NHS dental dark ages: 'I couldn't find a dentist... Now, aged 21, I've had to have all my teeth removed'

Like so many young women, Amy King always took great pride in her appearance. Standing in front of the mirror to check her make-up before a night out, the 21-year-old would always try a smile - friends told her they loved the way it lit up her face. Eight weeks ago, all that changed. The student from Plymouth was admitted to hospital where, in a single operation, she had every tooth in her mouth removed.

Amy, whose dental problems were caused by untreated gum disease, does not go out any more. And when she looks in the mirror she hardly recognises the face staring back at her. 'Even with my mouth shut I look different,' she says. 'My cheeks are hollowed and my face looks thinner. I look like an ugly, old woman.'

Amy's story gets worse. First, doctors have told her they can't fit a set of false teeth until her gums are sufficiently healed and that could take six months. But she has also been warned that there is a slim chance they will never recover enough for dentures to be fitted.

Second, Amy believes that had she been able to get dental treatment earlier, then all the pain and disfigurement she has experienced might have been avoided. 'I feel that if I'd managed to see a dentist sooner or could have afforded to have private treatment I wouldn't be like I am today,' she says, explaining how it took months of searching and dozens of phone calls to find an NHS dentist willing to treat her - by which time it was too late. 'I thought that losing all your teeth only happened to people in the Dark Ages - not a 21-year-old living in modern Britain.'

If only that was the case. While Amy's experience is an extreme one, it highlights growing concerns about the state of the nation's dental health. Last week, statistics obtained by the Liberal Democrats revealed that the number of people having teeth extracted in hospital has risen by one third in the past four years. More than 175,000 Britons had their teeth removed under general anaesthetic in 2007/08, up 40,000 on the 2003/04 figure.

The number of children having teeth out has shot up, too. But more pertinent is the fact that the rate of these extractions gathered pace after a deeply controversial contract for NHS dentists was introduced in April 2006. The year before, the number of extractions was fewer than 150,000. Two years later, it had risen to more than 175,000 - an increase of 16 per cent. Could the contract - hailed by the Government as a revolution in the provision of state-subsidised dental care - be linked to this alarming new trend in tooth extraction?

Critics such as Norman Lamb, the Lib Dems' health spokesman, are in little doubt. He says: 'I am hearing from people who still cannot see an NHS dentist and are therefore neglecting their teeth or waiting until it is an emergency. 'Other patients have to pay extortionate amounts for private treatment to save a tooth or else wait weeks, often in pain, to get a tooth extracted on the NHS.'

But it is not just a continued lack of access to NHS dentists that is causing concern. There is also growing evidence that the new payment system introduced by the contract is discouraging dentists from undertaking more complex, time-consuming work. This work is not being done at all or being left to newly-trained dentists. Both routes are more likely to end up with the patient being referred to hospital to have teeth extracted. The end result is more people like Amy - who, for the rest of their lives, will only have to look in a mirror to be reminded of a dental system that is still failing to deliver.

For a reminder of the depths to which NHS dentistry had sunk under New Labour, pay a visit to Scarborough. In 2004, three years after the date by which Tony Blair promised that everyone in Britain would have access to an NHS dentist, hundreds of people queued on the town's streets. They were desperate to register for NHS treatment at a new dental surgery. Most were unsuccessful and the image summed up the shocking state of this key plank in the nation's healthcare.

More shocking still was the story of local resident Valerie Holsworth. Her inability to access NHS dental care since the year 2000 had forced her to resort to excruciatingly painful DIY dentistry. Valerie described how, using a pair of her husband's pliers, she wrenched out seven teeth. 'I have a gum disease for which I take painkillers,' says the 68-year-old great-grandmother. 'But when the tooth becomes agonising I have to take it out myself. I take a good mouthful of whisky before I get started to keep it sterilised. 'Then it is just a matter of tugging and wiggling until the root comes loose. I then just throw the tooth in the bin.'

Evidently, something had to be done. While the number of registered dentists has steadily increased over the past two decades, many had drifted away from state-funded treatment and moved into the private sector. In a bid to reverse this trend, and to target treatment effectively, the dental contract was introduced. As a sweetener, it held out the promise of improved pay. Indeed, incomes have increased by 11 per cent since the reforms - to an average of more than £96,000.

But the most fundamental change focuses on the way dentists are paid for the work they carry out. Under the old system, there were 400 treatments, each commanding a separate fee. The concern was that dentists were effectively being paid for piece-work - the more 'drilling and filling' they did, the more money they got paid. Instead, it was decided that dentists would be paid according to Units of Dental Activity (UDAs). These relate to the treatment on offer, the 400-odd individual procedures in turn being divided between three bands.

The value of UDAs is set by Primary Care Trusts, varying around the country according to need. But to the average dentist, each UDA will be worth about £25. If a dentist does a 'simple' band one treatment, involving a checkup, X-rays, cleaning and polishing, they will earn one UDA, or £25. A more complicated band two treatment, involving fillings or extractions, will earn the dentist three UDAs (£75), while a band three course that needs lab work (such as dentures or crowns) earns 12 UDAs (roughly £300). And unless they are exempt from paying due to age or pregnancy, patients must still pay charges ranging from £16.50 to £198.

