Business Economic Notes 7

Dentists

These notes are issued to Inspectors of Taxes to assist them in examining accounts. They are intended to provide a general background to the trade, with some explanation of its most important features. Business Economic Notes are not intended to provide an exhaustive or definitive picture of any particular trade or profession.

Contents

1. The Profession

2. Practice structure

3. Working for the NHS

4. Payment for NHS work

5. The mechanics of NHS payment

6. Patients charges for NHS work

7. Private work

Small items
NHS work for which approval not obtained
Anaesthetics
Provision for expensive items

8. Other sources

Consultations, Anaesthesia, etc.
Dental products
Recovered metals
Cancellation fees
Rents from dental technicians, hygienists

9. Income and expenditure

Appendices

1. Average income and expenditure

2. Scale fees

3. Specimen forms

4. Glossary

1 The profession

There are about 16,00 dentists in general practice in Great Britain who work partly at least within the National Health Service. There are also an unknown number of dental practitioners who perform only private work. The geographical distribution of dentists is uneven. In Northern England and the Trent Region there are 4,500 people per dentist, whilst the ratio is less than half in North West Thames.

To practise within the General Dental service of the NHS, a dentist's name must be included on the Family Practitioner Committee's dental list in England and Wales or the Health Board in Scotland and Northern Ireland. To practise at all in this country, his/her name must be included either in the Dentists Register or in the Medical Register. Although dentistry is concerned with the treatment of disease in a relatively small part of the body dentists undergo training somewhat similar to the medical students course. On qualifying the dentist has a thorough knowledge of the masticatory apparatus and of the tissues of the mouth, can recognise disease in those tissues and is able to prevent and treat them.

On obtaining a university degree in dental surgery (e.g. BDS) or the Diploma of one of the Royal Colleges of Surgery (e.g. LDS, RCS) of both qualifications, the dentist can apply for admission to the Dentists Register. Although dentists can then set up in practice as self-employed principals, relatively few are able to afford the capital expenditure involved in setting up in business on their own account at such an early stage in their careers. Most join established practices as associates. Some however opt for employment as assistants in established practices. Others choose employment in the community or hospital services or in the Armed Forces. A dentist deciding at any time to set up his/her own practice, can approach companies which specialise in providing mortgages for such purposes.

Some dentists study for higher degrees such as a Master Degree (e.g. MSC, MGDS) or Doctorate (e.g. DDS) or diplomas such as the Fellow ship in Dental Surgery (FDS, RCS) or diplomas in dental public health (DDPH) or Orthodontics (D.Orth). Such dentists are usually employed in the hospital or community services, but they can also be found in the general dental services, where some restrict their services to a specialised field (e.g. Orthodontics - the treatment of irregular teeth, periodontics - treatment of gum conditions, or endodontics - treatment of infected roots).

Dentists qualified as Oral Surgeons may undertake maxillo-facial surgery (i.e. the rebuilding of faces) for medical or cosmetic reasons. At present about half of the Oral Surgeons in the country are qualified as medical practitioners as well as being dentally qualified.

A dentist is obliged to re-register annually and the Dentists Register shows the date of his initial and subsequent qualifications. Copies of the Register are available locally. In addition a list is prepared by the local Family Practitioner Committee of the names of those dentists who provide treatment under the general dental services of the NHS.

2 Practice structure

It is difficult to generalise about practice structures. Traditionally dentists practised alone or in small partnerships. But in recent years, especially in big cities, there has been a tendency to promote larger groupings of dentists usually working on an "associate" or "assistant" basis. There is nothing to prevent an associate or assistant having their own practice which may well be solely for private patients. A General Practitioner may also have subsidiary employment at a local hospital.

Assistants

Assistant dentists are employed under a contract of service by a principal to provide general dental services on their behalf. Principals must be able to supervise their assistant's work adequately and may not employ more than two assistants at any one time - for work under the general dental services of the NHS, without the consent of the Family Practitioner Committee. There are no fixed salary scales for assistants: these are a matter for negotiation and may take the form of a fixed salary or a percentage of the profits or a combination of both. The number of assistants employed has gradually declined in recent years.

Associates

Associates enter into a contractual arrangement which is neither partnership nor employment. All parties remain self-employed, but one provides the practice facilities, including premises, equipment, materials and back-up staff. In return the others either make an agreed payment, usually monthly, or forego a proportion of their income. The proportion foregone will often be as much as half the income after deduction of laboratory costs.

