YOU AND YOUR DENTIST A GUIDE FOR PATIENTS

YOU AND YOUR DENTIST A GUIDE FOR PATIENTS INTRODUCTION In the six years since this Guide was last updated in 2001, much has changed in UK dentistry. The dental health of the nation overall has continued to improve and fewer than 8% of the population now have no natural teeth left. Our children s teeth are among the healthiest in Europe. And advances in cosmetic dentistry and such things as dental implants have given some patients in some cases quite literally a positive life-changing experience. There have been other changes, too. Since 2006, in England and Wales, local Primary Care Trusts and Health Boards have taken on the responsibility for working with NHS dentists in their locality, taking over this role from central Government. At the same time, dentists who are, unlike doctors, mostly self-employed independent practiceowners have seen their NHS contracts changed totally. No longer are they paid for each item of treatment they carry out, but instead are paid according to the complexity of each course of treatment. These reforms have not been popular with many dentists and have not, as yet, delivered the increased access to NHS dentistry which was promised. The proportion of people (still around 50%) visiting an NHS dentist has not changed very much. In Scotland and Northern Ireland, NHS dentistry is still delivered on the fee per item model introduced in 1948, although reforms are in the pipeline here too. And although the new English and Welsh system has simplified the NHS patient charge system, there are now four different payment systems across the UK (see page xx) 1

In 2004 for the first time, dentists in the United Kingdom carried out more work privately than on the NHS, and despite the recent changes, this trend looks set to continue. At a time when the demand for high-tech and time consuming cosmetic dentistry continues to rise, but the demands on the wider NHS are also rising, it is questionable whether NHS dentistry can continue to hold its own, let alone develop. Most dental disease is preventable and the earlier positive action is taken (in infancy and childhood) the better the guarantee of a dentally healthy lifetime. Scientific experts agree that fluoride toothpaste, introduced in 1972, was a major factor in the improved dental health of younger people today. Working with your dentist, you can ensure that you retain optimal dental health for a lifetime. 2

FREQUENTLY ASKED QUESTIONS Must my dentist give me NHS treatment? No, not necessarily. Dentists unlike GPs are generally free to accept or refuse to accept patients on the NHS. In England and Wales, a dentist with a full NHS contract cannot discriminate against accepting a patient on equality grounds (such as age, ethnicity health or religion), whilst some have children only NHS contracts and cannot accept adults (although they cannot refuse to treat children on condition that their parents come privately). In Scotland and Northern Ireland, a dentist must offer NHS treatment to their registered NHS patients unless both agree to private treatment. Patients in England and Wales are no longer registered with an NHS dentist although the dentist will usually arrange for routine check-ups If you are accepted as an NHS patient and there are significant difficulties of access in some areas then the dentist is bound by the NHS rules and you are bound to pay the charges, in return for which the NHS will pay some of your treatment costs. How much does NHS dentistry cost? Since 1951, there have been patient charges for NHS dentistry (with some exemptions, see below), effectively to limit government spending. Despite some simplification of charges following the 2006 reforms in England and Wales, the overall UK picture is still complicated. In England and Wales, there are three bands of NHS charge. Currently these are: Examinations, scaling and polishing, x-rays (Band 1) 15.90* Band 1 plus fillings, extractions, gum treatment etc (Band 2) 43.60* 3

Band 1 or 2 plus dentures, bridges, crowns 194.00* *in Wales these Band charges are currently: 12.00; 39.00 and 177.00 In Scotland and Northern Ireland, NHS charges are still per item of treatment. In Scotland examinations are free ( 6.16 in Northern Ireland), a simple filling is about 6.50, full dentures about 134.00. The maximum NHS charge is 384.00. These figures are correct at the time of going to press. Because NHS fees are usually revised each year, you should check current rates with your local Primary Care Trust or Local Health Board. All NHS dentists must display a poster showing the current NHS patient charges. Who can get free NHS dentistry? All children under 18 years (and those under 19 in full-time education), expectant mothers and those with a child aged under 1 are all automatically exempt from NHS dental charges. Patients in receipt of some State benefits are also exempt, whilst others, and those receiving family tax credits may also be exempt or entitled to help with their charges. Forms explaining the exemptions and assistance should be available from the receptionist at the dentist, or from your Post Office. Ask your dentist, your local Health Board or PCT, or Citizens Advice for more details. There are Useful contacts details at the end of this booklet. How do I find a dentist? Most people ask friends, family or neighbours to recommend a dentist local to your home or work. You can look in Yellow Pages, or you can contact your local Health Board or PCT for listings. Or you can contact the appropriate NHS website (see Useful contacts). If you have special needs (for instance if you are very frightened of going to the dentist or need a particular specialty) you can call the British Dental 4

