Defective margins

It is only human nature that our attention is drawn to certain things – rightly or wrongly – in preference to others. Sometimes our attention is being actively solicited (marketeers do it all the time), sometimes it is driven by our own interests and priorities, but, either way, important matters can get lost or overlooked at the margins when our focus is elsewhere.

This has happened in four areas of dentistry recently. The first is the oral health of the most socio-economically deprived groups within our communities. It is well known that their oral health is likely to be worse than those in more affluent areas, and their oral health needs are greater. They are totally dependent upon the NHS. And, yet, a government which loudly and publicly pledged to raise standards and eliminate inequalities in healthcare, and based its oral health strategy on the same principles – a socialist government, lest we forget – saw fit to introduce a system of delivering primary dental care that virtually excluded those at the margins of society who were likely to be in greatest need. Children in the most deprived families are at particular risk as result of this.

The current access problem was, in many ways, engineered into the 2006 dental contract for dentists in Wales and England. It has since become a predictable product of it because practitioners are not just disincentivised, but actively penalised, for taking on patients with high dental needs. The legislators saw this coming, and the provider contracts incorporated specific clauses to remind providers that they should see past these financial disincentives and
penalties and ‘do the right thing’. But this aside, it would be difficult to imagine a system less likely to reach out and care for the most vulnerable in our society from a dental health perspective. It was a matter of deliberate policy to break the chain of regular dental attendance and to encourage a looser relationship between patients and dental health providers.

Nobody told the patients with high dental needs that they were, in many cases, exiting NHS dentistry through a one-way door, least of all the government whose idea this was in the first place and whose delight at the NICE report on recall intervals was clear for all to see. And we all know why.

In fairness, the DoH has been trying to balance this shameful fact by pressing hard for
fluoridation. But the UDA system is still here and universal fluoridation is not – and that must surely be the ultimate test of commitment.

Dentate elderly
A second area of concern must surely be the dentate elderly. Under the present UDA system they are in trouble if they have a lot of ageing fillings or fixed restorations, in trouble if they have extensive periodontal disease, in trouble if they have active caries (or root caries) and even bigger trouble if this is coupled with impaired salivary function. They are also in trouble if they have poor oral health and need to be treated in a domiciliary setting, and in trouble if they have poor oral health and are one of the millions who have been prescribed bisphosphonates by their medical practitioner. The few that remain are no doubt delighted with the system – but apart from them, if you were trying to design a system that would serve the dentate
elderly less well than this one, you would really be struggling. It truly is a shocker.
One could be fearful that we could see a return to the days when the dentate elderly were treated with forceps and vulcanite – or acrylic, anyway.

Private dentistry
The evidence is starting to gather that the recession has been taking a bite out of the profits of private dental practices and perhaps this is not so surprising given the state of the economy and consumer confidence. The combination of fewer new patients, existing patients extending their frequency of attendance, and a general nervousness about raising fees in these difficult times (or reducing them in an attempt to maintain footfall) would hardly be welcomed by any business.

But this will be the first experience of private dentistry in a downturn since many of these dentists stepped back from their reliance on the NHS, and not every practice will have the business experience to know the smart ways to deal with this in order to preserve practice profitability. Many private practitioners report that the gaps in the book are becoming longer and more
frequent. This is potentially dangerous for patients as well as for the practitioners concerned.

Another development which has been as predictable as it has been unhelpful, has been the upward spiral of gold and other precious metal prices. When this has happened back in the days of fee-per-item, a targeted temporary increase in the relevant fees made it possible to maintain a bit of stability. When this isn’t possible (and UDAs make it mighty difficult because they don’t distinguish between different kinds of Band 3 work), the temptation to postpone the provision of crown and bridgework could move from overwhelming to irresistible.

And speaking of all things precious, it seems that the cardiologists and orthopods in some parts of the country have decided to mount yet another rearguard action against the new NICE/BNF guidance on antibiotic prophylaxis for dental procedures. This seems to be very much a local phenomenon (and in several instances can be traced back to individuals) rather than being
co-ordinated centrally.

The problem that remains is also a personal, idiosyncratic one. Some patients see their historic antibiotic prophylaxis as a kind of chemotherapeutic security blanket without which they can’t sleep at night. Some clinicians never liked giving (and some patients never liked taking) the antibiotics in the first place and they were thrilled to have it officially confirmed that they were better off without the stuff.

What makes life particularly difficult is the influential local consultant cardiologist (or orthopaedic surgeon) telling their patients – and in some cases, writing to them – that they definitely need the antibiotics and any dentist who doesn’t prescribe them is being irresponsible and placing them in mortal danger. How would they react, I wonder, if dentists reciprocated by writing to all their patients and suggesting precisely the reverse? Well actually, it has happened – and let’s just say that the sound of ruffled feathers was deafening.

Our medical colleagues can be a little precious at times, when mere dentists find their voice.
But we too can be at least semi-precious when we sense that a medic is trying to ‘pull rank’ or treat us like second-class citizens. It would all be quite amusing if only real patients weren’t being caught in the crossfire. It needs sorting out because it reflects no credit upon either profession, and the patients really don’t know who to believe.

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