Refused dental bridge on the NHS because it's "cosmetic"?

rojoh0357

Hi,

My OH (an NHS patient) has been told that he can't have a filling on a molar as there's not enough tooth left. He's been offered an extraction on the NHS (Band 1 around £73), but has been told that any further treatment (implant, bridge etc) will have to be done privately because replacing a missing tooth is "cosmetic" and there is "no clinical need".

The private work would cost between £1,800 and £3,000 which we can't afford. It would also have to be carried out by a specialist although I'm not sure why.

This situation seems crazy to me. The NHS does offer bridges, but I'm not sure what the purpose of them is if not cosmetic or, idk, being able to chew food. There are a ton of articles online saying that having missing teeth isn't great for your oral health.

The other factor is that our dentist surgery has recently lost an NHS dentist so a fully private dentist is now seeing all the NHS patients, including my OH. So I suspect that the real reason for the refusal is that she doesn't want to do NHS work. 

Am I being unreasonable for expecting that we are able to access NHS treatment to replace a missing tooth with, say, a bridge? And isn't it unethical for dentists to try and get you to have private work when there is NHS treatment available? TIA.

brook2jack2

If you are suitable, the teeth next to the gap are healthy enough, you have no gum disease and you only have one tooth missing at the front then you MAY get a bridge on the NHS . 

The NHS will not offer bridges for back teeth because they are not necessary to secure health. Strictly speaking you only need 20 teeth to be dentally fit. If you are missing more than one back tooth you may be offered a denture on the NHS because that is the simplest way to secure dental health. 

One molar missing makes no difference to your oral health. A front tooth missing , with no other teeth missing is distressing and so is seen as a health need. 

More than one tooth missing overall then you will be offered a denture , if anything. 

Just because something is available on the NHS list doesn’t mean you are automatically entitled to it. It depends on clinical need and one molar tooth missing is not a clinical need. You might want it replaced with an implant or bridge (implant is gold standard because the other teeth are not drilled down for it) but that would have to be privately. 

welshdent

A few points really.

Regards the point of a specialist having to do implant or indeed posterior bridge work does not sound unusual to me at all 
Implant provision is not a clinical skill taught at undergraduate level and very much is an enhanced skill requiring a great deal of additional training. The average dentist does not typically provide this. 

Implants are also not an NHS treatment option except for specific limited scenarios. 

Bridgework also can be very complex. We can not see your husbands case so can not say if it IS complex but it is not outside the realms of possibility. FWIW i can not recall the last time I have placed a molar bridge on otherwise unprepared teeth and typically do not offer it unless the teeth either side have easily removable restorations/pre existing crowns.

Arguably a molar gap being restored IS cosmetic as a single gap wont affect function greatly. It may be annoying but I have seen patients that can demolish a steak with no teeth whatsoever so its not likely anyone will be unable to eat at all with one gap. 

There is even a concept called the shortened dental arch where nothing is replaced past the second premolar teeth. This is a stable, healthy and functional arrangement. IMHO as dentist of circa 2 decades, do not agree that missing teeth isn't great for your oral health. 

Oral function maybe. Aesthetics maybe. But not having a tooth wont affect health. If anything, a retained failing tooth is detrimental to oral health or a badly designed and implemented bridge is more damaging. 
Also to place a bridge, especially one replacing a molar, will typically require placement of a crown to a retaining tooth. 20% of otherwise healthy teeth that have crowns placed go on to develop nerve damage/death needing root canal treatment or extraction. They are also harder to clean due to stagnation sites beneath the false tooth. It can therefore be argued that a bridge may worsen oral health and as such would be against the aims of the NHS requirements for the dentist. 

NHS dental provision is to achieve dental health and that determination is at the interpretation of the clinicians based on examination,  a diagnosis and  treatment plan. Yes there absolutely is and should be patient discussion and a full consent process. But the dentist does not provide a shopping list for you and consent/treatment options are a 2 way street.  Bridges being "available" is to ensure dentists an option should they feel it is necessary but it does not mean they are a requirement to be provided. They may not be appropriate. They may not be necessary, they may not be the right option but thats a clinical decision. I wouldn't have one if I had other options and would leave a gap if the teeth either side were healthy and an implant was not an option. 

