SUMMARY

  Root canal treatment is a complex and time consuming procedure which presently unfairly receives no remuneration with Units of Dental Activity (UDA) within the new contract. It is a worthwhile procedure for the patient enabling them to retain teeth and possibly avoid the inconvenience of a denture. It is unclear whether the Department of Health wishes dentists to carry out this procedure out as opposed to an extraction. It is a factor that dentists consider as to whether to continue with the new GDS contract. The matter of root canal treatment standards was raised at the Health Committee Inquiry in 2001 and since then no progress has been made at all. The new contract gives no guidance or protocols for treatment and no UDA award to carry out the procedure as opposed to extractions of teeth which carry a UDA value of three UDAs.

  1. I write with reference to the sections being considered covering "Patients' access to NHS dental care" and the "Quality of care provided to patients".

  2. The provision of root canal treatment was discussed at the previous report of the Health Committee into "Access to NHS Dentistry" published 27 March 2001. Little progress in this area of dental care has been made since then, despite the assertion made by Lord Hunt in paragraph 111 of the report. He agreed to Mr Brand's suggestion that the quality of root canal treatments be tracked to see whether the outcomes are different from those published in a survey by Professor Dummer in the Dental Practice Board magazine Dental Profile in 1997-98. This reported that only 10% of root canal fillings assessed by the Board met the requirements of the European Endodontic Society guidelines. I am not aware that the Department of Health assessment was ever carried out. With the introduction of the new contract the situation has gone into reverse in that there are no protocols for root canal treatment at all now and no way of recording how many are being carried out under the new contract. There is no guidance for practitioners as to what is required in root canal treatment techniques for practitioners and given the number of foreign dentists coming into the country it is important that they should know what is expected of them when practising in the UK. We have recently received guidance on preventive care for children so why not root canal treatments for the acute, painful problems involving the root canal systems of teeth. These problems are a very common occurrence for patients in dental practice. If not treated properly patients return at a later date costing more money to correct or eventually have the tooth extracted, possibly unnecessarily involving the overstretched secondary care agencies.

  3. There appears to be confusion with some members of parliament about what treatments are available within the General Dental Services, indicating that root canal treatment is not one of them, although the profession has not been advised about this. Alan Johnson MP, in his letter to the Sunday Telegraph on 4 November 2007 stated that types of root canal treatment "are not available on the NHS" and Anne Keen MP in her recent letter to Labour MPs stated that "the new contracts ... encourage dentists to carry out less complex and invasive courses of treatment". Root canal treatment would fall into the category of complex treatment.

  4. As a practitioner working within the GDS, trying to balance the problems of the provision of clinical care for patients needs with the financial problems of running a business, it is frustrating to have to provide time consuming root canal treatment at a loss. No Units of Dental Activity (UDAs) are awarded at all for any root canal procedure. Some teeth, such as molars, can take 2 hours of time to treat and in addition we have to dispose of the instruments used within the root canals at each visit (at least two visits would be common). Some courses of treatment could include more than one root canal treatment, with no additional UDAs allowable under the new contract, even though there is extra expense with the mandatory one-time use of the instruments to prevent the possible spread of Creutzfeldt-Jakob disease. Each visit (likely needing two) could cost in the region of £30-40 for a molar and not much less for other smaller teeth. If the tooth concerned is a visible one, an extraction with a denture replacement, instead of a root canal treatment, would be awarded 12 UDAs (or 13.2 if seen as an emergency at a previous visit). The denture would likely cost about the same to have made as the unrewarded costs of the root canal instruments used if a root canal treatment had been carried out to save the tooth. This presents an unfair dilemma for the dentist. Do they carry out time consuming, tooth saving root canal treatment for the patient (and not impose on them the life time need to wear a denture) for no remuneration, or receive 12 UDAs for the easy and quick option of an extraction and make a denture? I do not know whether this happens or not but it is a factor considered when dentists are considering their position with regard to committing to the new contract or not. The NHS Information Centre dental statistics show a reduction of 45% in adult courses of treatment involving a root filling from 2003-04 figures to 2007 (April to July) and an increase in extractions.

  5. The new contract could sadly disadvantage children involved in an accident with their front teeth in the present, unbalanced situation just described. Should a tooth be knocked out or severely displaced the options would be to either remove the tooth and commit the child to a plastic denture and collect the 13.2 UDAs for not much more than ¾ hours work, or spend a considerable number of hours saving the tooth over a period of weeks to months with root canal treatment (having to dispose of the costly instruments during the process) for zero UDAs; 3 UDAs would be awarded only for a filling provided at the end, the facial appearance saving root canal treatment would have no UDA value. The child could well be spared the crippling effect for them of a denture for the rest of their life with careful root canal treatment.

  6. In the report of the Health Committee in 2001 (para 98), Mr D Hinchliffe MP identified that "there is a tension between independent contractor status, the private business interests and the community interests and the service interests". This present contract, instead of making NHS dental practice more appealing by addressing those stated problems, has made them more extreme. The problems with root canal treatment and the new contract, that I hope I have highlighted, have accentuated these conflicting interests and there has been no improvement since 2001. In fact the situation has become far worse. Clinical decisions with the new contract are now geared, in terms of UDA payments, to the quick-fix solution instead of quality based solutions. It is very sad.

Stephen Day

Dental Practitioner

December 2007