Memorandum by the British Endodontic Society
NHS DENTAL AND ORTHODONTIC SERVICES
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.
2001 HEALTH COMMITTEE
"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."
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
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
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
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.