Standard agreements are common. As the owner of the facilities return on investment depends upon the associates' gross receipts, the associates will usually have to accept a certain number of patients or an agreed minimum hourly usage of the equipment. They will also have to provide a locum when ill or on holiday. Usually, gross fees are assigned to the principal who pays the net amount to the associate.

Principal dentists sometimes adopt an even looser arrangement than association. An agreement can be made to share certain common expenses such as premises, equipment like xray machines, postage and telephones, and some or all of the staff costs. The cost of dental supplies is rarely shared. The principals continue to work individually and do not share income. A separate bank account is often maintained into which the dentists make more or less regular payments to cover the expenses which are paid out as required. Such arrangements are clearly not partnerships, although the members may describe themselves as partners and may draw up annual accounts for the funding of the practice.

3 Working for the NHS

Dentists who want to treat patients under the general dental services of the NHS must be registered with the local Family Practitioner Committee or the Health Board. The list of dentists so registered should be available at local libraries and main post offices. However the fact that a name is on the list does not mean that the person will necessarily accept new patients for NHS work.

Unlike doctors, dentists do not have "lists" of patients. There is no obligation for the patients to return to the same dentist, or for the dentist to see the patient once a course of treatment is over. When he or she agrees to take on a national health service patient, the dentist is obliged to offer only the treatment considered necessary to make the patient dentally fit and that the patient is willing to undergo.

In practice patients do of course tend to return to the same dentists. Many practices encourage this by sending out reminders for regular check-ups, or even arranging for the next check-up at the end of a course of treatment.

Work done under the NHS is subject to some check. Courses of treatment which include certain specified items of treatment have to be submitted to the Dental Estimates Board for prior approval. (There is a separate Board in Scotland.)

Dental Officers of the Health Departments may be asked to examine patients and consider whether the treatment proposed is essential for dental fitness. They also examine a random selection of all patients after treatment, to ascertain that the treatment has been satisfactorily completed and that the patient has been rendered dentally fit. They have also asked to examine patients of some dentists whom the DEB have noted as having an unusual pattern of practise or whose remuneration is significantly higher than those of their colleagues. However the number of dental officers fell from 36 in 1970 to 28 in 1984, whilst in the same period the number of dentists in general practice increased by about 40%. A report produced by the British Dental Association in September 1983 noted that some practitioners had not experienced a random check for years.

4 Payment for NHS work

Whereas doctors are paid broadly according to the size of their "lists", dentists are paid for the work they actually undertake. However, like doctors the review body on doctors' and dentists' remuneration recommends a "target average net income" for each year. Once a recommendation is accepted, the dental rates study group sets about producing a new scale of fees which take into account the target income and the latest information on practice expenses.

The information on practice expenses is drawn from a random sample of dentists' accounts which were submitted to the Inland Revenue, supplemented by details of movement sin prices, earnings and wage rates. For example, the target average net income for 1985/86 was about £20,000. The study group estimated the average expenses would be about £20,000. This meant that the average dentist had to gross roughly £49,000 from something under 1600 hours for the NHS. The fees structure is intended to be ordered in such a way that the time spent on treatment is equally remunerative regardless of the type of treatment undertaken.

Further information on target average net incomes and fees is contained in Appendices 1 and 2.

5 The mechanics of NHS payment

When a patient is accepted for NHS treatment, the dentist completes a form FP17 (a copy is included in Appendix 3). This form records the treatment which will be required. In about 5% of cases the dentist has to forward details of the work needed with an estimate of the fee to the Dental Estimates Board for approval. In all cases, once the treatment is over, the form is sent to the Dental Estimates Board as a claim for the fees less the patient's contribution.

The Dental Estimates Board show on the schedules any charges which patients should have paid. These charges and the fees payable to dentists are based on the rates which are current at the time the treatment was started. A well kept appointments book will often show the date and amount of payment for each patient. Dentists are obliged to issue receipts (on form FP64) although this is not always observed.

The Dental Estimates Board advise the local Family Practitioner Committee or Health Board of the payments which are due to the dentist. These are made monthly, after a deduction for superannuation and certain other items. The advice of payment consists of two forms: one summarises the total scale fees due. the total patients contribution and the balance due after any adjustments, the other gives a patient by patient breakdown.

Although payments are made monthly, dentists receive more than 12 payment schedules in any year. Adjustments to scale fees are normally made in the autumn when a retrospective addition is made to fees which have been charged since 1 April on the old scale. A separate payment notice will give details of these additions.

