The British Endodontic Society (BES) welcomes the opportunity to submit evidence to the Health Select Committee inquiry into the new GDS and PDS contracts. Root canal treatment is a therapy aimed at preventing or treating apical periodontitis, a prevalent disease process caused by infection of the root canal system within a tooth. The complexity of root canal treatment varies from a straightforward single root canal to complicated molar teeth with four or five root canals. This is precise and fine work which requires time in order to achieve a quality result, the instruments are also costly and disposable. Many practitioners have made a significant investment in equipment (eg magnification loupes, microscopes, electronic devices to help measure the length of teeth, endodontic motors etc) in order to carry out this treatment to modern standards.

  The dental health of our younger population has improved, however the restorative and endodontic needs of older adults are likely to increase. This reflects the fact that people are retaining an increasing number of teeth for longer. In 1998, 50% of middle aged adults in the UK had teeth with fillings (Pine et al, 2000). There will be an ongoing need for complex restorative care of this aging population, despite a younger, healthier cohort following through. Future decennial surveys of adult dental health will be important in monitoring this trend.

  The 2001 Health Committee report raised several important issues in regard to dental provision, including access to NHS Dentistry and the remuneration system. The introduction of the nGDS contract April 2006 saw significant changes in the way NHS dental services were commissioned. The British Endodontic Society is concerned that the introduction of the UDA monitoring system does not recognise the time, skill and expense of providing root canal therapy procedures.

BACKGROUND, QUOTED FROM THE 2001 HEALTH COMMITTEE REPORT

"Para 27 under quality of care considered written evidence from one GDS dentist regarding details of the low success rate of NHS endodontic (root canal) treatment (10%), as measured against European radiographic standards. He noted additional costs to the service this sub-standard care imposed and discussed the reasons why it occurred, which he ascribed to the lack of time and the use of ineffective and out dated techniques and materials. His comment sums up the problems:"

"What is required is more time and the use of adequate equipment that is expensive, neither of these can be funded by the very low NHS fees."

"Para 28. The DoH did not accept that there was hard evidence to suggest that the quality of NHS dentistry is not up to the standard they expect. They pointed to the regulatory system; the comprehensive inspections undertaken each year by the Dental Reference Service, and the introduction within the GDS of clinical governance and clinical audit. In response to the evidence quoted above, Dame Margaret Seward, the Chief Dental Officer, told us;"

"the report . . . actually was saying that the way the filling was put into the root canal failed against European endodontic standards and, as you quite rightly quoted, [the success rate] was 10%. What it did not actually say was that the whole root filling had failed, it was the way that the root canal had been filled with the material. As we call it. In the report it did admit that the technical quality of the root filling does not necessarily affect the outcome. There are a million canals root filled and we do not have great numbers of them failing."

THE BRITISH ENDODONTIC SOCIETY COMMENTS

  We believe Dame Margaret is referring to the survival rate of teeth treated by root canal therapy in the NHS, such information has not been available until recently. Lumley, Lucarotti and Burke (submitted for publication) have demonstrated a 74% survival rate of teeth treated by root canal therapy in oGDS without any further intervention over a ten year period. This work demonstrates the value of such therapy to patients and the NHS. Although considerably higher than 10% this figure does remain 23% lower than survival rates reported through the Delta insurance scheme in the USA, an alternative remuneration system (Salehrabi R, Rotstein I. 2004).

  All parties are concerned about quality of care and outcome for the patient. A GDS dentist in 2001 raised the issue of low fees in regard to root canal therapy which can be complex and time consuming to deliver. The nGDS contract has seen significant changes in the way dentists are remunerated moving from fee per item to a contract with a PCT monitored against a number of UDAs which are calculated from bands of treatment. Root canal therapy may be performed as part of a band 2 or band 3 course of treatment and is completed by definitive restoration of the crown of the tooth. In the current monitoring system the dentist receives the same number of UDA's for restoring the tooth regardless of whether a root canal filling has been placed or not. Root canal therapy involves preparation and disinfection of the root canal and placement of a root filling. This will normally take between ½ and 1¾ hours in routine cases depending on tooth position. More complex tooth anatomy and heavily infected teeth require more time. The British Endodontic Society suggest that this additional time and care is not recognised under the current UDA monitoring system.

  This situation has been compounded by the recent introduction of single use instruments which places an additional financial burden on the nGDS dentist.

  Many infected teeth can be retained by root canal therapy, the alternative way of rendering patients dentally fit is to eliminate pain and remove infection by extracting the tooth. The preliminary results of the dental treatment band analysis in England from April to July 2007 demonstrate that there has been a reduction in approximately 45% of adult courses of treatment that contain a root-filling episode from 2003-04 to 2007 and an increase in extractions.

  The British Endodontic Society is concerned that the UDA monitoring system does not appear to recognise the placement of a root filling and that the introduction of single use instruments may result in teeth which could be reasonably saved being extracted. Extraction is a simpler procedure, takes less time and has the same recognition under the UDA monitoring system. Extraction of a tooth and replacement with a single tooth partial denture carries four times the recognition (12 as opposed to three UDA's), takes less time to deliver but does involve laboratory work.

  In summary the British Endodontic Society requests the UDA monitoring system be reviewed in and modified in order to recognise the time and skill required to perform root canal therapy in nGDS to appropriate standards.

Professor PJ Lumley

President British Endodontic Society

December 2007

REFERENCES

Ten year survival of root canal fillings in the general dental services in England and Wales. Lumley PJ, Lucarotti PSK and Burke FJT (submitted for publication)

Pine CM, Pitte NB, Steele JG, Nunn JN, Treasure ET (2001) Dental restorations in adults in the UK in 1998 and implications for the future. Brit Dent J 190: 4-8

Salehrabi R, Rotstein I. (2004) Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. Journal of Endodontics.30,846-850.

Dental treatment band analysis England 2007 preliminary results. April to July 2007 and comparisons with 2003-04. The NHS information Centre, Dental Statistics.