in the routine treatment of children and the development of specialist community officers, particularly in orthodontics. The community service might develop into a high quality specialist service for children providing skills in, for example orthodontics, general anaesthetics and the management of child and adult handicapped patients; or into a comprehensive service for children removing the treatment of children from the general practitioner; or into the spearhead of a preventive dentistry programme and as a safety net for those children whose parents do not obtain regular care for them through the general dental service.
9.50 A recent collaborative study by the World Health Organisation has raised the question of the appropriateness of double systems with different services for children and adults, and indicates that dental services should be available for all age groups alike in the same environment. Routine treatment for children is readily available in the general dental service and, under present methods of payment, is more economically carried out there. Although it seems that dental care for children may best be provided in the setting of a family practice, there will continue to be a need for a safety net for those children who cannot or will not go to a general dental practice. The size of this net will vary; in some parts of the country the routine treatment element of the school dental service will need to be built up and in others to be run down.
9.51 It is not our intention to go over ground so ably covered in the Court Report, but we want to emphasize that the primary functions of the community dental service should include:
- the annual inspection of all children of school age and where possible preschool children, and the collection of epidemiological data; the encouragement of those needing treatment to attend their family dentist;
- the identification of those who are not getting treatment; the capacity to offer a comprehensive service to those children who are not getting treatment in the general dental service; and
- the organisation of dental health education and preventive measures in school and community.
The presence of a salaried service alongside the independent contractor service allows a potentially flexible method of meeting difficult needs. We recommend that manpower in the community service should be increased so that it can fulfil the primary roles mentioned above. Further development would depend on the identification of reasonable local needs by the ADO and the Area Dental Advisory Committee and local rather than national determination of the best use of resources.
9.52 As we have noted the efficient and flexible use of the community service will depend largely on the quality of the basic data which it can collect and maintain. This is particularly important in keeping track of those children who receive care from a general dental practitioner and those who do not. In Scotland a system has been developed whereby all information about the dental treatment of children either by the community or by the general dental service is recorded in the same way. The linking of that information makes it possible to identify those children who are getting no treatment. Steps can then be taken to offer it to them. We recommend that a similar system is adopted in England, Wales and Northern Ireland.
9.53 As we noted earlier, handicapped patients of all ages, and many elderly patients in particular, need special dental care and it is encouraging that the regulations governing the community dental services have been relaxed so that this care can be given to adults as well as children by that service. Although their treatment is inevitably more time consuming, many handicapped people can appropriately be treated by general dental practitioners. We recommend that the availability of services to the handicapped should be further improved by the payment of fees, authorised on a discretionary basis by the DEBs.
The Future
9.54 Our assessment of dental health and dental care in the UK can give no grounds for complacency. Due to a number of factors, but mainly to the highly efficient and cost-effective service provided by general dental practitioners, there has been a substantial improvement since 1948, but it is also true that the level of dental disease is still unacceptably high. Many of the complaints we have received from the public and the profession spring from the present commitment to a comprehensive service which is not matched by adequate resources. We noted above that dental manpower is not evenly In some areas, NHS dentistry is difficult to obtain whilst new graduates are beginning to find difficulty in getting employment in the areas of their choice. On the whole, demand is probably being substantially satisfied. However, as we have seen, only a minority of those who need treatment seek regular dental care.
9.55 How far the gap between aspiration and performance is closed will depend on the political will. We consider this as part of the general problem of the level of funding and public expectation of the NHS in Chapter 21.
9.56 If we regard the retention of a natural set of teeth for life as a fundamental aim for a national service, the present approach via the treatment of established diseases has little prospect of success. People living in London and the south east of England have the best access to treatment and also the best record of dental health, but no one would pretend that even here the general standards of dental health approach this aim. Even so, it appears from Table 9.4 that if the same access to care as in North West Thames RHA were to be enjoyed by the other English regions then the number of dentists would have to increase by about 60%.