The system has not always worked smoothly. For instance in 1978 and 1979 an interim scale enhancement was introduced in July and a retrospective payment made for the period since April. The final scale came into effect in October requiring a second retrospective adjustment for the period since April. There were thus 14 advice of payment notices in those years. In earlier years pay policy had complicated the system. There were changes in scale fees, with retrospective effect, to account for movements in the expenses ratio, but actual net pay increases were restricted to "pay supplements" which were given quarterly with a separate notification.

6 Patients charges for NHS work

From April 1977, patients were liable to bear the full cost of minor items of treatment, subject to a maximum sum payable. From April 1985 the full cost of treatment is chargeable up to £17 and thereafter a proportion of the cost is charged, subject to a maximum sum. Throughout this period, there have been separate set charges within the maximum sum for dentures, bridges, crowns, pinlays, inlays ad gold fillings.

No charges are made to any patient for a routine examine, arrest of bleeding, calling a dentist out to the surgery in an emergency, home visits or repairs to dentures and bridges. The dentist claims the full fee from the DEB. Certain patients are exempted from all payments (e.g. people under 19 in full time education and others under 18 (except that those over 16 have to pay for dentures and bridges), expectant and nursing mothers.

People getting supplementary benefit or Family Income Supplement and people getting free milk and vitamins and/or free prescriptions because they are on a low income also get free treatment automatically. Other people on a low income can get free treatment or help with charges by applying to the DHSS. In all cases, except where only partial remission of charges has been granted, the dentist will get full payment for the treatment given from the Family Practitioner Committee or Health Board.

7 Private work

Most dentists will have some private work. Some patients will seek private treatment as a matter of course. Otherwise it is likely in four possible areas.

Small items

When a course of NHS treatment is inexpensive, patients meet the fee for work done themselves, apart from the examination and report fee (E&R Fee), which the dentist claims from the DEB. For the sake of administrative convenience the dentist may undertake treatment wholly on a private basis and forego any claim for the examination fee.

Usually this is done with the patient's consent although some dentists may simply not submit the completed NHS form. There is then no record on the monthly advice of payment from the Family Practitioner Committee.

NHS work for which approval is not obtained

Some complex and expensive work like the provision of bridges, multiple crowns and most orthodontic treatment, can only be done under the NHS once approval has been obtained from the Dental Estimates Board (approval is not required for most metal based dentures).

About half the applications for such treatment are refused, usually because the DEB thinks that the cheaper treatment will be satisfactory. The dentist can then either offer the alternative treatment which the DEB is prepared to allow, or will suggest that the work be done privately.

Certain types of treatment are never approved under the NHS service which leans towards the "restoration" side of dentistry rather than prevention. This is partly because the quality and outcome of preventive work cannot be checked easily. Preventive measures other than scaling and polishing and oral hygiene instruction, such as the application of topical fluorides and sealants, have to be done privately. Some dentists specialise in preventive dentistry, the importance of which is becoming increasingly recognised, especially in middle class areas.

Pure cosmetic dentistry, that is, treatment designed solely to improve personal appearance is provided entirely outside the framework of the NHS. Appearance can however be a significant influence on the patient's mental health, and some treatments designed to improve appearance can be done for good medical reasons. However, the line would be drawn where, for instance, a patient wished to replace a perfectly adequate set of false teeth with a more expensive and natural looking pair or to substitute white fillings for amalgam fillings in back teeth. Such work would have to be done privately.

Anaesthetics

To prevent pain, there are three options available to the dentist; a local anaesthetic, a general painkiller (analgesia) or a general anaesthetic. A local anaesthetic is an injection near the appropriate tooth or nerve to render a part of the mouth numb. The dentist can do this and does not require an extra room or staff to cope with dozy or unconscious patients. Moreover, the work done rarely warrants more than a localised anaesthetic. Accordingly, it is the method most commonly used. The dentist receives no separate fee but absorbs the cost in the payment received for the dental work itself.

Occasionally it may be necessary for medical reasons to render a patient totally unconscious. There are NHS fees for the administration of a general anaesthetic by a second practitioner (another doctor or dentist).

The Dental Estimates Board does not question that a general anaesthetic is medically necessary if a patient is under 16 years old, where extractions or certain other specific types of treatment are involved, or if there are clear reasons why the patient needs to be generally sedated (for instance, where the patient is a spastic, has a pathological fear of dentists, etc.)

