The view from up there
On the whole, the dental profession is quite a young profession, certainly compared to the profession I joined back in the 70s. This fact gives me something of an advantage over almost everybody practising in that I have a much longer perspective on the profession than they do. This is further enhanced by the fact that many dentists do not practice all their working lives anymore, many changing course.
Consequently, many dentists have little concept of how different their working lives are from those of their predecessors. The first two decades of the health service are often referred to as the golden years in dental practice and in many ways they were. The patients’ fees were tiny, the dentists’ fees were generous and there was a bottomless pit of treatment need. Of course the dentistry was very different to that practised today. There was precious little emphasis on prevention and most of the practitioner’s time was taken up with providing fillings, extractions and dentures.
This was before the days of silicone impression materials, so crowns and bridges were rarely made and many dentists never made them. Impressions for crowns and bridges entailed taking individual impressions of each prepared tooth in composition (a bit like sealing wax), which was retained in a copper ring or cylinder that had been made to fit exactly over the prepared tooth. These rings came in a range of sizes and were cut to fit using special short bladed copper ring scissors. The final individual composite impressions were then related to the rest of the arch with an alginate over impression; very fiddly, time consuming and often not very accurate. A small number of practitioners used reversible hydrocolloid in water cooled impression trays but this tended to be limited to privately practising crown and bridge specialists. A crown or bridge appointment was thus a major event in the day and would probably take up most, if not all, of the working session.
It’s amazing to recall that until the 60s there was little understanding of the relationship between bacterial plaque and periodontal disease. Up until this time there were no high speed turbines or ultrasonic scalers and the only tooth coloured materials were acrylic and silicate. They could only be used in front teeth, had poor marginal seals, readily admitted the ingress of bacteria, had poor colour permanence and often contributed to pulp death. Even when the first composites appeared, Adaptic and Concise, they were placed in unetched cavities, were composed of two pastes mixed together, contracted on setting and so were pretty much as leaky as the older materials and were still only suitable for anterior teeth. They were thought to be poisonous to the pulp, but it was only because they leaked bacteria so much that the pulps could die. So from the patient’s point of view maybe those decades were not so golden.
Imagine if you will, practising today with no high speed cutting equipment, no rubber impression materials, no composites, no glass ionomers, no adhesive products, no Maryland bridges and trying to ablate root canals with little silver rods. And it’s not all about what we didn’t have or didn’t do. We used to do things either completely pointless or actually harmful, like getting rid of periodontal pockets by lopping off large chunks of the patients’ gums, telling expectant mothers and children to swallow fluoride tablets and giving a high dose of penicillin to patients with a history of rheumatic fever prior to scaling their teeth. Of course it’s all very well for me to mock these antics with the wisdom of hindsight and modern knowledge, but I did these things and we all did them with the best of intentions.
The other big change that I can now see from my lofty perch of time is the steady deterioration of the British dental profession’s relationship with the Government. Believe it or not, when NHS dentistry was first introduced in 1948 there were no treatment limits and no patient charges, but in the second year patient charges were introduced and the fees were virtually halved. Despite this, NHS dentistry was a pretty lucrative arrangement for the first two decades; it was only in the mid 70s that the rot really started to set in.
Getting into trouble
Most readers won’t remember the industrial unrest, three-day week, frequent power cuts and eye watering inflation that lead to the winter of discontent in 1977/78 with rubbish piling up in the streets and the dead not being buried. At the time the leader of the Transport and General Workers Union was a man named Jack Jones, an old school shop steward type, who had the ear of the increasingly desperate Labour Government. Wage increases obtained by means of frequent strikes were now in the order of 30% per annum and in 1975, in order to prevent the Government bringing in a statutory incomes policy he suggested that everybody, regardless of their income, should only have a pay increase of £6 a week. This rule was applied to NHS dentists’ gross income, not net income. Imagine the effect that would have on your practices now. Taking account of inflation it would probably mean NHS fees being adjusted to increase your gross by say £25 a week out of which you would have to pay practice expenses running at double digit inflation.
Nevertheless, when I left the Navy and went into general practice in 1978, NHS dentistry still worked well and within a year I was able to buy a three-man practice for the princely sum of £15,000. Of course, I had no business training so running a three-man practice seemed like running a major company and was a very steep learning curve. At dental school we were only taught clinical dentistry; no one taught us how to run a practice, even though that’s what most of us would end up doing. I had heard the stories of practices failing and dentists going bust but I couldn’t see how that would happen if you worked reasonably hard and applied a little common sense, but those days didn’t last. Within a few years I was in trouble, slammed by a continuing shrinkage of NHS fees followed by eye watering 15% interest rates during the time of the UK’s exit from the exchange rate mechanism with Europe in 1992.
Changes for the better
Many changes have of course been for the better. When I qualified and in my first seven years in practice we ‘sterilised’ instruments in boiling water, which of course didn’t really sterilise them at all, and nobody wore gloves. Many surgeries were appallingly unhygienic by modern standards and yet I do not recall any tales of patients being harmed by being treated in these environments. That doesn’t mean of course that none were and I certainly wouldn’t advocate going back to those working conditions, but it does show how easily we can become comfortable with the status quo and feel that there is little room for improvement. Practice regulation has made huge strides in improving and maintaining hygiene and cross infection control despite the irksome and often clumsy way it has been applied via bodies such as the Care Quality Commission, which has made often very necessary regulation unpopular.
In the 70s and 80s, dentists looked with increasingly envious eyes at general medical practice where doctors were paid for simply having patients registered with them. We in general dental practice felt we were on a piece work treadmill compared to our medical colleagues and so, after years of complaining about this, a new contract was introduced in 1991 whereby capitation fees were brought in for the first time. We thought this would change our lives and get us off the treadmill. Well it sort of did, but it also gave the Government another stick with which to beat us. It was the beginning of a slippery slope that led to the hated UDAs (units of dental activity). This also coincided with the launch of the new Denplan scheme soon followed by other private capitation schemes. Many of us at the time thought these would be our escape hatch from NHS dentistry. Were they? The answer to that will have to wait to be covered in a future article.