The age old proverb has it that, 'For want of a nail a shoe was lost, for want of a shoe a horse was lost, for want of horse a rider was lost, for want of a rider a battle was lost, for want of a battle a kingdom was lost...and all for the want of a nail.'

A similar cascade might be applied to a person's lifelong dental experience. It begins with a small fissural cavity in an adult molar, which is treated with an occusal restoration. In due course the restoration leaks, secondary caries invades and a larger occlusal is required. Interproximal caries intervenes and the restoration becomes a mesio-occlusal; then an MOD, perhaps with a buccal or palatal extension. A cusp breaks, undermined by weakened enamel. A full cuspal coverage inlay (or onlay) is created. Then a crown, then a root treatment. Perhaps another crown. Maybe an extraction and an implant. Dentistry. Dentistry begets dentistry...and all for the sake of a fissure sealant.

The preliminary results of the 2009 Adult Dental Health Survey, highlighted in my first editorial of this year1 trumpeted the continuing positive progress of oral health in the UK and I was subsequently fortunate enough to witness a lecture by the Survey's principle author Professor Jimmy Steele (and author of the 'Steele Report').2 I do not wish to make Professor Steele blush, but it was a pivotal piece of presentation. Using bar charts to illustrate his point, he demonstrated to the symposium audience that virtually everyone now under the age of 44 years in England, Wales and Northern Ireland (Scotland declined to participate) has a functional natural dentition and if you go up one further age cohort and include those 45-54 years of age, the figure is still 90%. But what this showed so graphically was that, coupled with a massive decline in caries, thanks arguably to the contribution since the 1970s of fluoride toothpaste, fewer and fewer people have fewer and fewer teeth that have started on the downward spiral which begins with a small occlusal cavity. While those who have, have managed to contain the disease process at that stage. The over-riding message is that there is less and less dentistry to beget less and less dentistry.

Crossing curves cause anxiety

Now, almost certainly this is great news for oral and for general health and we should be delighted. However, there is another curve which is meeting the downward sweeping trend in the need for dentistry and that is the upwardly surging curve of qualified and qualifying dental professionals.

The previous government invested strongly in new dental schools and in expanding the intake of existing schools in response to a 'shortage' of dentists. Yet the shortage was not so much of dentists per se as of dentists who were prepared to work in the NHS. Politically it might have been seen as a positive move, in terms of popularity it may have been perceived as the correct course of action but with a wider view it might also be seen as having the potential to create far more dentists in due course than the levels of disease require.

What concerns me is that some of the tell-tale signs are already beginning to emerge, just as they did in the 1960s and 1970s. It struck me when writing an editor's summary for a research paper in a recent BDJ issue on the utilisation of dental hygienists/therapists.3,4 Trained to provide treatment that represents some 70% of that which a dentist can provide, these professionals are finding that nobody much wants to employ them for their therapist talents and so consequently they are becoming deskilled and potentially disillusioned. It is so very reminiscent of the circumstance that led to these, now team members, being effectively squeezed out from the workforce and their then only school, New Cross, being closed. Is this the thin edge of the same wedge? I hope not, but I fear so.

What I believe is that before very much longer the seismic forces of these two conflicting trends will engage and what I worry is that many erstwhile professionals, until then innocents in the global scheme of things, will find themselves at best under-employed and at worst unemployed. What we need fairly soon, actually, probably now, is some planning, some decision making and some leadership on the dental workforce of the future. By the time we reach the year 2027, for example, (only 16 years away, or the late-thirties for dentists graduating this year) Jimmy Steele's cohorts with 90-100% functional dentitions will stretch downwards from the age of 70. What will there be left to do? It would be sad indeed if for want of a timely review an opportunity was lost, and if, to follow the rhyme, a profession was lost...and all for the want of a thought.