How many teeth do we need?

That's the difficult question we may now have to face, as a new payment system for dentists is set to change the way we look after our teeth. By Jeremy Laurance

There are 32 teeth in the human mouth, including the wisdom teeth at the back that most people have removed. But how many of them do we seriously need?

This question has exercised dentists since the dawn of the NHS with its cash-limited budget for treatment. Now it has surfaced again as ministers plan the introduction of a new payment system for dentists that is designed to transform the way the nation looks after its teeth.

Dental experts are asking how much it is reasonable to expect the NHS to do for us – and how we are going to pay for it as a nation. The question is also relevant for patients who pay privately for treatment – do you really need that crown, bridge or implant costing hundreds of pounds, or could you manage by leaving a gap?

The problem, in a sentence, is that life expectancy is growing, our teeth are decaying, and aspirations are rising. Where once we accepted granny's gap-toothed smile – or gleaming denture – now everyone wants to go to their graves with a natural set of pearly whites. Is it possible?

Teeth evolved to last 45 or 50 years, which has been more than adequate for most of human history. We died before our teeth fell out.

But in the last century or so life expectancy has doubled to almost 90. Teeth are subject to damage and decay from childhood and have very minimal capacity to repair. If they become decayed or lose gum support you don't get it back.

About 20 years ago, when implants – the titanium screws fitted directly into the jaw to replace missing teeth – first came on the dental scene, they prompted a new question: for people with no teeth, how many implants could you get away with?

As the core function of teeth is to allow the individual to eat, researchers considered what constituted the minimum functional dentition. The answer the experts came up with was 20 of the total of 32 teeth in the mouth. In the UK population, among people with more than 20 teeth, the use of dentures falls sharply.

But which 20? Dentists argued that in a system with limited funds such as the NHS, it made sense to concentrate resources on the front teeth and work steadily backwards until the money ran out. Front teeth were more important, cosmetically, than the molars, which were more difficult (and expensive) to treat.

Could there be a way round this? The ultimate treatment for a failing tooth – front or back – is replacement with an implant. Implants are not generally available on the NHS because of their high cost, which ranges from £2,000 to £4,000 per tooth in the private sector. But researchers have calculated that for someone with no teeth, two implants to support a bridge (top and bottom), which would help them eat and substantially improve their quality of life, could be provided for £500 using the bulk-buying power of the NHS.

As the population ages, the pressure to provide implants on the NHS is likely to grow. Yet even at this price it is difficult to see how they will be afforded. The generation over 40 are already heavy users of crowns, root treatments and bridges – and the maintenance costs of this elaborate dental work are bound to grow.

Professor Jimmy Steele, the head of the dental school at Newcastle University and author of the dental review published last year, believes these developments are pushing in one direction – towards higher patient charges.

"Our high-disease, high-treatment past – courtesy of the NHS – is catching us up. Our maintenance costs rise every year and we would quite happily consume everything that the taxpayer could throw at us to save our progressively damaged dentitions from failure and our collective horror at the prospect of dentures. So that leaves us with the rather awkward prospect of higher patient charges within the NHS as a way of keeping a broad dental healthcare system viable. It would be reasonable to ask patients to pay a bit more in order to obtain a reasonably comprehensive service."

His view will not be popular with the residents of Saltash, Devon, where the last NHS practice in the town announced it was going private in September. A new NHS practice is promised by the spring but in the meantime residents of the coastal resort are obliged to travel to neighbouring towns to get NHS treatment.

It was to deal with setbacks like this, caused by the drift of dentists to the private sector, that Professor Steele was called in by the Department of Health to review the 2006 dental contract. Despite increasing spending on NHS dentistry, now standing at £2.8bn annually (including £500m raised in patient charges), in the two years following its introduction the number of patients receiving NHS treatment slumped by more than a million.

