The Three Degrees can hardly have recognised, in 1974, just how significant their chart-topping single would become for UK dentists in the years ahead. They can hardly have recognised that the controversy surrounding recall frequency would go on to become one of the central issues in dental healthcare.
Spookily, their second hit single, Take good care of yourself, might have been tailor-made for the same debate, as we've come to recognise the essential role the patient plays in the maintenance of good oral health. In the old adage; 'there is nothing the dental team can do which will overcome what the patient won't.'
Back in 1974 (or probably since a US toothpaste advertising campaign in the 1930s), the six month check-up was at the heart of dental practice. In the old fee-per-item, pre-1990 contract there was a time-bar against any check-up that dared intrude into this sacred 26-week period. Only children, pregnant and expectant mothers were permitted one additional dental examination in any 12 months.
This state of affairs continued untroubled until the 1990s, when the arrival of the first 'new' NHS dental contract provided for patient registration and the payment of a small continuing care allowance. The law of unintended consequences saw every moving humanoid promptly registered for a two-year period, triggering the payments whether their dental encounter was once in a lifetime or twice/thrice a year.
This miscalculation led to a significant cut in dentists' remuneration and contributed, over the following 18 years, to an inexorable rise in private dentistry. This, in turn, focused the attention of the media, and ministers, on 'access' to NHS care.
The situation was not helped when, in the mid 1990s, in an attempt to curb the dental budget, the two-year registration period was reduced to 15 months, cutting the statistics of dental 'attendance' off at the ankles.
The challenge since then has been to cap the dental budget, while ensuring all who needed to, could access NHS dentistry.
An innovative solution was to be found in the authority of Nice, whose guidance was sought shortly before the seminal Options for change document was published in 2002.
An examination of research evidence in the resulting Nice guideline, published in 2004, concluded that:
- there was little evidence to support or refute a six-month recall interval
- there was little evidence to suggest an optimal interval
- uncertainty existed about how patients value their dental health
- further research was needed to clarify the cost-benefit and clinical effectiveness of different recall frequencies.
As is by now well-known, Nice went on to suggest 'appropriate' recall intervals and these were duly built into the 2006 contract. Dentists were again reminded of this 'statutory requirement' in a letter at the end of March 2011.
Nice pointed out in their report that the proposed new contract of 2006 would include a comprehensive oral health assessment, 'personalised care plan' and 'patient journey', however these details were, in practice, lacking from a contract which initially failed to record these features, the patient's health and risk status or their proposed recall frequency.
The removal of the 'six month time bar' paved the way for new 'unintended consequences', all of which has led to the likely demise of this contractual arrangement by 2014.
We are now in a very different world. Much dentistry is provided privately in the UK, more dentists and dental care professionals than before are available for deployment, and economic rationality, not to say rationing, is the status quo.
It was enlightening, therefore, to read how UK dental undergraduates are being taught and trained in minimal intervention dentistry, formal risk assessment for dental disease, and growing awareness of associations between dental ill-health and holistic disease.
Pickard's Manual of Operative Dentistry (9th edition) was published earlier this year. It represents probably the nearest thing to a standard textbook for future practitioners and dental professionals.
Based on the modified ICDAS classification of dental caries, it proposes recall intervals between two and 18 months. For patients exhibiting no current disease but with a high risk thereof, a three-six month recall is suggested.
It's little wonder that dental professionals do, and will, find themselves confused. If this confusion is passed to patients, then it's difficult to see how a 'statutory guideline', clinical experience, patient consent and (to be a bit gloomy) the likelihood of complaints or litigation are to be balanced off against each other in the future.