People's History of the NHS


Teeth and National Identity

Artist Jessine Hein handmodeled David Bowie's teeth from photographs:

In retrospectives of David Bowie’s career following his death in January 2016, much was made of his ability to transform himself, not just musically, but also in terms of style and identity, as marked most memorably by his adoption of the character of Ziggy Stardust in the early 1970s. Yet, looking back at his image, across six decades as a public performer, we are also reminded of the loss of something which has come to feel much more familiar, down-to-earth, and endearing: the boyish, handsome face and smile of the David Jones of the 1960s, which ages towards the end, but never fully goes away. There is however one striking difference: Bowie’s teeth. Looking back at the Bowie of the 1970s, it is the gloriously imperfect teeth that identify ‘the man who fell to earth’ as still the English boy from the suburbs. The teeth began to change in the early 1980s. After his marriage to supermodel Iman in 1992, Bowie emerged with what we might call the full American smile. Whether this was down to the social pressure of living within a world of sparkling white, straight teeth, or just another reinvention and role, is difficult to say. Arguably it is in tension with our idea that one of his great achievements of Bowie was to herald a world in which difference could be embraced.

Bowie was not alone among British celebrities who abandoned their British teeth as they tried to establish themselves in the United States. Novelist Martin Amis was another, and in his case the makeover was the subject of caustic commentary in the media. In the 1990s, there was still something vaguely unpatriotic about such an act. In America and beyond (in Mexico, someone with bad teeth has ‘dientes Ingles’), the idea that the British had bad teeth had become a powerful stereotype. In an episode of the American animated sitcom The Simpson’s from 1993, a dentist terrifies his patient into adopting dental hygiene by showing him the ‘Big Book of British Smiles’. The stereotype was also fostered in the Austin Powers film series in the late 1990s; the joke being that only a British spy could have crooked yellow teeth and see himself as a sex symbol. When comedian Ricky Gervais took on the role of a dentist in the Hollywood film Ghost Town (2008), an American interviewer was shocked to find out that his ‘awful’ teeth in the film were his own rather than fakes, and was bemused as to why he hadn’t had them fixed.

The stereotype of bad British teeth no doubt contributed to the ongoing suspicion of socialised medicine in the United States. But, beneath the non-whitened, crooked surface, British teeth were actually better than they seemed. Indeed, by the start of the new century Britain was overtaking the United States when it came to measuring the dental health of twelve-year olds. By 2008, the UK in fact had the joint best rating in the whole of the OECD. The inequality between the healthiness of teeth among the rich and the poor was also less marked than in the United States. The teeth of the rich may have been in a better state than in the UK, but poor Britons generally had better teeth than their American counterparts.

The national stereotype appears to have been there already at the end of the 1950s, set out with an element pride, in Spike Milligan’s ‘Teeth’ which was included in his Silly Verse for Kids, first published in 1959:

English Teeth, English Teeth!
Shining in the sun
A part of British heritage
Aye, each and every one.
English Teeth. Happy teeth!
Always having fun
Clamping down on bits of fish
And sausages half done.
English Teeth! HEROES’ Teeth!
Hear then click and clack!
Let’s sing a song of praise to them –
Three Cheers for the Brown Grey and Black.

The National Health Service had been a major boon for the teeth of the nation, but it still left teeth in a poor state of repair. Milligan’s poem indicates how a combination of stoicism, humour, and the fact that things were better than they had been (at least there was now fish and sausages to eat) made it possible to laugh at the situation, even to see it as somehow linked to that wartime spirit of making do that continued in the era of post-war austerity. English teeth might now seem increasingly English in comparison to those of the Hollywood stars, but at least they now made a comforting ‘click and clack’ – a noise that betrayed the fact that many of them were new NHS dentures.

Unexpectedly, free dental treatment had been included in the NHS as it launched in 1948, and this saw huge take up. Provision of dental care had advanced in the previous half century. Inspection and some treatment for children followed the introduction of a school medical service from 1907. And treatment was available on a limited basis to a significant proportion of the working population under the 1911 National Insurance scheme. But dental hygiene was in a parlous state, and for many the treatment options were limited. Teeth had come to be seen as a problem best got rid of as quickly as possible. Lack of fresh food and an increase in sugar as part of the British diet had led to a serious decline in dental health over the 19th century. In George Orwell’s famous account of the ‘Road to Wigan Pier’ in the 1930s, it was difficult to find a working-class person with good natural teeth. Even children’s teeth had a bluish tinge. Anyone over thirty with their own set of teeth was an abnormality.

The advent of the NHS saw a deluge of demand to remove rotten teeth and to replace these with dentures. Further demand came from those who had been hanging on to old sets and needed replacements. New acrylic dentures replaced older vulcanised ones and were better fitting and more realistic. A million sets were distributed in the first nine months of the service. There was also huge demand for teeth extractions and fillings. This astonishing demand for dental treatment was key in the NHS soon breaking with the principle of services being free according to need. Charges for dentures were introduced in 1951, halving demand. And a general charge for dental treatment was introduced from 1952. It was this issue that led to the resignation of Aneurin Bevan, the Minister who had been crucial in bringing the service into being.

Over the next decades under the NHS, dental health would improve significantly. The proportion of twelve-year olds with no significant dental decay was 19% in 1948, but had risen to 62% by 2003. Dentures became something largely associated with those whose teeth had rotted away in the days before the NHS, with just 6% of the population having no natural teeth by 2015. This owed much to broader changes in diet, to the fluoridation of toothpaste from 1959 (doubly important because of the reluctance to fluoridate the water supply across the nation), and to the messages of public health and a new emphasis on the importance of good dental hygiene. A system of payment of dentists per treatment – ‘drill and fill contracts’ – if anything encouraged too much intervention. It also meant that cheaper materials were used to keep costs down. Metal began to fill the mouths of the post-war generation, mainly in the form of fillings, but also increasingly through orthodontic braces. Cosmetic appearance was a low priority, and regulations on what types of treatment were available on the NHS held this back. A generation brought up to see it as their right to have free healthcare were reluctant to go privately where such services were available. So the advent of the NHS brought about much healthier teeth across all classes, but did less to change the look of these teeth. Indeed, as dentures became less common, the possession of a slightly misaligned and yellowed set of teeth may have become more distinctively British than ever. Such distinctiveness was very much a product of the NHS.

Over the last decade, there have been signs that the system established in 1948, of the vast majority of the British people receiving the vast majority of their dental care from the NHS is becoming less distinctive. The same may be true for the distinctiveness of the national teeth. A shift in the system of paying NHS dentists has meant that the problem has changed from one of possible over-treatment, to a challenge, particularly for those most in need of treatment, of finding an NHS dentist willing to provide any treatment at all. In parallel, there has been a rise in DIY treatments for such things as fillings. And there is a growing private sector providing the cosmetic treatments that have been difficult to access through the NHS. In other words, if there is story of how the NHS helped to give us British teeth, that story could now be coming to an end.


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