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My dentist wants me to see him for a check-up every 6 months. Or at least he would if I had one. Like 44.6% of people in the UK I haven't got an NHS dentist1 and I object to paying for one of the few things the government still tells me I should get for free. In fact, the last time I did get to see the dentist it was privately and this particular practice liked to make routine appointments not twice but three times a year. To be fair to them, they did have to cover the rent on their swish central London premises; it was difficult to knock their business acumen.
Twice a year. That's more often than I see the doctor—or my grandmother, come to that. Neither of them seem to mind, but my hypothetical dentist does. I am being a little unfair. The National Institute for Health and Clinical Excellence (NICE) actually advises that adults no longer need to be routinely seen biannually but anywhere between 3 months and 2 years depending on need.2 That's still an awful lot more spontaneous invitations to attend than I receive from my GP. Which seems a little strange to me: apparently my heart, lungs, liver and spleen can comfortably be left to their own devices, but my teeth? Better keep a close eye on those precious little ivories. Imagine if I didn't look after them and I developed complete tooth failure? I might end up needing total artificial teeth replacement (dentures to the layman). Presumably, the rationale for routine dental screening is the very high incidence of dental disease3 in much the same way many groups are provided with routine optometry appointments on the NHS. But compulsory check-ups are not the only way we fetishise our pearly whites: no other part of our anatomy has a whole medical profession devoted to it in quite the same way. It seems highly unlikely we would have arrived at this state-of-affairs if we had planned in advance:
Asclepius:Let's see, I think we'll want to create at least three healing professions.
Zeus:OK—well I guess we should divide up humans and animals first.
Asclepius:Good idea, boss—it's easy to triagei problems into animal related or human related. We'll call the animal healers ‘vets’ and the human healers ‘doctors’.
Zeus:Weren't we going to have a third category? How about we divide up the vets into ‘large animal’ and ‘small animal’ or ‘mammal’ and ‘non-mammal’?—there's an awful lot of different animals after all.
Asclepius:Well, we could do. But I was thinking we could have one for teeth instead?
Zeus:Teeth? So one profession that just looks after animal and human teeth?
Asclepius:No, they'll just do human teeth—we'll call them ‘dentists’.
Zeus:Right, so we've got the ‘vets’—they'll do all the animal healing including teethii…
Zeus:And the ‘dentists’—they'll do all the healing of human teeth. And the ‘doctors’ will be in charge of healing all the parts of people apart from teeth.
Asclepius:Makes sense doesn't it?
The roots of dentistry are, of course, inextricably bound to the rest of medicine: Pierre Fauchard, the father of modern dentistry, started life as a physician4; The Operator for the Teeth, the first dental book written in English, was written by Charles Allen, a physician5; even John Hunter played a part with his The Natural History of The Human Teeth.6 However, when The Medical Act of 1858 united the physicians, surgeons and apothecaries under a single register under the oversight of the General Medical Council (GMC)7 (laying the foundations of the modern medical profession in the process), dentistry was still in its infancy—the first British dental schools were not to open until a year later.5 Had The Medical Act required dentists to be registered with the GMC (not unreasonable as the first dental register wasn't established until 18795), the passage of time may have seen the physicians, surgeons, and dentists united into a single profession with a common registration degree.
It is always dangerous to play fantasy history, but in this case I can't help but wonder at what might have been. For a model of how dentistry could have been provided as a medical specialty rather than a separate profession we need look no further than the provision of ophthalmic care.iii Like dental disease the burden of ophthalmic disease is very high (almost everyone wears glasses at some point in their lives) and like dental disease much ophthalmic disease can be managed in relative isolation to the rest of the body. The work presently performed by the dentist would then be split up three ways. Just as the public presently have direct access to an optometrist to test their visual acuity, screen them for glaucoma, prescribe spectacles, and pick up the occasional intracranial tumour,8 they would be able to self-refer to a dental hygienist. In this parallel universe the hygienist would have an extended remit and, in addition to scaling and polishing teeth (presently included in 44.1% of NHS funded courses of treatment9), would perform routine check-ups—screening for dental problems which require referral on to the hospital based specialty of oral surgery. Oral surgery would then be a postgraduate secondary care specialty which, rather than being involved in the theoretical screening of the entire UK population, was simply focused on providing specialist interventions for those with dental and gingival disease (possibly as part of the same specialty as maxillofacial surgery).
General practitioners would also have a role; they would all have undertaken a short rotation in oral surgery during their time at medical school and might be consulted (in their capacity as generalists) about a dental problem just like any other health problem. Conditions they felt confident to manage in the community such as dental abscesses they could treat themselves and refer on cases requiring more complicated interventions to the oral surgeons. Much as some GPs presently develop a special interest in minor surgery and undertake lists of abscesses, cysts, lipomas and so on, in our alternative reality you might encounter a GP with a special interest in oral surgery who ran a list of basic dental procedures on a Thursday afternoon.
There's no danger of us flipping over to this parallel universe anytime soon. Even if we decided it was preferable, the change would generate a QWERTY problem of gargantuan proportions—not to mention a lot of angry dentists. All the same, it seems like things could so easily have been very different. I might even have been able to get my teeth scaled on the NHS.
Competing interests None.
Provenance and peer review Commissioned; not externally peer reviewed.
↵i This conversation is history's earliest recorded use of the word ‘triage’.
↵ii This is not quite the full story. Although most animal dentistry is performed by veterinarians, one can be an equine dentist without being a veterinarian first. People have dentists, horses have dentists, but chimpanzees and cats only have veterinarians.
↵iii As an interesting reversal of this thought experiment—what if ophthalmology had ended up as a separate profession just as dentistry is presently?