Fees are also payable for operator administered sedation or relative analgesia in connection with extractions or oral surgery or where, in the opinion of the dentist, any necessary treatment could be provided as a result of a condition of physical or mental handicap or a form of mental illness requiring medical attention or as a result of disproportionate dental anxiety. Outside these areas no fee is payable. However, there is a significant demand among adults for general anaesthesia or analgesia (which puts the patients in a "twilight" sleep) for restorative treatment. The cost of this can only be met privately. In such cases the restorative work itself should also be undertaken privately although some dentists do incorrectly offer a private anaesthetic with NHS work.

With both analgesia and anaesthesia there is a choice between intravenous injection or inhalation of a nitrous oxide and oxygen mixture. The use of gas is safer, but intravenous injection is preferred by patients, and its availability can help to build up a practice. Many dentists prefer another dentist, rather than a doctor, to act as an anaesthetist. In some surgeries, a partner would be encouraged to take a course in intravenous anaesthesia. Generally, practices with a high proportion of patients requesting a general painkiller, will have a high proportion of private work.

Provision of expensive items

Some dentists refuse to undertake certain work under the NHS because they believe the fee is inadequate for the time and effort involved. Patients whose dentist operates in this way will either have to accept that the work will be done privately or will have to find another dentist who provides the service on the NHS.

8 Other sources

Consultations, anaesthesia etc.

Dentists may receive consultation fees from other dentists. In some cases they may actually do part of the work on the patient. In such cases they can either claim separately from the Dental Estimates Board or receive payment from the dentist who referred the patient to them and who claims the full fee. Dentists who specialise in anaesthetic work may have a significant income from this source.

Dental products

Dentists are in a good position to recommend and promote the use of particular dental products by giving away free samples or by selling toothpaste and brushes. If a hygienist is attached to the practice, the relationship with the principal will determine who receives this income which in any case is unlikely to be substantial.

Recovered metals

The metals used in dentistry are expensive and will not be wasted. Back fillings are made from an amalgam of silver blended with mercury. The remnants of old fillings and surplus fresh amalgam collected in the dentist's spittoon are emptied out each day and stored. Some dentists pass the money made to charity. In 1985 a kilo of amalgam fetched about £28, but values have fallen substantially over the last 5 years and continue to fall.

Gold is also used in dentistry and can be similarly recovered. Different laboratories may produce different gold alloys and the smaller ones may only be interested in receiving back their own. However mixed alloys can be disposed of to the larger firms who have the assay facilities to grade the various qualities they are offered and will quote a price for each.

Finally, practices which take a lot of x rays may find it worthwhile to recover the surplus silver and silver salts under in the photographic process.

Cancellation fees

Dentists often charge cancellation fees for missed appointments. The amount of fee is at their own discretion and may sometimes be waived depending on the circumstances.

Rents from dental technicians and hygienists

A dentist may set up a self-employed dental technician in a room in the practice on condition that work is taken only from the principal, including sub-contracted work from other dentists. This will give rise at least to rental incomes. Many practices also provide facilities for hygienists who work on a similar basis to associate dentists.

9 Income and expenditure

	Average Actual Gross earnings	Average Expenses (excluding notional rent)	Proportion of expenses	Average Net Income	Target Net Income

1978/79	23,773	13,303	56.0%	10,470	8,829
1979/80	28,420	16,315	57.4%	12,105	11,128
1980/81	34,323	20,001	58.3%	14,322	14,675
1981/82	37,892	22,922	60.5%	14,970	15,555
1982/83	40,930	24,587	60.1%	16,343	15,435
1983/84	43,197	NA	NA	NA	17,556
1984/85	45,799	NA	NA	NA	18,707

There are many factors which can affect achieved earnings, but the following are the main ones:-

Age

Dentists have to perform very precise operations in a restricted space, often from an uncomfortable position. The skill and stamina required inevitably favour the younger practitioner.

Because they lack capital and business experience most young dentists start out either as employees or associates. Once they have found their feet, earnings capacity is likely to increase rapidly and peaks early in their careers. It commonly begins to decline in the late 30's, and dentists over 55 receive supplementary seniority payments.