To stop the rot, Professor Steele proposed – again – a switch of focus from the drill-and-fill philosophy of the past and its replacement by a new emphasis on maintaining oral health. He recommended a return to patient registration backed by a capitation payment and a new payment for quality of care. To cover the extra costs, payments to dentists for activity such as fillings would be reduced.

Discussions are now under way to select practices to pilot the proposals, which are designed to incentivise dentists to spend more time and effort preventing problems from developing – while still treating those that do. But the bigger problem, which Professor Steele was not asked to address in his report, remains: how to provide a satisfactory dental service to a population with high expectations, from a budget too thinly spread.

NHS dentistry is still cheap by comparison with the private sector, and arguably has helped curb private dental charges, which are lower in the UK than in many comparable countries. But if Professor Steele is right, and there is no reason to doubt his analysis, the pressure to raise patient charges for NHS dentistry looks certain to grow.

News
news

Emergency call 'started off dumb, but got pretty serious'

News
people

Britain First criticised for using actress's memory to draw attention to their 'hate-filled home page'

Arts and Entertainment
Liam and Zayn of One Direction play with a chimpanzee on the set of their new video for 'Steal My Girl'
music

Animal welfare charities have urged the boy band to cut the scenes

News
Russell Brand was in typically combative form during his promotional interview with Newsnight's Evan Davis
people

Thought you'd seen it all after the Jeremy Paxman interview?

PROMOTED VIDEO
Life and Style
ebooksA superb mix of recipes serving up the freshest of local produce in a delicious range of styles
Life and Style
ebooksFrom the lifespan of a slug to the distance to the Sun: answers to 500 questions from readers
Arts and Entertainment
On The Apprentice, “serious” left the room many moons ago and yet still we watch
tv

Greatest mystery about the hit BBC1 show is how it continues to be made at all, writes Grace Dent

Voices
Funds raised from the sale of poppies help the members of the armed forces with financial difficulties
voicesLindsey German: The best way of protecting soldiers is to stop sending them into conflicts
Arts and Entertainment
A scene from David Ayer's 'Fury'
film

"History is violent," says the US Army tank commander Don "Wardaddy" Collier

News
The Edge and his wife, Morleigh Steinberg, at the Academy Awards in 2014
peopleGuitarist faces protests over plan to build mansions in Malibu
News
peopleFox presenter gives her less than favourable view of women in politics
Property
One bedroom terraced house for sale, Richmond Avenue, Islington, London N1. On with Winkworths for £275,000.
property
Sport
Erik Lamela celebrates his goal
football

Argentinian scored 'rabona' wonder goal for Tottenham in Europa League – see it here

Voices
Nigel Farage has backed DJ Mike Read's new Ukip song
voicesNigel Farage: Where is the Left’s outrage over the sexual abuse of girls in the North of England?
News
i100
News
Mario Balotelli has been accused of 'threateningly' telling a woman to stop photographing his Ferrari
peoplePolice investigate claim Balotelli acted 'threateningly' towards a woman photographing his Ferrari
Arts and Entertainment
Paul Anderson plays Arthur Shelby in Peaky Blinders series two
tvReview: Arthur Shelby Jr seems to be losing his mind as his younger brother lets him run riot in London
Voices
Don’t try this at home: DIY has now fallen out of favour
voicesNick Harding, who never did know his awl from his elbow, is glad to see the back of it
Arts and Entertainment
Miranda Hart has called time on her award-winning BBC sitcom, Miranda
tv
Sport
Phil Jones (left) attempts to stop the progress of West Bromwich Albion’s James Morrison on Monday
Chelsea test can be the making of Jones and Rojo, writes Paul Scholes
Latest stories from i100
Have you tried new the Independent Digital Edition apps?

ES Rentals

    Independent Dating
    and  

    By clicking 'Search' you
    are agreeing to our
    Terms of Use.

    iJobs Job Widget
    iJobs General

    DT Teacher - Resistant Materials

    £4800 - £33600 per annum: Randstad Education Manchester Secondary: A full time...