Health Foundation or the British Dental Association or search their websites (Useful contacts). What should I look for in a dental practice? It is a good idea to visit the dental practice you are interested in before you book an appointment or register, if you can. A good practice should look clean and tidy and the staff should be knowledgeable, helpful and welcoming. Ask about the availability of NHS or private treatments, and what treatment is available. A good dentist will make sure that check-up or treatment appointments are available within a reasonable time and that emergencies are normally seen within 24 hours or so. NHS dentists in England and Wales no longer have to provide out of hours emergency cover themselves, but there should be an NHS emergency service provided by the PCT or Health Board although the extent of this will vary from one area to another, and some will only see extremely urgent cases such as severe infection, pain bleeding or trauma. The dentist should be friendly and communicative, and be able and willing to answer reasonable questions about your treatment. You should be put at your ease, and any concerns or needs addressed. Treatment options and any risks should be clearly set out and any costs or charges openly discussed. Your dental examination should be thorough, usually beginning with your medical and dental history, especially any past or current problems. Expect to have the condition of your teeth, gums and mouth lining examined and their condition explained to you. Dental x-rays may be needed before a treatment plan can be agreed. These are very safe and low dosage and although you should always tell your dentist if you are, or may be pregnant, this is no longer normally considered a risk. Your treatment plan should be explained clearly with costs, and if it is at all extensive, should be provided in writing. 5

The modern dental team may include other registered dental professionals such as hygienists, therapists, dental nurses and technicians. If appropriate, their part in your treatment should be explained (See Who can provide dental treatment below). Good dental treatment should be unhurried, caring and as comfortable as possible. In particular there should be assured attention to pain control both during and after treatment. How often should I go for a check-up? The six month check-up is now generally accepted as a useful rule of thumb, but no more than that. The NHS is encouraging dentists to recall their regular patients at intervals of up to one year (for children) and two years (for adults) if they are dentally healthy and are not at particular risk of developing problems. This was recommended by a Government report in 2005. Many people who value their dental health like to have the reassurance of regular contact with their dentist, and you should discuss and agree with your dentist how long it should be before you return for a check-up, or for a Hygienist appointment. What if I need urgent treatment? As noted above, in England and Wales, PCTs and Health Boards are responsible for out of hours dental emergencies and this coverage varies from place to place. Sometimes there are rotas of dentists on call, sometimes you will need to go to an A & E Department or a Dental Access Centre. These Centres have been set up to provide urgently needed NHS treatment. Look in your phone book under PCT or Health Board or try NHS Direct (Useful contacts). In Scotland and Northern Ireland, dentists must provide reasonable out of hours cover for their NHS patients (or through a rota). 6

The General Dental Council, which regulates all dentists in the UK whether NHS or private, expects dentists to offer reasonable access to out of hours care for patients under their care. How do I find a private dentist? Unlike NHS dentists, private dentists are not listed with NHS Direct. Personal recommendation is the best route, or look in Yellow Pages for advertisements. Some companies offering dental plans keep listings of dentists who are registered with them. You can also look at the websites of the British Dental Association, the British Dental Health Foundation, or Denplan (Useful contacts). How do I find a specialist? If you have particular or complex needs, your own dentist should be able to refer you to a specialist if he or she does not offer those particular services. The General Dental Council s website lists all officially registered dental specialists, or you can contact the British Dental Association (Useful contacts) Can I go to any dentist? Yes you can. Unlike doctors, dentists do not have a catchment area. However, in England and Wales, PCTs and Health Boards may agree with NHS dentists that they will normally only accept patients from within the area funded by that particular authority. Check with your dentist. If you move home or work you may prefer to remain with the same dentist, but bear in mind that travelling particularly in emergency may prove difficult. 7

