Any discussion of NHS dentistry has to begin with an acknowledgement that it has almost disappeared. Use of the term "NHS" implies a universal service that is free at the point of use. NHS dentistry is neither. Since 1951, when charges for dental treatment were first introduced, the cost has increased steadily. Overall, patients who pay charges contribute approximately 80 per cent of the cost of their treatment (it is free for children, pregnant women and those on benefits). The choice for patients is, therefore, not between private and NHS dentists,but between expensive dentistry and slightly less expensive dentistry.

Tony Blair pledged at the Labour Party conference in 1999 that everyone would have access to an NHS dentist. He never delivered. In March 2007, the Department of Health was forced to admit that two million people did not have one. By the end of last year it was clear that though the number of dentists doing NHS work was rising, and the cash going in was increasing, the number of patients treated on the NHS had fallen by more than one million in the two years since the new contract was introduced (though it has started to rise again). Alan Johnson, the then Health Secretary, announced an inquiry into what had gone wrong.

Its report, under the chairmanship of Professor Jimmy Steele of Newcastle University, carries a sense of deja vu. The Department of Health had been under fire since it overhauled the dentists' NHS contracts in 2006 to end a perceived "drill and fill" culture. Dentists used to be paid 400 separate fees for each item of treatment, leading to worries about overtreatment. Under the 2006 changes, they received an annual income for carrying out an agreed amount of work, based on "units of dental activity", which carried a financial incentive to do less for each patient, leading to worries about undertreatment.

This reform led to a sharp fall in more complex treatments – crowns, bridges – carried out on the NHS and an increase in the amount of work dentists did in the private sector. Professor Steele's review recommends a return to patient registration backed by a capitation payment – first introduced in 1990 – and a new payment for quality of care. To cover the extra costs, payments for dental activity such as fillings will be reduced. The idea is to incentivise long-term care, by placing greater financial weight on looking after the patient's oral health and less on the speed with which they can cram in fillings.

The basic challenge for the new system is meeting the very different needs of Britain's two dental generations. For the fluoride generation, aged under 40, who benefited from the introduction of fluoride toothpaste in the 1970s and have better teeth than their parents (many have no fillings at all), the principal need is for good oral care and to discourage excessive intervention.

For the generation over 40 who lacked the protection of fluoride and were subjected to a different dental philosophy based on intervening over every sign of decay in the belief that it would preserve teeth, their needs are very different. Their restorations are beginning to crumble and the task now is to provide the highly complex root, crown and bridge work required.

Across Europe, the trend is away from universal provision of state-funded dental care and towards increasing patient contributions. With the shrinking of the public purse and the coming squeeze on NHS finances from 2011 onwards, the real pain of going to the dentist is likely to be felt in the pocket.