Braced for change: Why the NHS might put an end to free dental care

If your children need their teeth straightening, you could be in for a shock, as new rules state only the more serious forms of dental deformity will be treated free by the NHS

WHEN Colin Shields used to pose for photographs, he could never quite bring himself to break into a full grin. Having lived with a mouth of crowded and uneven teeth for many years, the 32-year-old had learned how to hide his dental defects from the camera.

Now, thanks to braces fitted by the NHS, he is looking forward to being able to smile with pride, his imperfections corrected and his confidence returned. But this is an option which could be denied to many young people in future, as the health service tightens its thresholds for who qualifies for free treatment, leaving some left to pay thousands for it themselves or, if they cannot afford it, live with the more snaggle-toothed look.

Dentists have been told that Scotland must now fall into line with guidance already adopted across the rest of the UK which limits NHS-funded treatment to the more serious cases of dental deformity. Those with more minor defects – however badly they feel they are affected psychologically by their appearance – may in future have to grin and bear it, or, like Shields, not grin and bear it.

“I was never quite confident enough with my smile. I would always try to keep my lips quite shut in photographs,” he says. “But my top row is nice and straight now so I will pull a big grin. I was very conscious of how my teeth were before, but I wouldn’t say I was feeling depressed because of it.”

Shields, from Edinburgh, was first suggested for orthodontic treatment aged 12, but his dentist decided his dental hygiene was not good enough to put him forward.

“I didn’t successfully argue with him that it was because my teeth were so crooked that they were so hard to clean. I have always had a very uneven bottom row of teeth at the front and at the top I had one that was recessed right back because there was not enough room in my mouth. I just lived with it, but they were becoming progressively harder to clean and, as a result of that, I was getting a lot of decay and a lot of extractions.”

Thanks to a sympathetic dentist, Shields was referred for NHS orthodontic treatment in his thirties to deal with his dental health problems. Paying for the treatment himself would have cost £2,500.

But, perhaps surprisingly, he does not think everyone should qualify for NHS orthodontic treatment just because they want to have nice-looking teeth.

“If you need it done, rather than wanting to get it done, then I am all for people who need it getting it on the NHS,” he says. “But for cosmetic reasons, I don’t think the NHS should be doing that.”

This same line of thinking has been adopted by the Scottish Government. It says it is not looking to reduce spending on dental services, but instead wants to make sure it is focused on those who will benefit most.

This will also mean some who would previously have qualified for free treatment now finding it denied. The change is due to the adoption of advice known as the Index of Orthodontic Treatment Need (IOTN). The index sets out the level of deformity where NHS treatment should be considered. It means that if a child’s teeth are a bit wonky they will not get NHS treatment unless this is causing them problems, such as a severely uneven bite or increased risk of decay.

Some dentists believe the changes, which came in at the start of the month, will mean many young people will no longer be able to access NHS treatment as they have in the past.

Dentist Mark Donaldson, who has practices at Elgin, Peterhead, Ellon and Aberdeen, says he estimates that around 50,000 people a year in Scotland could be affected by the new thresholds. “About a third of my clinical time is caught up with providing orthodontic treatment to my patients, and about a third of my patients present with a bite problem that is very real to them but would not cross the threshold for these new scores. That would mean I would have to advise them that orthodontic treatment is possible, but unfortunately the NHS will no longer fund it for them.”

Donaldson says there has always been an “unwritten benchmark” on who could access treatment on the NHS. But he believes that benchmark has now been raised.

“Previously, in very mild cases, my line of fire was always for the parent and the patient,” he says. “We will ask the question whether we can get approval or not, but saying it is a mild case, so ,therefore, might not be approved. Occasionally, a form would be returned and Practitioner Services in Edinburgh [who rule on who can get NHS treatment] would inform me that they don’t feel this justifies treatment. That’s sometimes acceptable if the case is very mild. It is just ‘Where do you draw the line?’”

Donaldson says he accepts that, without an endless amount of money, the NHS has to set limits somewhere, but this will undoubtedly affect his patients.

“If they don’t have the financial wherewithal to have the treatment funded by themselves then they will go without.

“You realise that [the NHS] is not a bottomless pit. If it’s a choice between a heart transplant or a kidney machine or straightening little Johnny’s front teeth, that is not a decision I would like to have to take. I completely understand the economic forces at play. but I can only comment on how it will affect my patients.” Donaldson says his experience is that only around a fifth of parents whose children are refused NHS treatment pay for it themselves.

In many cases, the willingness to pay comes down to how patients and parents think their appearance will affect their future chances in life – both professionally and personally. Americans often refer to “British teeth,” meaning uneven, decayed teeth which do not meet their own high standards of perfectly straight and unnaturally white gnashers. Many parents in the US even take out insurance policies so their children can access orthodontic treatment to give them the ideal Hollywood smile should they need it, believing that otherwise they will be held back in life.

This is likely to continue to be the case even though last year saw some heralding a new “fashion craze” led by gap-toothed models such as Lara Stone and Georgia Jagger.

Psychologists believe how someone feels about their appearance – however mild their perceived defect – can have serious effects on them. Susan Marchant-Haycox, a member of the British Psychological Society, says celebrities have helped spread the idea that having perfect teeth – preferably gleaming white – is the ideal.

“With so many people going round now with these perfect teeth, it can make some people feel a lack of self-esteem,” she says. “If someone does have gaps in their teeth and rotting teeth, that does affect the way they look and feel about themselves.

“So, having perfect teeth helps people feel more confident in themselves because they feel they look more healthy.”

Marchant-Haycox says makeover programmes on TV often start by sorting out people’s uneven, unhealthy teeth, helping perpetuate the idea that this is a vital part of appearance, adding: “Nobody is ever happy with every part of their body, but particularly their teeth because we know that how someone looks after their teeth does affect what people think of them. It affects their looks and their self-image.”

Some believe the new guidelines, while denying NHS treatment to some, will widen it to others who will benefit more.

Robert Kinloch, chairman of the Scottish Dental Practice Committee, says some milder cases would have been refused NHS treatment in the past even before the new thresholds were introduced, although some would have been cleared.

But he says that the changes might not lead to a drop in children getting braces overall, as some not currently getting treatment may now be identified as in need and get help quicker: “There is quite a pool of unmet need out there. So there could be quite a few children who would still be above this threshold who had not been at an orthodontist before because maybe there was a waiting list.

“ So, potentially, there could still be as many people getting treatment as now, but it could be for more serious problems.”

Kinloch also says that some people will still want to have treatment because they are worried about their appearance and prospects in later life: “Folk are more and more conscious of image and in certain jobs and professions it could be a factor.

“But the level of malocclusions [problems with the way teeth fit together] that are not being treated are not going to be something that from across a room someone will say, ‘That looks strange.’”

Those who have undergone orthodontic treatment – whether for serious problems or minor imperfections – believe the difference to their lives cannot be measured by guidelines and thresholds.

Shields has now been wearing his braces for almost a year, and faces keeping them for up to another year before his new grin can be fully revealed to the world.

“I would have loved to have had it done earlier. It would have made me more confident when I was at school as I was quite shy,” he says. “I wouldn’t have had to get so many fillings. To make space in my mouth I had to get four of my teeth taken out because there were so many teeth and not enough space.

“If I’d had it all done when I was younger it would all be sorted by now and not a problem.”