9.57 The dental service is no longer a pain – extraction – denture service but has become substantially a repair service. A major shift in policy towards prevention is long overdue. This will require changes in the attitude and practice of dentists and their teachers and in the public’s apparent indifference to dental health. A much more positive approach to dental health must be adopted if progress is to be made. Four main measures seem to be required:
- fluoridation of water supplies;
- better financial recognition for preventive work by dentists;
- effective dental health education supported by relevant behavioural studies; and
- increased support for biomedical research directed towards prevention.
Fluoridation
9.58 We have been impressed by the weight of written evidence in favour of fluoridation. The Royal College of Physicians of London commented on the enormous body of information on the subject of fluoride and health which justified their conclusions not only on the effectiveness of fluoridated water in caries prevention but also its safety both from personal and environmental Fluoridation of water supplies has also been repeatedly advocated by the World Health Organisation, by the DHSS and by the Court Committee on Child Health Services. Eighty four of the 90 English area health authorities have agreed to the measure, as have four out of eight AHAs in Wales, all 15 health boards in Scotland and all four health and social services boards in Northern Ireland. Nevertheless, only 12% of the population in Wales, 9% in England, 0.9% in Scotland and 0.5% in Northern Ireland receive fluoridated water.
9.59 Despite the fact that fluoride occurs naturally in the water supply in a number of places in the UK with obvious benefits for dental health, and that the safety of fluoridation in recommended quantities is no longer in doubt, an effective campaign waged by a small group continues to dissuade some local authorities from agreeing to it on the grounds that it would interfere with personal freedom. However, as the Royal College of Physicians’ report points out, substances such as copper sulphate and chlorine, aluminium and calcium are already regularly added to water supplies without arousing protest. The Court Report puts the matter succinctly:
“the cost (of not fluoridating water supplies) in unnecessary disease, personal pain and discomfort, misuse of professional resources and national expenditure has been immense.”
9.60 Caries is a disease which attacks almost every child in the UK. We have the power to reduce its incidence substantially without requiring personal effort from any child or parent by using a method which is not only effective and safe but also by far the cheapest available. We are not simply convinced of the wisdom of introducing fluoridation, if necessary compulsorily; we are certain that it is entirely wrong to deprive the most vulnerable section of the population of such an important public health measure for the sake of the views of a small minority of adults for whom its benefits come too late. We recommend that the government introduces legislation to compel water authorities to fluoridate water supplies at the request of health authorities. Otherwise children who cannot choose for themselves will continue to suffer the ravages of a disease which can be substantially reduced by a method that has been shown not to have any deleterious effect.
9.61 What this means in human terms is illustrated by treatment figures from Birmingham where the water supply was fluoridated in 1964 (Tables 9.6 and 9.7). The staffing of the community dental service and the number of practitioners in the general dental service remained remarkably constant throughout this period, as did the number of children, with the exception of a slight rise in 1974 when 23,000 children from unfluoridated Sutton Coldfield were added. In terms of demands on the service these figures provide a striking indication of the relief of misery among the young. Tables 9.6 and 9.7 are based on treatment records with no control group. However, a recent statistically controlled trial in Northumberland on smaller groups of five year olds indicated a very similar reduction in toothache and the need for extractions under general anaesthetics.
TABLE 9.6 Emergency Visits to the Dentist: Birmingham Children 1965-1976
| “Emergency” visits for the relief of pain | |||||
| 0-4 yrs | 5-9 yrs | 9-15 yrs | 15+ yrs | Total | |
| Not | |||||
| 1965 | collected | 5,978 | 3,399 | 891 | 10,268 |
| 1966 | 722 | 5,648 | 3,015 | 602 | 10,037 |
| 1976 | 43 | 994 | 878 | 420 | 2,335 |
Source: Data provided by Birmingham AHA(T) Community Dental Service.
