It is over an hour before the emergency dental clinic is due to open, but Jodie Manning is taking no chances. She hasn’t been able to eat for four days – “I can’t physically bite down any more” – and is determined to get an appointment. Sitting on a plastic chair outside a community centre in Bury St Edmunds, Suffolk, the student hairdresser is a picture of misery, periodically clutching her cheek and looking down at the number she has been given to mark her place in the rapidly growing queue.
Aged 19, she has been to hospital with severe toothache “three-and-a-half times” in the previous year. The half is when they sent her home without treatment; on the other occasions, she was kept in overnight after collapsing from pain and dehydration, when even drinking liquids hurt her swollen mouth. Morphine has become her crutch: she fell asleep in college recently after taking the powerful painkiller. Like many of those waiting grimly in line, she has been struck off by her NHS dentist after not attending for two years, even though surgeries were shut to all but emergency cases during Covid.
She isn’t the only one in the 50-strong queue surviving on liquidised food; others complain of constantly bleeding tongues catching on broken teeth. Some are self-medicating with half a bottle of whisky every night, according to a man with an abscess wearing a hammer and sickle pin badge who turns out to be Darren Turner, the only Communist party councillor in England (he was elected to Bury St Edmunds council on a Labour ticket but defected in protest against Keir Starmer’s leadership).
“I personally have been trying for probably the best part of the last five or six years to get an NHS dentist, but it’s just impossible,” he says. “I had a wisdom tooth out in Cambridge privately and I needed to take a £500 bank loan to pay that. I’m a single father and I don’t have that kind of money hanging around to spend on my teeth. Feeding my children and putting a roof over their head has to come first.”
Further up the queue, David Mead is more cheerful. Having recently been homeless, living in a tent in nearby Sudbury – “Look me up, I was in the local newspaper: ‘Sudbury rallies around homeless 19-year-old’!” – he says he has hardly cleaned his teeth for 10 years. A few weeks ago they started to hurt as he ate. “I want to find out what’s going wrong there,” he says.
Others share tales of misfortune . “I cracked my tooth eating a Curly Wurly – as you do,” says Dean Leighton, a plumber in the utilities department at Cambridge University. He has turned up in a lime green T-shirt bearing the legend: Macho Man. It is a tribute to the late wrestler, Randy Savage, but could be read as a declaration of bravery.
Dean Leighton undergoes an extraction in the Dentaid clinic in Bury St Edmunds. Photograph: Linda Nylind/The Guardian
Probably the saddest sight is the children who can no longer chew food normally. Some have never been able to see a dentist. Ruby Moore, clutching her teddy bear, Lucy, is only six, and has lost most of the enamel off her molars – a problem that can be caused by sugary drinks and snacks, poor brushing or, less often, genetics. “My teeth hurt,” says Ruby in a voice that lisps a little since she slipped on some hand sanitiser during Covid and knocked out a front tooth.
She and her mum, Tamsin, had an NHS dentist but were booted off the list for reasons Tamsin still doesn’t quite understand. She is also in pain, sucking on tubes of Orajel, which temporarily relieves toothache. She has tried to get an emergency appointment elsewhere but has been turned away. “They told me, ‘Unless you are bleeding profusely we can’t see you,’” she says.
Hence taking Ruby out of school on a Thursday morning to see a mobile dentist from a charity originally set up 20 years ago to deliver dental equipment to the developing world. Dentaid was founded in 1996 off the back of a project to help treat prisoners at a jail in Ukraine. It then began refurbishing donated equipment and sending it to charitable dental clinics across the world. As funding increased, Dentaid started projects in 70 countries including Malawi, Cambodia and Uganda.
Tamsin Moore and her daughter Ruby wait to be seen by a Dentaid dentist. Photograph: Linda Nylind/The Guardian
That the charity has ended up treating patients in the back of a car park in one of the wealthiest towns in Suffolk is a sad indictment of a broken system, according to the local Labour councillor Donna Higgins: “These are people who need urgent healthcare.”
The same desperation can be seen across England, particularly in the north and east. Only a third of adults – and less than half of English children – now have access to an NHS dentist, according to the Association of Dental Groups (ADG). At the same time, three million people suffer from oral pain and two million have undertaken a round trip of 40 miles for treatment, the ADG calculated recently, calling dentistry “the forgotten healthcare service”. Tooth extraction is now the most common reason for a child to be admitted to hospital, costing the NHS £50m a year.
Dentaid’s first UK project took place in Dewsbury, West Yorkshire, in December 2015 with free clinics for people who were struggling to access dental care. It now has four mobile dental units, soon to be joined by a fifth. Most of their work is for homeless and vulnerable people across the UK, but they are doing an increasing number of public access clinics.
The charity’s first two visits to Bury St Edmunds were prompted by campaigning from a group called Toothless in Surrey and funded by Dentaid. To pay for the return trips, Higgins and seven fellow councillors, including Turner, chipped in £400 each from their “locality budgets”. It is not really what those funds are for, she says. “They’re supposed to be for getting up a playgroup, or if the community centre asks us to fund a second tea urn.”
Bury St Edmunds is not the sort of place you associate with desperation. It has England’s poshest branch of Greggs, housed in a Grade II-listed, 17th-century wood-panelled building; a Waitrose and a shop that only sells gourmet ready meals. But not everyone in the town can afford to spend a fiver on a microwave dinner for one – and certainly not on private dental care, which is the only option after all the local surgeries stopped accepting new NHS patients, even children. A similar story has played out across England, with “dental deserts” developing in all parts of the country, particularly away from the major cities.