In theory, it all sounds easy. In practice, however, serious problems have emerged. UDAs are related to completed treatments and not the number of items in the treatment plan. So, a treatment with crowns will pay 12 UDAs irrespective of whether there is one crown or 20. (It is much more expensive for the dentist to perform such treatments privately.)

Equally problematic is the fact that each band covers such a wide range of treatments. Some are easier and quicker to perform, yet all attract the same payment. Finally, the number of UDAs each practice can earn is fixed in advance by the care trust. If dentists exceed that number, they will not be paid extra work.

The terms of this contract are complicated, bureaucratic, and heavily target-driven. The upshot has been to alter the behaviour of the health practitioner in unintended ways. Mark Watson, chief executive of the Dental Practitioners' Association, explains: 'We have gone from a system where dentists were paid to do as much as possible to one that encourages them to do as little as possible. The idea is that they will see more people, but each person gets less done.' This is all well and good if the patient has healthy teeth and gums and does not require much treatment. But while dental health among the young is improving, there remains a large number of people whose needs are more complicated. Under the contract, there is little incentive to take these cases.

'Everyone who is self-employed looks at what is profitable and what is not, and tends to want to do as much of the profitable stuff as possible,' says Mr Watson. 'Dentists are no different. As there are only three bands, any course of treatment at the upper end of a band makes a loss while that at the lower level makes a profit.' The Department of Health's argument is that it is swings and roundabouts - what dentists lose on one treatment they make on another. But life doesn't work like that.

It is this chain of events that some believe is behind the increase in hospital tooth extractions. Dentists are not encouraged to carry out the sort of complicated work that might prevent a patient from ultimately having their teeth removed.

Further evidence of this move away from complex treatments was highlighted by the Commons Health Committee. It found that the number of treatments such as crowns, bridges and dentures had plummeted by 57 per cent since 2006. The MPs believed this was happening because NHS dentists have no financial incentive to give appropriate treatment. In Scotland, which did not bring in the new contract, the number of complex operations had gone up.

What is equally galling is that despite pumping more taxpayers' money into NHS dentistry - and more dentists taking on NHS work - the number of patients being treated fell after the introduction of the contract. In the two years following the reforms, 26.9 million people saw their dentist - just 52.7 per cent of the population. That is down 1.2 million compared to the two years leading up to the changes.

An annual survey by Simplyhealth, a group of healthcare companies, found that the numbers struggling to find an NHS dentist have increased in the past year - up from 23 per cent to 35 per cent. If these people can't find an NHS dentist what options do they have? Suffer in silence or go private. The private route can be extremely expensive, forcing increasing numbers to travel abroad for cut-price treatment.

In 2007, there were 50,000 dental tourists. Simon Purchall, founding director of Smile Savers Hungary, has seen a 60 per cent rise in patients since January 2007. 'A lot of people come to us after years of putting off dental work,' he says. 'They can't find an NHS dentist, they're not willing to accept the solution offered such as dentures or they can't afford the high prices charged by private British dentists for modern solutions, such as implants.'

Louise Webb, a 44-year-old careworker from Stoke-on-Trent, knows this only too well. Plagued by dental problems, she was referred to Birmingham NHS Dental Hospital and was told the only option was to have all but four teeth removed. 'They told me they were going to rip them all out and then they would leave me for three or four months until the gums had healed before they gave me dentures,' she says. 'I'd already given up my job because I was so embarrassed by the way my teeth looked.' Desperate to end the pain, Louise agreed to the operation. But the day before it was due to take place it was cancelled. This happened on two subsequent occasions. In the end, her husband Andrew, who works for the NHS as a locum audiologist, found the solution.

'He came in one day and found me, exhausted, asleep with my head on the table,' she says. 'I had a hot water bottle on one side of my face to try to deaden the pain. I looked awful. He just thought: "Enough is enough." '

Having searched the internet, the couple came across Smile Savers and within a week Louise was in Budapest having the first of two operations. These involved the removal of 14 teeth and their replacement with 13 implants plus 22 crowns. It cost £12,000, a lot less than the £70,000 she was quoted by a private British dentist.

While Louise does not expect the NHS to provide cosmetic dentistry, she says it was the failure to end the pain that left her feeling let down. 'We pay our taxes, and yet I was unable to get the treatment I deserved,' she says. 'I was known as the Yoghurt Queen because I was having to liquidise my food. I lost two stone in weight. My NHS dentist's hands were tied because she could only do so much treatment.' The dental work has transformed Louise's life. 'My daughter says the biggest change about me is that I am happy,' she says. 'I used to go out with a scarf wrapped around my mouth to hide it, but now I laugh all the time.'

Just how many people will leave their NHS dentists with a smile on their face, only time will tell. A Department of Health spokesman says: 'We have appointed an independent review team to help us understand what more needs to be done to ensure that every person who wants to visit an NHS dentist can do so, make NHS dentistry fit for the future and ensure that all NHS dental services meet the highest standards of care.' [The British bureaucracy is very good at bulldust -- but not much else]

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