Sheer know-how can outweigh the effects of age, and the introduction of modern equipment has made life more comfortable for dentist and patient alike, although it cannot compensate for a shaky hand. A good dentist over 65 with an efficiently organised practice may do as well as another practitioner who is younger, but the general trend of declining income and increasing expenses is shown by the following table:

Age	Average Actual Gross Earnings	Average Expenses	Proportion of Expenses	Average Net Income

Under 35	46,087	27,667	60.0%	18,420
35-44	43,833	26,053	59.4%	17,780
45-54	35,555	21,705	61.0%	13,850
55-64	26,611	17,160	64.5%	9,451
65 and Over	12,281	8,999	73.3%	3,282

Practice structure

Partnerships and sole practitioners who share facilities can be expected to have a lower proportion of expenses. In 1982/83 the average single-handed dentist's expenses were 61.1% of earnings, whilst for the average partner the proportion was 56.8%.

Those comparatively few practitioners who employ assistants will obviously have greatly increased expenses. For the far larger number who have associates, the financial arrangements and the way in which accounts are drawn up can have a marked effect on the apparent expenses. If we take a simple example, with two dentists each grossing £10,000, facilities costing £10,000, and a "charge" to the associate of £6,000, the expenses of the dentist who owns the facilities could be shown in three ways:

	1	2	3

Gross income	20,000	16,000	10,000
less expenses	14,000	10,000	4,000

Net income	6,000	6,000	6,000

% expenses	70%	62.5%	40%

In example 1, the associate has assigned his fees and receives a net £4,000 from the "principal". The "principal's" accounts appear much as they would if an assistant was employed. In the other two examples, the associate receives his fees gross and then pays for the facilities. Example 3 is more likely with the cost to the "principal" being reduced by the payment, although it could be shown as increasing the income as in 2.

Practice location

The location of the practice, and more importantly its clientele, will inevitably affect the way it operates and its profitability. However, there is no absolute link between the prosperity of the area and the prosperity of the dentist.

The competition from other dentists may well be less in "poorer" areas. In years past treatment consisted largely of extractions, which could be done quickly and at little cost, followed by the fitting of dentures which carried a high fee. A few predominantly "denture" practices may still exist, but nowadays it is usual to offer conservative treatment. Many patients will be exempt from charges or entitled to remission. Surgeries can be organised to allow the maximum throughput of patients.

By contrast, a dentist working in a predominantly middle-class area may feel the need to provide a better appointed surgery and a more personalised service. Expenses are likely to be higher, but recompense comes through a greater willingness to have work done privately.

Local traditions and changing values can affect the work which is undertaken. For instance, there is an increasing demand for cosmetic white fillings in back teeth as well as those which show. Gold crowns are especially popular in some immigrant communities, and certain practices will have a highly profitable turnover from gold crowns and inlay work.

Practice organisation

Dentists are paid for the work which they actually perform. The better organised practices try to maximise operating time. In a dual surgery the dentist may have two patients under treatment at the same time. Whilst one is undergoing active treatment, the other is waiting for an anaesthetic to take effect.

Some dentists have invested large sums in premises and equipment in order to set up the equivalent of health centres for dentistry. The total number "employed" may exceed twenty-five including associate dentists, hygienists and technicians as well as dental nurses and clerical staff. In addition to the principal's own fees, he or she will be receiving a proportion of fees from the associate dentists, as well as the hygienists and technicians.

The extent to which practice organisation and the hours put in can affect the gross earnings is shown by the fact that whilst in 1984/85 the target gross income was below £50,000, 281 dentists grossed more than £100,000, of whom 24 grossed more than £150,000. Two over £200,000 with the highest individual earner grossing some £241,590 from the NHS.

Appendix 1 - Average income and expenditure (1) Great Britain, £ Per Dentist

Financial year

74/75

75/76

76/77

77/78

78/79

79/80

80/81

81/82

82/83

83/84

84/85

85/86

5,650

8,176

+391

7,643

10,529

+60

7,643

11,789

-198

7,643

13,000

-187

8,829

14,450

+22

11,128

16,400

-33

14,675

19,650

-55

15,555

21,760

-488

16,435

23,500

-191

17,556

25,100

-6

18,707

27,265

-76

20,083

28,535

-203

14,217

17,962

19,234

20,456

23,301

27,495

34,270

36,827

39,744

42,650

45,896

48,415

14,406

18,351

121

19,662

221

20,456 (6)

414

22,786

28,347

34,234

37,801

40,837

43,000

197

45,594

215

14,501

7,818

18,472

10,156

19,883

11,684

20,870

11,873

22,845

13,303

28,420

16,315

34,323

20,001

37,892

22,922

40,930

24,587

43,197

26,144 (7)

45,799

6,683

8,316

8,199

8,997

9,542

12,105

14,322

14,970

16,343

17,053

Schedule D

income and

expenses

Gross income

Practice expenses

Expenses ratio

16,209

8,755

54%

20,596

11,324

55%

22,469

13,224

59%

21,695

12,941

60%

26,312

14,748

56%

30,816

17,713

57%

36,149

21,094

58%

40,820

24,727

61%

44,054

26,513

60%

46,638 (7)

28,403 (7)

61% (7)

(1) Expenses throughout include net capital allowances.

