Abstract
The consequences of the 2006 contract for general dental practitioners have been frequently discussed. Recent government tinkering with it has made little difference and access to NHS dentistry is now difficult, if not impossible, in some parts of the country. The promises of the 1950s and 1960s that teeth could be saved and kept for life have been broken by the concept of ‘units of dental activity.' Older generations in particular have been let down badly by their introduction.
Key points
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The 2006 contract in the United Kingdom for dentists has not been good for dentistry.
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NHS dentists cannot afford the costs of providing the complex dentistry often needed by baby boomers.
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The heavy metal generation are being failed by the NHS.
Teeth for life?
I am a child of the 1940s. A baby boomer. I cannot recall any healthcare provision other than that from the NHS. The doctor's waiting room was small and cramped, probably a room in his house, but there, my ears were syringed and my tonsils examined - for free. If I was bed bound at home, he would draw up outside our house in his Humber Super Snipe and walk up the short driveway carrying his leather case containing his stethoscope and otoscope. Again, no money changed hands, unlike as in my parents' childhood, as they often told me, when they had to pay half a crown for a doctor's visit or sixpence for an extraction at the dentist.
In dental terms, I am a part of the heavy metal generation. In the 1950s, my parents soon picked up on the advantages of the free six-month dental check-up. It became a school holiday routine. Not necessarily pleasant, though, with the smell of the oil of cloves, the gurgling steamy sterilisers, the clank of metal on the crenelated porcelain bracket table, the jointed arms of the whirring drill cords and the dreaded rubbery approach of the gas mask. I still remember the unpleasant dream I had under the not quite deep enough anaesthetic when some rotten baby tooth needed to be removed.
But, despite the bad memories, the six-month check became this ingrained habit, so that our generation could keep our teeth. That was the purpose. Times had changed from before the war. Toothlessness was not inevitable. Teeth were valuable and important, not a disposable nuisance. Cavities, though, still seemed to be inevitable as sugar came off the ration. But teeth could be filled - sometimes painfully - but filled they were, at no cost to my parents, and vast swathes of sound teenage enamel were sacrificed to stop the rot as the metallic magic of silver tin alloy prevented the previously inevitable arrival of the gas mask.
And thus came about our post-war heavy metal generation. We have our teeth because the NHS provided free salvation from the ravages of Jammie Dodgers and Sherbet Dip Dabs. The dentists of the 1950s and 1960s did what they could to save our teeth rather than extract them. They used the materials they had - basically amalgam - but the materials they had required mechanical cavity retention and hence the removal of much sound enamel and dentine for occlusal locks and undercuts, according to the mantras of G. V. Black. And they were rewarded for doing so, with a fee scale which paid for each item of treatment. The NHS encouraged this slaughter of our sound fissures and the massacre of our marginal ridges because, at the time, there was no alternative if our generation was to keep our teeth.
Today, the consequences of those early decades of NHS dentistry are clear. Those changes of attitudes to regular check-ups and the availability of restorative treatments were largely effective. Edentulous rates have fallen dramatically. Most of my baby boom generation have at least some of their teeth. Many of us have most of them. And I for one am grateful for the amalgam pluggers of old. But the consequences are more significant than just a number count of standing teeth.
The consequences have greater significance for individual teeth. Setting amalgam expands, setting up stresses in the tooth structure. Cusps are weakened by retentive undercuts. Dentine becomes less elastic as age increases and so cusps fracture. In the worst cases, teeth suffer vertical fractures through to the furcation. The long-term irritation from acidic lining materials or the thermal conductivity through metal inflames the pulp and it dies. Wear and tear take their toll. The restoration of these teeth is complex, often requiring endodontics and cuspal coverage to retain what is left of the natural tooth structure. Treatment and treatment planning is potentially made even more difficult in older patients - my heavy metal generation - by medical issues and polypharmacy.
There is, surely, a reasonable expectation that dentists and the NHS of today will cope with these complexities. After all, the NHS dentists of the 50s and 60s did their best to help me keep my teeth with the materials they had available to them at the time. Why should that not be possible now? Materials have changed, adhesive dentistry has arrived and ‘minimally invasive' is the mantra now. Dentine pins are in the bin and thermoplastic sealers for root canals have superseded the sprouting gutta percha points of lateral condensation.
However, for many, this is not happening. And the answer lies in the 2006 dental contract. Instead of being remunerated for specific treatments, dentists were to be remunerated for ‘activity' (and sometimes, inactivity). In 2006, the fee to be earnt for an extraction was the same as for a molar root filling. The fee for one crown was the same as for two crowns. The fee for one denture was the same as the fee for two. The time-consuming nature of the discussions to be had about the alternative treatments for a heavily broken-down tooth were forgotten. The complexities of dentistry for the heavy metal generation were completely ignored in that contract. The consequences of multiple loss-making treatments were too much for the small business model of dental care. Recent tinkering with the contract will not change this. On economic grounds alone, ‘activity' for my generation probably means a return to the days of blood and acrylic.
The 2006 contract may work for the well-cared-for mouths of a post-fluoride generation. Some may argue that the contract had to change because fee-per-item remuneration was abused by some with overtreatment. Despite that, the replacement contract has failed baby boomers. The concept of dental care from the cradle to the grave, under the care of a national health service to retain your teeth for life, has been completely blown out of the window.
John Launer, a former general medical practitioner (probably a fellow baby boomer, possibly not old enough to have driven a Humber Super Snipe) wrote recently in the British Medical Journal about the current deficiencies of the NHS. He said that, in his old age, he is now frightened that he will end his days ‘on a ward where staff, however hard they try, won't have the time or resources to give me the care I need...we lived our lives with the hope of a better NHS, a better old age...that hope has been betrayed'.1
The same can be said of NHS dentistry. Baby boomers have been betrayed by units of dental activity.
References
Launer J. A generation betrayed. BMJ 2023; 381: 901.
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Hellyer, P. Teeth for life? Some hope.... Br Dent J 236, 95–96 (2024). https://doi.org/10.1038/s41415-023-6711-y
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DOI: https://doi.org/10.1038/s41415-023-6711-y