Who can provide dental treatment? In the UK, the practice of dentistry is regulated by the General Dental Council. As well as registering dentists, the Council also registers Dental Hygienists, Dental Therapists and Clinical Dental Technicians (as well as other dental team members including, from July 2008, Dental Nurses). Hygienists are trained to provide scaling polishing, gum treatments and oral health advice. Therapists can additionally provide simple operative treatment such as fillings. Hygienists and Therapists must work under the prescription of a dentist. Clinical Dental Technicians can provide dentures direct to the public. In all cases, you can check the registration status of all dental team members with the General Dental Council s website (See: Useful contacts) What about dental treatment overseas? The rising cost of dentistry in the UK has led to more people seeking treatment in other countries, especially eastern Europe where costs and fees are generally lower. Although dental professionals in other countries are generally subject to regulation and training and may well be of an equivalent standard it can be difficult to verify this yourself and you should bear in mind that if follow-up care is needed, or complications arise, it may be difficult to arrange conveniently. Complaints may also be difficult and expensive to pursue Can I mix NHS and private treatment? In general, yes you can. The NHS rules allow a dentist and an NHS patient to agree to have some of the work done privately, but the dentist cannot refuse to provide the treatment under the NHS if you do not agree, if that work is appropriate and necessary for your dental health. Purely cosmetic dentistry and individual preferences such as 8

white fillings are not usually permitted within the NHS. You should discuss all such options with your dentist before work commences and ensure that the details and costs are provided in writing. Dentists who work in Health Board or PCT clinics or Access Centres may not be permitted to carry out private treatment. Can I or my children get orthodontic treatment on the NHS? In recent years, the NHS has increasingly restricted the amount of orthodontics available for children and it is only very rarely available to adults in the most severe cases. Orthodontics the straightening of crooked or crowded teeth - have become increasingly popular, but NHS waiting lists are very long in some areas and you may have to seek this treatment privately. Discuss with your dentist if you think you need this treatment. How much does private dentistry cost? Private fees are set by each individual dentist. There are no national guidelines to regulate the cost of private dental care. Private fees are a matter for agreement between the dentist and the patient and constitute a contract between them, even if not written down. However, you should insist that for all but the simplest treatment, your dentist gives you a written treatment plan and costs. Because no treatment is totally predictable, this plan may vary, but expect a full explanation and a revised written account. Why do private dental charges vary from one practice to another? As each dentist is an independent practitioner his or her costs will also be different. Your treatment costs will include not only the dentists fee, but also the costs of employing and training the practice staff, the maintenance of the premises and the need for the dentist to comply with a large amount of important regulations and law, 9

for example cross-infection control, health and safety and waste disposal. Dental equipment and materials are also among the most costly in health care. All of these costs will vary from dentist to dentist and from practice to practice. Dentists may also choose to invest in further and/or specialist training for themselves and their staff, and to offer additional or particular treatments. What do I get for the extra I pay in private dentistry costs? If you choose to go privately, your dentist may be able to offer you a wider range of treatments than you can get on the NHS. This particularly applies to cosmetic treatments such as crowns veneers or white fillings, and to particularly costly dentistry such as dental implants which may be very difficult or impossible to obtain on the NHS. Private dentists may also choose to use more expensive or improved materials and equipment. Private care should mean that your dentist has more time to spend with you and can therefore provide you with a more personal service. How do I know that the dental treatment proposed is really what I need? Everyone has individual needs and a good dentist should give you a full and clear explanation of what has been found during your dental examination, the care and treatment needed, and any options, risks and costs. You should then discuss with your dentist any matters which are unclear, and proceed only once you fully understand and are happy with what is proposed. A written treatment plan should be provided for all but the simplest treatment. What controls are there on dentists? Dentists in the UK are subject to a range of controls and regulation. The General Dental Council registers and regulates all dentists, whether NHS or private, as well as 10

