The Big Question: What is so wrong with NHS dentistry that people are pulling their own teeth?

Why are we asking this now?

People unable to find an NHS dentist have become so desperate that some are resorting to pulling their own teeth, according to a survey published yesterday by the Commission for Patient and Public Involvement in Health. Of 5,000 people questioned, three quarters said they had been forced to go private because they wanted to stay with their NHS dentist who was switching or they could not find an NHS dentist.

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One in 10 – 500 people – said they did not have a dentist at all and almost one in five said they had gone without treatment because of the cost. A patient in Lancashire said he had removed 14 of his own teeth himself. One in Harrow said: "Because I could not afford the treatment cost, I had to extract my own tooth on one occasion." Another in Wiltshire said: "I took most of my teeth out in the shed with pliers. I have one to go."

How come patients are having to remove their own teeth?

The Government claims there are more dentists working in the NHS than ever before and that 93 per cent of patients receiving NHS treatment say they were happy with it. Official figures show there are 21,047 dentists with NHS contracts, 4,000 more than a decade ago in 1997.

However, dentists are free to divide their time between NHS work and private work as they choose – and the evidence suggests that they are spending more time doing private work and less on the NHS. In the two years from March 2005 to March 2007, 56 per cent of the population saw an NHS dentist – down from the all-time peak figure of 60 per cent.

Last March, Rosie Winterton, former health minister, said in a parliamentary answer that two million patients who wanted NHS treatment were unable to get it. That admission came eight years after Tony Blair pledged at the Labour Party conference in 1999 that everyone would have access to an NHS dentist.

Does Gordon Brown have an NHS dentist?

No. Earlier this year, when Chancellor of the Exchequer, he had root canal work done by a private dentist, Mervyn Druian, who runs a surgery in Primrose Hill in north London. Mr Druian charges up to £650 for root canal work according to press reports, compared with £340 charged more commonly by private dentists and £43.60 on the NHS.

A Treasury spokesman said in March: "The Chancellor of the Exchequer does not go for regular NHS check-ups and as such, under the old system, he could not stay on an NHS list. As a result, whenever he has needed to go to the dentist over the past decade he has been to see Mr Druian, an old friend of [his wife] Sarah Brown's family." Mr Druian said that Mr Brown had "a good pain threshold" – he did without an anaesthetic for the root canal work.

Why are dentists going private?

Surprise, surprise, because the pay is better. (See above). Dentists also say the higher rates they can charge mean that they can spend more time with patients and do a better job, which is more satisfying. The increasing trend to private work accelerated in April 2006 with the introduction of a new NHS contract. This irritated dentists. What was a sellers' market – with private dentists chasing upmarket clients – has become a buyers' market as more of them have switched more of their work out of the NHS, driving patients into the private sector.

What does the NHS charge – and what's wrong with the new system?

A new NHS contract was introduced in April 2006 designed to sweep away the old system of 400 separate payments and make things simpler for patients and dentists. In its place there are now three NHS price bands: £15.90 for an examination with x-ray and scale and polish (if necessary), £43.60 for one to six fillings and £194 for crowns and dentures (down from the previous maximum charge of £390). These charges are intended to cover about 80 per cent of the total cost. For a couple of fillings charged at the Band 2 price, the dentist would receive about £60 in all.

What is confusing for patients is that the same dentist may offer NHS and private treatment. If the payment for one filling is the same as the payment for six, then there is a big incentive for dentists to accept the easy patients with good dental health on the NHS and insist that the complex patients who require lots of fillings pay privately. Although they are not allowed to discriminate, this is hard to police because a dentist can refuse a patient NHS treatment on a variety of grounds. For example, they may say they are saving their NHS budget (fixed annually in advance) to treat children and people in pain.

What does the Government say about the survey?

The Department of Health said in a statement: "It reflects a very narrow view of NHS dentistry which is at odds with the picture we have. We know that patients in some areas still face difficulties and that there is more to do but the NHS now has the foundations on which to build more high quality local services."

The department is placing its faith in the fact that the number of NHS dentists is rising, but is ignoring the fact that the amount of work they do for the NHS is falling. There are wide local variations. As the map (left) shows, it is harder to find an NHS dentist in the south than in the north.

Has the new dental contract made matters better or worse?

It was designed to end the drill and fill approach and encourage more conservative treatment. Those born since the 1970s when fluoride toothpaste was introduced, have better teeth than their parents and need less intervention. But its effect has been to drive more dentists to go private, deterring more patients from seeking treatment because of the cost.

And if you must pull out your own teeth?

Favoured by period movies for its mix of drama and cruelty, tying your tooth to a door handle and then slammin g the door is almost certainly apocryphal. One practising dentist, who asked not to be named, said: "It wouldn't work, except for a baby tooth that was already loose. Extracting your own teeth with pliers is also unwise – I saw a patient who had tried and only succeeded in snapping the top off his tooth, exposing the nerve and leaving him in excrutiating pain."

He added: "The first thing is to control the pain with pain killers. Don't use Oil of Cloves – it is an effective painkiller but it can give you a nasty burn on the inside of your cheek. I did see a man in the main square in Marrakech once pulling teeth with a pair of pliers. He wiped the pliers on a greasy apron between patients, and he had five or six teeth in his bowl. I don't recommend it. If you have a dental emergency ring the NHS helpline."

Is NHS dentistry in crisis?

Yes...

* Two million patients who want NHS treatment can't get it, according to the Government

* Patients unable to get on an NHS dentist's list are resorting to desperate measures, including pulling their own teeth

* The new NHS contract has made things worse by driving more dentists into the private sector

No...

* There are 4,000 more NHS dentists today than were a decade ago in 1997

* Over 28 million people, 56 per cent of the population, have seen an NHS dentist in the past two years

* The new NHS contract has made things better because it has simplified the payments

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