(2) Set by the Government in the light of the recommendations of the Review Body on Doctors and Dentists Remuneration.

(3) Estimates of average Schedule D income and expenses are derived from statistical enquiries conducted by the Inland Revenue on behalf of the

DRSG. The Study Group then apportions total Schedule D expenses between GDS and non-GDS expenses. The enquiries provide final

estimates of expenses 3 years in arrears (with provisional figures 2 years in arrears) and these date form the base from which the DRSG forecast

practice expenses for the current year.

(4) These include an addition for net notional rent, a deduction to fund the seniority payments scheme and (in some years) retrospective corrections

for over or underpayments in previous years.

(5) Seniority payments, cash supplements and threshold payments.

(6) Include £945 paid retrospectively in 1978/79.

(7) Provisional figure.

Appendix 2 - Scale fees - Reecent Changes

Where a new scale is introduced which results in an uplift this does not usually involve a simple percentage addition, each fee is separately recalculated, but for the purposes of the retrospective addition needed to payments made under the old scale and estimated average percentage increase is applied.

The following table sets out, in a simplified way, the changes which have taken place in recent years. The dates given relate to England and Wales; in Scotland and Northern Ireland a similar pattern applies. For various reasons, the pattern is atypical:-

Date change effective at DEB	Change (average %)	Retrospective to

October 1974	16.32%	April 1974
May 1975	14%	April 1975
August 1975	8.3%	April 1975
January 1976	New Scale, adjustment between fees	No retrospection
October 1976	3%	April 1976
May 1978	8.74%	April 1978
September 1978	4.84%	April 1977
October 1978	19.4% (England and Wales)
October 1978	24.93% (Scotland)	April 1978 only
October 1978	New Scale, average 1% increase	No retrospection
July 1979	10.0%	April 1979
October 1979	8.8%	April 1979
April 1980	7.5%	No retrospection
July 1980	6.8%	April 1980
October 1980	3.1%	April 1980
August 1981	4.8%	April 1981
October 1981	2.4%	No retrospection
August/October 1982	3.6%	April 1982
October 1982	1.0%	No retrospection
October 1983	3.5%	April 1983
October 1984	3.9%	April 1984
October 1985	4.4%	April 1985

The complications in 1978 have the following explanation. In 1977 the dental rates study group failed to reach agreement on a new scale and that for 1976 was continued. In 1978 an agreement was reached for an additional 4.84% to be paid on all fees calculated for 1977/78, payment being made mostly in September. In the same year the existing scale continued during April to September 1978 but an interim percentage addition of 12% was added to scheduled fees. In October 1978 a new fee scale was introduced and final adjustments for April to September were made.

Appendix 3 - Specimen forms

Reproduced on following pages are specimens of:

Appendix 3 (a) Form FP17 and FP17B

Appendix 3 (b) Monthly "advice of payment" schedules

Appendix 3 (c) An advice of retrospective addition to fees already paid

following a change in scale rates (expenses ratio only)

Appendix 3 (d) A quarterly advice of cash supplements

3 (c) and (d) are adapted from those relating to an actual dentist but 3 (a) and (b) are fictitious.

A number of points are worth noticing about 3 (b). On the general summary the fees are divided according to the date on which treatment commenced, since payment for long-term treatment may not take place for several years and a percentage addition is required to take account of subsequent changes in scale rates. For the most part however treatment has to be completed within 6 months (or 12 months where dentures are fitted following extractions). The most likely item of long-term treatment is orthodontic work. Dentists are entitled to interim payments for orthodontic work on children and an example is shown on part 2 of the form. The codes 1, 2 and 3 indicate whether or not the work required prior approval or was done as an emergency. The comments column will usually refer to time-barred items (that is which cannot be claimed for the same patient again within a given interval) special payments (for example replacement of lost dentures) remissions or negative adjustments.