I know this is not what you are hoping to be told. But I think the dentist is acting entirely within their remit and requirements and it is unfair to assume they wont do a bridge because they dont want to do NHS work.

Your husband is one of thousands of patients they see. A sizeable number will be NHS patients. If they didnt want to do NHS work then I suspect they would have withdrawn from the service by now. They wont risk complaints by withholding something they have no right to withhold. They do have that right not to offer it. 

Exodi

rojoh0357 said:

Hi,

My OH (an NHS patient) has been told that he can't have a filling on a molar as there's not enough tooth left. He's been offered an extraction on the NHS (Band 1 around £73), but has been told that any further treatment (implant, bridge etc) will have to be done privately because replacing a missing tooth is "cosmetic" and there is "no clinical need".

Agree so far, though an extraction is NHS band 2 not band 1 (but charge is correct). Having all of your teeth (especially molars) is not a clinical necessity. Presumably your OH still has his other teeth and will be able to chew food - I've been missing molars on both sides of my mouth for over a decade and it hasn't affected my life in any way. I'm not puréeing my meals every day.

rojoh0357 said:

The private work would cost between £1,800 and £3,000 which we can't afford. It would also have to be carried out by a specialist although I'm not sure why.

That is unfortunate but such is the price of that treatment. You have a cynical view on dentists, yes it requires a specialist (someone trained in prosthodontics), things are never as simple as Joe Public thinks. Dentists can specialise in different fields (periodontics, orthodontics, prosthodontics, etc), just like a doctor might specialise in arrhythmia, or endocrinology, or anesthesia. You wouldn't expect your taxi driver to be able to drive a lorry.

rojoh0357 said:

This situation seems crazy to me. The NHS does offer bridges, but I'm not sure what the purpose of them is if not cosmetic or, idk, being able to chew food. There are a ton of articles online saying that having missing teeth isn't great for your oral health.

Can your OH not chew food then? If he can as I expect then I think you've answered your own question. While I've no doubt there are a ton of articles online saying that having missing teeth isn't great for your oral health (hmm I wonder whether some of these sites have any motivation to say this), I'd imagine your OH can function completely fine with a missing molar (and the gap will reduce over time as the teeth drift inwards).

The biggest issue from missing teeth is usually on account of bone loss.as you don't have the physical impact of the tooth structure stimulating the jawbone so it starts to dissolve. But this happens with a bridge as well. The only ways to counter bone loss are to save the tooth (possibly with a crown, but I don't know the state of the molar, probably not possible or the dentist would have suggested it), replacing it with an implant or having a bone graft (with the intention to replace in the future).

Then you have the downsides of the bridge, such as the fact you will need to crown prep the two surround teeth (aka irreversibly shaving them down, which could be 30% of the tooth) and placing crowns on them. Not only does this permanently compromise two healthy teeth but it commonly leads to sensitivity issues and becomes harder to maintain good oral health. Personally I'd suggest it's worse for your oral health applying the bridge than not (but of course patients are influenced by aesthetics just as they much as they are by health).

rojoh0357 said:

The other factor is that our dentist surgery has recently lost an NHS dentist so a fully private dentist is now seeing all the NHS patients, including my OH. So I suspect that the real reason for the refusal is that she doesn't want to do NHS work. 

Am I being unreasonable for expecting that we are able to access NHS treatment to replace a missing tooth with, say, a bridge? And isn't it unethical for dentists to try and get you to have private work when there is NHS treatment available? TIA.

I sincerely doubt it. The majority of NHS patients have a strong aversion to paying anything for private work, they know that.

So unfortunately for you, I side with your dentist and suggest you are being unreasonable.

While I'm sure it's quite emotional now as the news has just been delivered, it really isn't that big a deal to be missing a molar...

rojoh0357

Thanks everyone. Good to have another perspective on it.