Introduction

Prominent psychologist, Abraham Maslow developed his model for a pyramid of need based on observational studies. It sought to explain the priority of need for human existence, which ranked different criteria from basic physiological needs to more esoteric needs, such as 'self-actualisation' or the achieving of one's full potential.1 Although mostly untested in a clinical environment as theory, it is taught widely in health care psychology, as it helps clinicians understand and perhaps focus on where their patient may be in their life at any given time and which need may be that person's priority to address at that time. This theoretical model was later represented figuratively as the well-recognised hierarchy of needs pyramid (Fig. 1).

Fig. 1
figure 1

Maslow's hierarchy of needs pyramid

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Although widely accepted as an appropriate model for how humans prioritise their psychological needs, there are certain challenges to the theory, which include:

  • People can regress to lower levels depending on their circumstances at any given time, plus aspects of culture may prioritise the level of needs differently to match their own beliefs

  • Self-actualisation will be very different for different people

  • Maslow's original model fails to differentiate between individual and collective need. In the potential model we explore below, we will of course be focusing on a collective need.

A dental hierarchy of need?

As clinicians, we will also face choices on how to prioritise our own patients on a day-to-day basis. This will be a skill learnt practising dentistry and as such, we will likely prioritise certain aspects of care more highly than others. But are these prioritisations consistent with the patient's actual clinical needs, and what about the systems we work in? Are these systems (for example, NHS dental care) also set up to meet the needs of the patients, or are other factors, such as universal access to comprehensive care, mindful of an analogous potential hierarchy of dental care need? Are all aspects of dental care given equal priority? Media stories on poor access to NHS dentistry often directly mix stories of 'DIY dentistry' for uncontrolled pain, to waiting numerous months for a check-up or new dentures. This seems to hint at universal difficulty in accessing all forms of NHS dentistry, but perhaps there should be a priority within the system for developing services to meet the more urgent needs in primary dental care. As such, a hierarchy of dental care needs pyramid (Fig. 2) could be used as a model for planning NHS primary dental care. The idea of this model is not to try and align exactly to Maslow's theories, but rather to place dental care needs in a logical order where the system is able to deliver a positive effect to the biggest portion of the population, and those with the greatest amount of need for dental care.

Fig. 2
figure 2

Dental hierarchy of needs pyramid

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NHS urgent primary care

In primary medical care, the concept of emergency care appears to be perhaps better developed. Most potential emergency/urgent patients know what to do when faced with a medical emergency, be it something life threatening and therefore requiring 999 and/or A&E, or minor ailments, which can be treated with over-the-counter medication from the pharmacist. The Fuller stocktake report,2 which sets out a vision for integrated primary care, very much focuses on the importance of both urgent care and prevention, which will be a vital part of the strategy setting the direction for the newly appointed integrated care systems (ICSs). These in turn will set the direction for all primary care in the NHS, including dental services. Within this new model for planning for care, our colleagues working as part of the ICSs will need support and direction from us, their NHS dental colleagues, to set the agenda for oral care. I'm sure that an easy-to-understand model for prioritising care would be very useful.

Emergency care

I believe that providing access to timely relief of dental pain should be the key role for all NHS dental services. The level of importance is analogous to the Maslow pyramid, where physiological needs underpin the whole model, such that unless you have food, warmth and shelter, pretty much everything else is superfluous, and the motivation to have this need met trumps anything else. It is not uncommon to be informed by patients that tooth ache is the 'worse imaginable pain'.

In the wider NHS, the fallback position for any patient with an urgent medical treatment need is either to contact their general practitioner (GP) or attend A&E if the emergency is suitably severe. However, whereas everyone has access to NHS medical services, access to NHS dentistry is not so ubiquitous. There are many reports of 'dental deserts' where no NHS primary care provision exists, urgent or otherwise, and GPs being presented with more urgent dental patients.3 The dental workforce is apparently shrinking, with a loss of 3,000 dentists between March 2020 and March 2022. Additionally, an estimated 45% of dentists say they have cut their NHS commitment since the COVID-19 pandemic and up to 75% are set to do so in the future.4 If this is the case, then provision of NHS dental services is likely to shrink further in the future.

Should not dental services be developed to mirror medical services, where emergency care is provided urgently where more routine care will attract a wait, when resources are being stretched? Possible solutions to the improvement of urgent dental care could include:

  • More comprehensive emergency dental services for out-of-hours care. Out-of-hours care (especially for weekends) should be an integral part of dental services

  • Urgent dental hubs as developed for care during the first months of the pandemic, possibly in close proximity to secondary care for more severe emergencies and intermediated minor oral surgery, for definitive treatment of complex extractions

  • More urgent slots being available in current NHS practices, though as mentioned previously, NHS dental services are very thin on the ground in many areas and this may not be effective in areas where NHS services are sparse anyway.