dental hygienists and dental therapists. Dental nurses, dental technicians and clinical dental technicians will also be fully registered from July 2008. All registered dental professionals must abide by the Council s guidance on standards. Dentists in the NHS are also required to work according to their Contracts or Terms of Service, which may include detailed requirements on premises and services provided. The Healthcare Commission in England and similar bodies elsewhere in the UK may also have regulatory powers over NHS and, more recently, some private dentists. Like other healthcare professionals, dentists have been affected by recent legislation and controls (such as the Shipman enquiry). Dentists must show that they have maintained and developed their professional knowledge and skills, and NHS dentists are subject to clinical governance requirements which may include inspections of their work and premises. The British Dental Association and some private dental plans also offer quality and accreditation programmes for their member dentists. The BDA s Good Practice scheme and Denplan s Excel Accreditation are examples, and to earn these privileges dentists must demonstrate their compliance with a range of requirements and this may include full practice assessments by an independent auditor. The Excel Accreditation scheme has standards which have been reviewed by the Patients Association, and as well as regular practice inspections, dentists must obtain and act on their patients views on their services, obtained through regular consultations. Patients are also given an Oral Health Score which details the results of their examination and measures the continuing health of their mouth. What does the dentist expect from me? You should try to attend your arranged appointments in good time, and to let the practice know well in advance if you cannot do so. Whilst NHS dentists in England and Wales may not now charge for missed appointments, all private dentists and NHS dentists elsewhere may do so, to compensate for the productive time lost. If you are 11

late or miss an appointment this will almost certainly inconvenience other patients of the practice. Do explain any dental problems or concerns to the dentist as clearly as you can. This helps to ensure that a correct diagnosis and treatment plan is proposed. If it helps, write down any details in advance. If you are taking any medicines (including over the counter remedies) let the dentist know and either take along the medicines or write down the details for the dentist. If you are very nervous, let the practice know. They should be helpful and sympathetic and may allow extra time for your appointment. Although out of hours services should exist, they may be organised by the dentist themselves, or if NHS, by a local PCT or Health Board. Only make contact if there is a genuine emergency. Bear in mind too that current regulations and guidance may limit treatment which a dentist can appropriately carry out without the support of a full chairside team in normal surgery hours. How do I complain if I am dissatisfied with NHS dental treatment? In the first instance, you should always discuss the matter first with the dentist or the practice directly. All dental practice must have an in house complaints scheme and other authorities may not take up your complaint subsequently if you have not done this. The scheme should enable you to be able to state your complaint without difficulty or embarrassment. If you are not satisfied, you should approach your local PCT or Health Board for an independent review of your complaint. In serious cases, the matter may be referred to an independent panel to hear the matter formally and you may be asked to attend and provide information to support your case. Cases may also be referred on to the Health Ombudsman or the Healthcare Commission (or equivalent in Wales, Scotland or Northern Ireland). The outcome of the matter, which may include a refund of fees paid, must be given in confidence to you and the dentist concerned. 12

Particularly serious cases may also be referred to the General Dental Council. If the Council s Fitness to Practise Committees find a dentist guilty of serious professional misconduct, the dentist s professional registration may be suspended or erased. The Council cannot, however, order compensation or repayment of fees. You should make any complaint in writing and keep a note of any face-to-face discussions or telephone conversations as soon as possible. You may wish to have someone with you when you complain. Remain calm and polite, but do be firm and persistent when appropriate. For further information ask for the Patients Association s booklet Making a Complaint. How do I complain about private dental treatment? Again, any complaint should first be made to the dentist who provided the treatment. The practice should have an in-house complaints scheme to enable you to do this. Some dental plan providers, such as Denplan, can also help you to look into complaints and may be able to provide an independent review, but they do not have the powers to compel dentists to provide solutions. They can, however, exclude an offending dentist from their membership. The General Dental Council has also, since 2006, set up a Dental Complaints Service to help patients with complaints about private dentistry. They can also refer a serious matter to an independent panel and can ask you to attend to make your case. They have the power to instruct a dentist to put matters right or refund fees, and can refer a dentist to the General Dental Council (see above) if they refuse. You can also seek redress in Court. In the first instance it may be helpful to take advice from a Citizens Advice Bureau or to consult a solicitor. Bear in mind that legal action can be expensive to pursue and can take considerable time to conclude. For further information ask for the Patients Association s booklet Making a Complaint. 13