    IT Systems Business Analyst - Watford - £28k + bonus + benefits

    £24000 - £28000 per annum + bonus & benefits: Ashdown Group: IT Business Syste...

    SENCO

    £21000 - £36000 per annum: Randstad Education Chelmsford: SENCO - Benfleet - J...

    Do you want to work in Education?

    £55 - £65 per day: Randstad Education Cheshire: Are you looking to work in Edu...

    Day In a Page

    Wilko Johnson, now the bad news: musician splits with manager after police investigate assault claims

    Wilko Johnson, now the bad news

    Former Dr Feelgood splits with manager after police investigate assault claims
    Mark Udall: The Democrat Senator with a fight on his hands ahead of the US midterm elections

    Mark Udall: The Democrat Senator with a fight on his hands

    The Senator for Colorado is for gay rights, for abortion rights – and in the Republicans’ sights as they threaten to take control of the Senate next month
    New discoveries show more contact between far-flung prehistoric humans than had been thought

    New discoveries show more contact between far-flung prehistoric humans than had been thought

    Evidence found of contact between Easter Islanders and South America
    Cerys Matthews reveals how her uncle taped 150 interviews for a biography of Dylan Thomas

    Cerys Matthews on Dylan Thomas

    The singer reveals how her uncle taped 150 interviews for a biography of the famous Welsh poet
    DIY is not fun and we've finally realised this as a nation

    Homebase closures: 'DIY is not fun'

    Homebase has announced the closure of one in four of its stores. Nick Harding, who never did know his awl from his elbow, is glad to see the back of DIY
    The Battle of the Five Armies: Air New Zealand releases new Hobbit-inspired in-flight video

    Air New Zealand's wizard in-flight video

    The airline has released a new Hobbit-inspired clip dubbed "The most epic safety video ever made"
    Pumpkin spice is the flavour of the month - but can you stomach the sweetness?

    Pumpkin spice is the flavour of the month

    The combination of cinnamon, clove, nutmeg (and no actual pumpkin), now flavours everything from lattes to cream cheese in the US
    11 best sonic skincare brushes

    11 best sonic skincare brushes

    Forget the flannel - take skincare to the next level by using your favourite cleanser with a sonic facial brush
    Paul Scholes column: I'm not worried about Manchester United's defence - Chelsea test can be the making of Phil Jones and Marcos Rojo

    Paul Scholes column

    I'm not worried about Manchester United's defence - Chelsea test can be the making of Jones and Rojo
    Frank Warren: Boxing has its problems but in all my time I've never seen a crooked fight

    Frank Warren: Boxing has its problems but in all my time I've never seen a crooked fight

    While other sports are stalked by corruption, we are an easy target for the critics
    Jamie Roberts exclusive interview: 'I'm a man of my word – I'll stay in Paris'

    Jamie Roberts: 'I'm a man of my word – I'll stay in Paris'

    Wales centre says he’s not coming home but is looking to establish himself at Racing Métro
    How could three tourists have been battered within an inch of their lives by a burglar in a plush London hotel?

    A crime that reveals London's dark heart

    How could three tourists have been battered within an inch of their lives by a burglar in a plush London hotel?
    Meet 'Porridge' and 'Vampire': Chinese state TV is offering advice for citizens picking a Western moniker

    Lost in translation: Western monikers

    Chinese state TV is offering advice for citizens picking a Western moniker. Simon Usborne, who met a 'Porridge' and a 'Vampire' while in China, can see the problem
    Handy hacks that make life easier: New book reveals how to rid your inbox of spam, protect your passwords and amplify your iPhone

    Handy hacks that make life easier

    New book reveals how to rid your email inbox of spam, protect your passwords and amplify your iPhone with a loo-roll
    KidZania lets children try their hands at being a firefighter, doctor or factory worker for the day

    KidZania: It's a small world

    The new 'educational entertainment experience' in London's Shepherd's Bush will allow children to try out the jobs that are usually undertaken by adults, including firefighter, doctor or factory worker