The ADG recently calculated the Top 20 “dental deserts” in England, with parts of Lincolnshire taking three of the four top spots, along with the East Riding of Yorkshire. North Lincolnshire has just 32 dentists for 100,000 people, the lowest rate in the country. Just 33.1% of adults and 35.3% of children there had seen a dentist in the 24 months up to June 2021.
Approximately 2,000 dentists will have left in the past year, serving more than four million patients in England, the ADG said, arguing: “If there was ever a candidate for ‘levelling up’, NHS dentistry must be it. Funding has been flat for the past decade (a real-terms cut after inflation), and recruitment is now near impossible in rural and coastal communities – particularly the east of England from Whitley Bay to the Wash.” Brexit has inevitably made it harder to recruit dentists from the EU.
The further a place is away from a dental training hospital, the more likely it is to have a shortage of NHS dentists, explains Charlotte Talbot, a dentist who has taken a day’s annual leave to volunteer at Dentaid’s Bury St Edmunds clinic. “It breaks my heart to see how desperate people are for treatment in a place like this,” she says. “I’m from Suffolk, I know Bury. It’s an affluent place. But the last time I volunteered here with Dentaid I saw a woman who had taken out 13 of her own teeth. It’s a sad state of affairs.”
She looks through the window of the Dentaid van at a construction site, where builders are erecting 79 homes on a new housing estate, Lyle Place. “They’re building all these houses but no one who lives in them will be able to get an NHS dentist.”
Even if the developers were obliged to contribute cash towards a new dental surgery, as they often are with new schools, there is no guarantee the NHS would be able to find any dentists prepared to staff it. Talbot, who now works in a London dental hospital providing treatment to disabled and homeless people, used work in an NHS community practice. “It was hard,” she says. “You see 30 patients a day in 10-minute appointments and can’t do the dentistry you want to do. NHS dentists have to work 30-40% harder to earn the same money as a private dentist, who are able to provide high-quality treatment without the same pressures or time constraints.”
Natalie Bradley, Dentaid’s clinical director and an NHS dentist, assesses a patient in the Bury St Edmunds community centre. Photograph: Linda Nylind/The Guardian
The decline of NHS dentistry has deep roots. Years of underfunding and the current government contract, blamed for problems with burnout, recruitment and retention. Dentists are paid a flat fee for services regardless of how long a treatment takes (they get the same amount if they extract one tooth or five, for example). Covid exacerbated existing challenges, with the airborne disease posing a health risk for dentists peering into strangers’ mouths all day.
As the British Dental Association put it in its most recent briefing: “NHS dentistry is facing an existential threat and patients face a growing crisis in access, with the service hanging by a thread.”
Natalie Bradley, Dentaid’s clinical director and an NHS dentist, says regular checkups would lessen most patients’ problems. The day before the Bury clinic, the team had been in Leiston, a town of 5,000 near the Suffolk coast that has had no dentist at all since April 2021, when the final practice was forced to shut after being unable to recruit enough staff.
“We saw someone with a suspicious lesion in their mouth that could be cancer,” she says. “We’re seeing much more extreme cases, a lot of DIY dentistry, people experimenting with extractions and fillings and cases where people have burned their gums using aspirins and clove oil, which can cause caustic burns.”
Cutting back on NHS services makes no financial sense, she says: “It costs about £400 every time someone turns up to A&E with toothache, even if all they can usually be given is painkillers. A checkup costs £20.”
Some of the dentistry performed in the Dentaid van is far from simple. It requires three dentists to diagnose the cause of Jodie Manning’s agony. A tricky extraction follows. Dean Leighton, in the Macho Man T-shirt, has a tooth pulled, too. David Mead, the formerly homeless young man, needs no treatment, and is sent away with toothpaste and a brush. Young Ruby has some fluoride treatment to build up her missing enamel and her mum gets four fillings.
But about 20 people are told after four hours in the queue that there is not time to treat them. Tony Judge, a scrapyard worker, is among them. He can only chew food in the middle of his mouth because of a cracked molar and a hole on the opposite side. He has no plan B: “I called 111 and they referred me to a private dentist, but they wanted a £200 deposit over the phone before I even got an appointment.”
People queue waiting to be treated. About 20 miss out due to lack of time. Photograph: Linda Nylind/The Guardian
In a statement, the Department of Health and Social Care says it has made £50m available to the NHS to fund up to 350,000 extra dental appointments. “We are also working closely with the NHS to reform the dental system and we are currently negotiating improvements to the contract with the British Dental Association.”
What, then, can stop the rot in NHS dentistry? Everyone seems to agree the government contract needs a serious rethink, but there are other measures that could be taken, argues Simon Hearnshaw, an NHS dentist for 35 years in Hull who now works on dentistry for Health Education England.
Fluoridisation of the water in areas of deprivation would be a start: “Only 10% of England has fluoride in the water, mostly in the Midlands and north-east,” he says. Daily supervised brushing in primary schools, as happens in Sweden, would be another.
Emergency charitable services such as Dentaid, however well-intentioned, cannot be the solution, says Hearnshaw. “Why is it acceptable to wait in a queue for dentistry? If that was happening for any other part of healthcare, we would be horrified.”