There are many different options and choices to address this issue but perhaps what is needed most is a paradigm shift in our views as a profession as a whole, where urgent care needs to be considered separately to routine (elective) care, a philosophy which seems to already exist in medical care. Additionally, quality emergency care may hold the possibility for converting previously irregular attenders into more motivated regular dental patients.5

Prevention

As dental disease is widely recorded as a group of preventable diseases, then it is perhaps fair to rank this as the second most fundamental priority on the hierarchy of need pyramid; the equivalent of 'safety'. As a profession, we are fortunate to have access to an evidence-based toolkit - Delivering better oral health6 - which not only has excellent, evidenced-based advice, but is also easy to use for all groups of patients, be they vulnerable or not.

Many different barriers to providing preventive care have been reported, including: funding and remuneration (not receiving additional funding for the time spent as is the case in the NHS); motivation to carry out 'less sexy' work; and patient motivation.7 However, once again, a change of emphasis on the use of good preventive care may be useful in changing our current, 'treatment focused' viewpoint. That is recognising the fact that patients who have less disease incidence due to embedded prevention behaviours will also be patients who have easier mouths to maintain, this being a definite advantage in health systems such as the current NHS, where the payment is the same irrespective of extent of disease and amount of treatment provided (!). Also, fully utilising other members of the dental team, including dental nurses, hygienists and therapists, to truly optimise the preventive care we provide our patients, should be a universal priority. For the health planners and governments, good preventive care is also likely to be the most cost-effective choice for improving and maintaining dental health in the long-term, although access to prevention will in itself be reliant on access to NHS dentistry as a general rule, which, currently, would be difficult to achieve, with access being as poor as it is.

Although we may be understandably proud of the elaborate and impressive items of complex dentistry we provide our patients, they would, I'm sure, in most cases, prefer to have their own natural teeth in a healthy condition, and spend less time sitting having surgical procedures in the dental chair, as well as having less stress on their personal finances.

Simple operative dentistry

The concept of having a core service in dentistry which concentrates on providing perhaps less choice but to a broader section of the public would be one option to help improve access and reduce inequalities.8 In my model of hierarchy of dental needs, I have placed simple operative dentistry, which equates to what would be provided as a core service, in the third layer of the pyramid, analogous with the very important psychological need of loving and belonging.

What perhaps holds this back is not only the reluctance of successive governments to treat NHS dentistry as anything close to a priority, but also the profession itself having perhaps a predisposition for offering complex treatment, with the most complex treatments being perceived as better. No one would argue that a removable prosthesis is favourable to a fixed or implant-supported prostheses in terms of functional ability, but how many additional patients could receive a part or full denture compared to those being treated with implants or bridges? Where money is no object, then most people would likely choose a fixed option, but in a cash-strapped NHS, where additional funding is unlikely to be available any time soon, then dentures are certainly a more pragmatic choice in the majority of cases.

More complex operative dentistry

The arguments for simple versus complex dentistry have already been briefly discussed, but in certain cases, more complex options for dental care not only have a place in considering what is an optimal choice for repair, but also what we as a profession enjoy getting trained to carry out, especially when the results are pleasing not only to our patients, but also to our professional pride.

However, how much more satisfied would a busy NHS general dental practitioner be for being paid an appropriate fee for complex work privately, rather than struggling to provide the same level of care under a restrictive units of dental activity arrangement? It is a shame that 'rationing' of NHS dentistry could be needed to make it more affordable for the NHS, the patient and for actual practices, but the current state of affairs is such that NHS dentistry is close to collapse.9 Very few people have access to comprehensive NHS dental care anyway, either due to unofficial rationing (for example, molar root canal treatment, cobalt chrome dentures etc) or just absolutely no access to routine NHS care at all ('dental deserts').

Cosmetic dentistry

Cosmetic dentistry holds the position of self-actualisation in our hierarchy of needs. Although very nice to receive as a (wealthy) patient with an eye for appearance, as well as provide a dentist with additional skills, as it is not available on the NHS, cosmetic dentistry has little impact on how the service itself is funded and provided for.

Conclusion

Within the NHS constitution, one of the key principles is 'access to NHS services is based on clinical need'.10

For the NHS itself and the politicians and professional leaders who shape dentistry, including the ICSs and its clinicians, having a hierarchy of needs in pyramid form similar to Maslow's original pyramid may be a useful tool and aide-mémoire to whomever plans the future shape of NHS primary care dentistry and its priorities.