Can I get a second opinion? Sometimes you might want a second opinion about your condition or the treatment recommended by your dentist. You may wish to discuss this first with the dentist, or to ask for a referral to a dentist who specialises in your particular problem, either working in specialist practice or in a hospital. How are private fees structured? Private fees should be explained in advance of commencing the work. Many practices have a list of typical private fees. Private fees may be charged for in three ways: Fee per item: each type of treatment or care has its own price Fee for time: charges are related to the time taken for the treatment: some materials costs may be charged in addition. Capitation: most dental plans, such as Denplan, charge a fixed monthly fee which varies according to the amount of work expected to be needed by a particular patient. The monthly cost is predictable and covers most routine work (usually not cosmetic work or implants). In most cases, prescriptions and laboratory fees (for crowns, bridges or dentures for instance), are charged for separately. What methods are available to me to pay for private dental treatment? You can pay the practice directly for each course of treatment. Some practices will ask you to pay a deposit or to pay as you go along, others will bill you on completion of the work. 14

Another option is to take our dental insurance. It may be that your employer may offer a dental insurance benefit. A regular premium is paid and when treatment is needed a claim form is obtained, filled in and returned to the insurers with the dentist s itemised account. It is usually necessary to pay the dentist yourself and then claim back the costs. Insurances are now on offer to cover costs towards either NHS or private dental fees. Make sure you read the terms and conditions of the insurance carefully before applying. It may be worth checking with your dental practice how much of their fees would be covered, and check the policy for details of any exclusions, such as problems evident at the time of taking out the insurance. Like insurance, dental cash-plans require regular payments (again this may be possible through your employer), and usually cover specific dental treatments up to specified limits. Both insurance and cash-plans may only cover a proportion of your costs. Finally, dental loans are also available and your practice may have details of companies who will provide such loans tailored to cover dental treatments, especially more expensive items such as orthodontics and dental implants (see Glossary). Can I get access to my dental records? You have a legal right to see your records subject to certain rules. The dentist must give access within 40 days of a request by a patient. You are also entitled to copies of your records, again subject to certain rules. Dentists may charge a reasonable administration fee (currently up to 50) for copying records and x-rays Can I take my records to a new dentist? No, unlike doctor s records, your dental record legally belongs to the dentist who provided the treatment or who owns the practice. Dentists are required to keep records 15

for a certain period of time. You can obtain copies (see above). Your new dentist will make a new record for you relevant to his or her diagnosis and treatment undertaken. Can I have a general anaesthetic? In general, dentists are not permitted to carry out treatment in a dental practice under general anaesthesia. A very few practices have the necessary and exacting facilities to undertake this but in general, such treatment is only permitted in a hospital. Some dentists with suitable skills and facilities can carry out dental treatment for appropriate patients under sedation. 16

GLOSSARY Abscess An abscess is an infection at the root of a tooth. Abscesses can be very painful, and if not treated with antibiotics, drainage or apicectomy, can lead to the loss of the tooth. Apicectomy An apicectomy is a surgical process by which a dentist cleans out an abscess at the root of the tooth. If the tooth is not already root-filled, this is usually undertaken at the same time. Bleaching The colour of teeth can be lightened by applying a bleaching agent (usually carbamide peroxide). It can be carried out at the surgery, or at home using lightweight plastic trays worn for several hours per day over a week or so. Bleaching can only be legally carried out by a dentist and so long as all instructions are followed it appears to be a safe process. Bridges A bridge replaces one or more missing teeth by fixing the replacement(s) to the natural teeth at the side of the gap. Bridges can be made of precious metal (gold) or porcelain attached to metal. Sometimes the bridge is adhesive or firmly glued to the adjacent tooth or teeth. Chronic Periodontitis This is the name given to the later stages of gum disease. Some of the bone that supports the teeth is lost due to slow infection from pockets around the teeth that are not, or cannot, be cleaned. It is a leading cause of tooth loss in adults. The condition may be avoided or treated by good oral hygiene or by root planning (see entry) Crowns A crown completely covers a weak or damaged tooth above the gum. The dentist prepares the tooth and takes an impression. The crown is then made in a dental laboratory to fit, whilst a temporary crown is worn by the patient. Crowns can be made of porcelain, or porcelain fused to a metal core, or entirely of metal for back teeth. Endodontics This is the term for the process or speciality of root filling teeth. Teeth which are seriously damaged or infected due to large cavities, may be saved by removing the 17