TABLE 9.7 Child Dental Health: Birmingham 1964 and 1977
| Year | General anaesthetics given | First teeth extracted | Permanent teeth extracted |
| 1964 | 22,628 | 44,410 | 13,429 |
| 1977 | 3,851 | 11,487 | 5,290 |
Source: Data provided by Birmingham AHA(T) Community Dental Service.
9.62 In fluoridated areas the first contact with the dentist is now much more rarely a frightening general anaesthetic and the extraction of aching teeth with all that this implies in the formation of negative attitudes to dental Carious teeth are few, they appear later and are much simpler to treat. Following fluoridation, a changed attitude develops towards dentistry, there is a greater uptake of treatment and more interest in the prevention of dental disease.
9.63 Fluoridation of water supplies also makes good economic sense in the short-term. There is no doubt that expenditure on repair work in a dirty mouth is often a waste of time and money. Prevention of dental caries is much less costly than the repair of its effects and fluoridation of water supplies is much cheaper and more effective than other methods of preventing such decay. Because, however, the aim of maintaining teeth for life will be brought nearer, it is likely that more sophisticated care will be demanded in the longer term.
9.64 If general fluoridation were agreed, it would take about two years for production of the main fluoride compound to be expanded to the necessary Installation of equipment might take as little as 18 months in some areas. It is estimated that 75% of the population of Scotland could be receiving fluoridated water within five years of starting the operation, but it might take 25 years to reach as many as 90%. The time factors make it urgent that a decision be made so that work can begin.
Alternative means of using fluoride
9.65 Even if fluoridated water were reaching more areas, there would still be some small communities in the UK not sharing the public water system. We have therefore considered some of the alternative measures which are said to reduce caries. They fall into two categories:
forms in which fluoride can be swallowed to strengthen developing teeth, eg. by fluoridation of individual school water supplies, or flour, milk or salt, or by the use of fluoride tablets. With all these methods, there are significant practical or economic disadvantages or a lack of adequate data on which to form a sound judgment. The use of fluoride tablets has been more widely researched but the results have not been consistent; and
ways of applying fluoride to the surfaces of erupted teeth, eg in fluoride toothpaste. A recent market estimate suggested that fluoride toothpaste sales now account for 90% of all toothpaste sold in the UK. In addition, the application of various formulations of fluoride to the teeth has been investigated in short term clinical trials and found to give encouraging results.
9.66 The general dental service is a treatment service. We doubt whether an item of service system of payment can provide the structure for a fully satisfactory preventive programme. The present fees schedule could be modified to encourage dentists to give preventive advice and individual application of preventive measures. There are difficulties, however. By no means all of the preventive measures used in private practice have been tested sufficiently rigorously for use in a national system. In addition, the introduction of preventive measures generally into the present scale of fees would have major consequences for the fees structure itself. We are pleased to learn that the DHSS are to look at this difficult area.
Dental health education
9.67 Recent work in Sweden has demonstrated the value of plaque control in adults by the intensive use of hygienists. This resulted in the almost total prevention of caries and periodontal disease over the three years of the experiment which covered 555 patients. Regular conventional dental care was given to the control group and proved to be much less effective. This work may well have a fundamental influence on the “best use of resources” and demands further study in the UK.
9.68 While the precise value of personal, intensive dental health education can be measured in such studies as those of Axelsson and Lindhe, public dental health education is a more difficult field. We comment generally on health education in Chapter 5. To increase the number of people cleaning their teeth efficiently, to persuade them to adopt sensible dietary habits, to increase the level of awareness and interest in dental health, to make tooth loss less acceptable and to persuade people to visit a dentist regularly must all be important objectives. However, much more evaluative effort is needed to define the best methods of approach in health education, taking into account the need for it to reach people of all social classes and backgrounds, against a variety of opposing influences. We also note from the White Paper “Prevention and Health” that restriction on advertising which may lead to undesirable dietary habits, particularly in children, is under consideration. We recommend that the health departments pursue an active policy in this field.