A comparison of the individual patient record with the level of fees and patient contributions for the period may given an indication concerning private work. The maximum patients charge is £7.00 (£36 if dentures, bridges, crowns, inlays, pinlays and gold fillings are involved), but there are no payments at or around £7.00 (except remissions) where the patient has met all or most of the fee. It is likely therefore that our dentist has been treating such payments at private. It is more difficult to judge concerning more expensive treatments, since there are a number of fairly high fees. A look at all the schedules for the year would be more revealing.

Glossary

A. Who's who in dentistry

Dental Estimates Board - has the function in England and Wales of considering all dental estimate forms submitted for prior approval or approval for payment and may given or withhold approval as it thinks fit. It may require the patient to be examined by a Dental Officer. In general the Board will only approve the treatment necessary to secure dental fitness.

Dental Hygienist - an ancillary worker to a dental surgeon working under instruction and general supervision. The hygienist's duties consist of cleaning, scaling and polishing teeth and applying preventive materials such as fluorides. He/she may also undertake post-operative hygiene of the mouth.

Dental Officers; (now known at Dental Reference Officers) - there are 28 dental officers in England and Wales and they may be consulted on points concerning dental practice by ministers. Family Practitioner Committees, the Dental Estimates Board and Dentists. They regularly examine patients selected by the DEB, both before and after treatment, to see whether treatment has been properly prescribed and carried out. The also examine patients at the request of FPCs or dentists, and examine surgeries at the request of FPCs.

Dental Rates Study Group - this has 3 tasks which were set by the Royal Commission:

a. To fix such times for each dental operation as could reasonably be taken by the average dentist.

b. To determine gross fees for each of these operations in such a fashion that the "target net income" for the average dentist would be achieved in the standard number of hours of work.

c. To ascertain the total number of hours worked per annum by the average dentist.

Of these tasks b. is by far the most important and difficult.

Dental Surgery Assistant - has duties which vary with the size of practice: in a small practice clerical and secretarial duties will be combined with surgery work, whereas in a larger practice the duties tend to be split. The assistant's work includes reception of patients and callers, keeping records, charts, account and the collection of payments. Attending to patients in the surgery before and after treatment; preparing and sterilising instruments, equipment and dressings, mixing fillings, processing X-ray films etc. Most are trained on the job, but some now take courses at dental hospitals.

Dental Technician - during training dental students learn how to make dentures, crowns, bridges and other appliances in order to become familiar with the techniques used and the properties of the materials.

Practising dentists do not, however, normally make dental appliances themselves. This is the job of the dental technician, who works closely to the dentist's instructions and may be an employee of the dentist, or of a central commercial laboratory receiving orders from a number of dentists. Dental technicians also work for the community and hospital services.

Family Practitioner Committees - the bodies responsible locally for making arrangements for the provision of general dental services and having 30 members drawn from local authorities and medical etc. committees.

It is the FPC which actually pays the dentists in its area. A sub-committee (the Dental Service Committee) investigates complaints against dentists.

Review Body on Doctors' and Dentists' Remuneration - make recommendations from time to time (of late: annually) on the level of remuneration of doctors and dentists for a given period.

B. What is what in dentistry

Bridge - A prosthesis replacing one or more clinical crowns of missing natural teeth, cemented or attached to one or more adjacent teeth and not intended to be removed by the patient.

Conservative Dentistry (also known as Restorative Dentistry) - treatment of teeth to remove diseased tooth tissue and restore tooth to healthy function.

Crown - a full or partial replacement of the clinical crown which is attached to the remaining part of the tooth.

Deciduous teeth - "milk" teeth.

Dental Caries - tooth decay.

Endodontics - treatment of root canals and pulp chambers.

Inlay - a large filling in which a piece of gold or porcelain is made to fit a hole in a tooth and cemented into place.

Orthodontics - the treatment of variations of form in relation to the bones, teeth and soft tissues of the mouth including the correction of irregular or badly occluding teeth.

Partial Denture - similar to a bridge but it fits onto remaining teeth with claps and can be removed.

Periodontics - treatment for gum tissues and the bony support of the teeth.

Preventive Dentistry - treatment or advice to anticipate and prevent dental disease.

Prosthetics - branch of dentistry concerned with the functional and aesthetic rehabilitation of the masticatory system by artificial replacement of missing teeth and associated tissues.

Produced by the Inland Revenue

October 1990

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