tooth nerve in their centre. This treatment can be extremely complex and demanding and whilst general dental practitioners are trained in root fillings, more complex and particularly back teeth may require a referral to a specialist in the field. Extraction The term for taking out a tooth. Generally teeth are only removed if they are beyond repair or untreatable due to advanced decay, infection or chronic periodontitis (see entry). Sometimes teeth have to be removed for orthodontic treatment (se entry) where they are too crowded to fit in the jaw. Gingivitis This is inflammation or bleeding of the gums around the teeth. It is caused by bacteria (germs) in plaque on the teeth and gums, which may also harden into calculus or tartar. It can usually be prevented or treated by thorough cleaning and good oral hygiene. Gingivitis may be a sign, or a warning of future chronic periodontitis (see entry) Halitosis Halitosis is bad breath. This may be caused by bacteria (germs) in the mouth or by serious dental decay or gum disease, however other causes can include inflamed tonsils or stomach disorders. Your dentist can advise and often treat this condition. Implant (Dental) A dental implant is a metal (titanium) or porcelain fitting which is screwed into the jaw, in either a surgically prepared site or the space left by an extraction. A crown or bridge can be fitted after the fixture has settled in usually 3 months, but sometimes sooner or even occasionally straight away. The result is often indistinguishable from a natural tooth. Implantology (fitting implants) is a specialised skill and requires training and facilities. Implants themselves are expensive and must be carefully maintained and cleaned by the patient in a well-cared-for mouth. They avoid the need for dentures and bridges. Oral Surgery This is surgery of the mouth, jaws or face. It may include the removal of wisdom teeth, cysts, buried tooth roots and other problems, right up to major reconstruction following accidents or major defects. Oral surgeons usually work in hospital and are often medically qualified as well, but increasingly dentists with specialist training may take referrals in practices. Orthodontics Orthodontists specialise in straightening or correcting the growth or appearance of teeth and jaws. Although in the past only available to children, this treatment is increasingly available to adults. Treatment now is usually with fixed appliances which are fixed to the teeth for a period of some months, however, removable appliances are still used to retain the teeth after treatment or for very simple 18

procedures. Treatment requires good oral hygiene and full co-operation from the patient. Most orthodontics is carried out by specialists. Periodontology This is the treatment of diseases of the gums and supporting bone around the teeth. This is now a specialist area and more complex cases will usually be referred, however, mild cases may be dealt with by dentists or dental hygienists in general practice. Root planning (curettage) Root planning is the term now used for scaling and polishing the root surfaces of teeth to remove infected debris that may be causing periodontal disease. Deep pockets that cannot b cleaned by the patient may require this treatment to halt the process of chronic periodontitis (see entry). Wisdom Teeth Wisdom teeth, or third molars, are the last teeth to appear, usually from age 18 onwards. As such there may be insufficient room for them to grow and they may become infected or cause pain or damage to adjoining teeth or gums. If symptoms occur they can be removed. More difficult wisdom teeth will need referring to a specialist oral surgeon. Veneers A veneer is a thin porcelain or plastic tooth-coloured material fitted to the front of a tooth to make it look better, either to correct the shape, size or colour of the original. 19

USEFUL CONTACTS British Dental Association 64 Wimpole Street London W1G 8YS Tel: 020 7935 0875 Email: enquiries@bda.org www.bda.org British Dental Health Foundation Smile House 2 East Union Street Coventry Warwickshire CV22 6AJ Helpline: 0845 063 1188 (9-5 Mon to Fri) Tel: 0870 770 4000 Email: mail@dentalhealth.org.uk www.dentalhealth.org.uk General Dental Council 37 Wimpole Street London W1G 8DQ 20

Tel: 020 7887 3880 E-mail: information@gdc-uk.org www.gdc-uk.org Dental Complaints Service (private dentistry complaints) Tel: 0845 612 0540 E-mail: info@dentalcomplaints.org.uk www.dentalcomplaints.org.uk NHS Direct Tel: 0845 46 47 (England): www.nhsdirect.nhs.uk (Wales): www.wales.nhs.uk (Scotland): www.show.scot.nhs.uk (Northern Ireland): www.n-i.nhs.uk Patients Association PO Box 935 Harrow Middlesex HA1 3YJ Tel: 0845 608 4455 E-mail: mailbox@patients-association.com www.patients-association.com Denplan Ltd 21

Denplan Court Victoria Road Winchester SO23 7RG Tel: 01962 828000 E-mail: Denplan@denplan.co.uk www.denplan.co.uk 22