9.69 Fluoridation of water supplies would cut the incidence of caries by half and is a true public health measure. The application of other methods of caries prevention, and indeed all the available methods of periodontal disease control, demand personal co-operation and effort. The behavioural sciences have an important part to play in innovation and evaluation of health
Research
9.70 We must look further ahead. The recognition of caries as a bacterial infection is relatively recent, and considering what has been achieved in the conquest of most bacterial diseases this has enormous implications. The Medical Research Council (MRC) has accorded high priority to an expansion of research directed towards counteracting disease processes initiated by bacterial aggregations on the tooth surface. It is from advances in biomedical research that methods for the antimicrobial control of dental diseases are most likely to accrue.
9.71 There appear, however, to be two problems. Research manpower is in short supply. Young researchers need a more adequate training programme and, once trained they are often discouraged from continuing in research by the lack of a career structure. Where clinical trials are involved most projects are funded over too short a period to establish the service value of the findings. Such clinical research has a long time scale and needs sustained support. We recommend that the dental profession should consider ways of overcoming these difficulties.
Conclusions and Recommendations
9.72 There is no doubt that dental health in the UK has improved since 1948, but the prevalence of dental disease remains at an unacceptably high The NHS should strive for the highest standard of care. We have recommended a number of detailed changes which should, if implemented, improve the quality of service offered to patients and the efficiency of the present system.
9.73 The prevention policies which we recommend for the future offer a real and attainable – perhaps unique – improvement in public health. A determined swing of policy towards a greater emphasis on prevention is needed. The most immediate requirements are for the full implementation of water fluoridation and for the funding of research on prevention and dental health education and the training and employment of more ancillary workers. Individual preventive work should be carried out by the general dental service and a way found for providing fees for treatment of this kind.
9.74 While these policies will require time to implement and will not bring changes overnight, their effect on the numbers, composition and training of the dental team will be profound. The appointment of the Nuffield inquiry to which we referred at the start of this chapter is, therefore, timely. Because NHS dentistry is likely to change significantly we recommend that a small committee representing government and other interested parties is set up to review the development of dental health policy and in particular a preventive strategy and the future functions of the community dental service. Its purpose would be to ensure that the impetus for improvement is not lost. Its starting point could be this report and that of the Nuffield Committee.
9.75 We recommend that:
- until the implications of a shift in policy towards prevention have been identified dental student entry numbers should not be altered but flexibility in meeting demands should be achieved through the increased use of dental ancillary workers (paragraph 9.18);
- the dental profession and government should experiment with alternative methods of paying general dental practitioners in addition to a capitation system for children (paragraph 9.23);
- the dental profession and government should make rapid progress to the introduction generally of an out-of-hours treatment scheme (paragraph 25);
- dental care for long-stay hospital patients should be as readily available as it is for men and women in the community (paragraph 9.33);
- dental teaching hospitals should be funded directly by region or health department (paragraph 9.35);
- the present technical college/dental hospital training schemes for dental technicians should be expanded (paragraph 9.42);
- a standardised national basis for the collection of dental data should be introduced (paragraph 9.46);
- manpower in the community dental service should be increased (paragraph 9.51);
- the Scottish system for recording all information about the dental treatment of children in the same way should be adopted in the rest of the UK (paragraph 9.52);
- the availability of services to the handicapped should be further improved by the payment of fees, authorised on a discretionary basis by DEBs (paragraph 9.53);
- the government should introduce legislation to compel water authorities to fluoridate water supplies at the request of health authorities (paragraph 9.60);
- the health departments should pursue an active policy in restricting advertising which may lead to undesirable dietary habits, particularly in children (paragraph 9.68);
- the dental profession should consider ways of overcoming the problems of long-term clinical research in dentistry (paragraph 9.71);
- a small committee representing government and the other interested parties should be set up to review the development of dental health policy (paragraphs 9.18,.9.31 and 9.74).