‘The idea really came to me the day I got my new false teeth,’ George Orwell’s Coming Up for Air begins. Two paragraphs later, we learn that the narrator is forty-five years old. In 1984, Winston is surprised at Julia’s advances: ‘I’m thirty-nine years old. I’ve got a wife that I can’t get rid of. I’ve got varicose veins. I’ve got false teeth.’ And in Keep the Aspidistra Flying, an even younger Gordon Comstock glumly evaluates his life:
thirty years old, with twenty-six teeth left; with no money and no job; in borrowed pyjamas in a borrowed bed; with nothing before him except cadging and destitution, and nothing behind him except squalid fooleries.
It’s not so much an oral fixation as a sign of the times. Teeth were hard to keep, especially if you were poor. In The Road to Wigan Pier, Orwell reads the teeth of working-class people in the industrial north:
The most obvious sign of under-nourishment is the badness of everybody’s teeth. In Lancashire you would have to look for a long time before you saw a working-class person with good natural teeth. Indeed, you see very few people with natural teeth at all, apart from the children; and even the children’s teeth have a frail bluish appearance which means, I suppose, calcium deficiency … In Wigan various people gave me their opinion that it is best to get shut of your teeth as early in life as possible. ‘Teeth is just a misery,’ one woman said to me.
By 1948, three-quarters of British adults were edentulous. At the passage of the National Health Service Act in 1946, many held off seeking treatment, determined to grit their rotten, aching teeth for two more years and receive care without cost. In its first year, the NHS replaced more than 33 million teeth. Government funding was insufficient to meet this colossal demand, and in 1951 dentures were the first NHS service to become chargeable.
A one-pound fee for other dental treatments followed a year later, along with the introduction of charges for glasses and prescriptions. Aneurin Bevan argued against the costs, protesting that the initial surge evinced the inadequacies of the previous system, and would soon settle down. He was right, but apart from three years when Harold Wilson was prime minister, dentistry has been chargeable ever since.
Corbyn’s Labour Party pledged to do away with prescription charges in 2019, calling them a tax on illness, but there has been no serious policy proposal to abolish NHS dental charges. A historical contingency has become a largely unchallenged reality. Yet bodies defy the disciplinary divide between dentists and doctors. Poor oral health is a determinant of health more generally, and bad teeth can seed or reveal problems elsewhere. If bacteria from the gums get into the bloodstream, they can travel to the heart, forming potentially fatal plaques in heart valve tissues. Periodontitis in pregnancy is linked to low birth weight and premature birth, and rapid tooth decay can be a sign of autoimmune disease, diabetes or HIV/Aids.
Merely being seen by a dentist now costs £23.80 in England, and more complex work can set you back £282.80, which is a week’s earnings on minimum wage. That’s if you’re lucky enough to get on an NHS list; private fees are much higher. Only a third of UK adults are now NHS patients. More than two thousand dentists left the NHS last year, and large areas of the country are now ‘dental deserts’ where people wait years for treatment.
The problem is the same as it was in 1948: the budget for NHS dentistry is inadequate to meet the population’s needs. Real terms government funding has fallen by more than £650 million since 2010, leaving patient contributions to rise by 40 per cent to cover the shortfall. Dentists have criticised government contracts that carve up and remunerate their work in ways that disincentivise more time-consuming, complicated care.
Dentistry is supposed to be free for children, but more than half cannot access NHS care. Many poorer children never have the luxury of check-ups, and instead see a dentist only when the problem has become distractingly painful or unsightly. Those growing up in the most deprived households are five times more likely to need extractions than those from the wealthiest. The problem isn’t a minor one: tooth decay is the leading cause of hospitalisation in children aged between five and nine.
In the absence of dentists and disposable income, many are resorting to DIY fixes. For less than ten pounds, you can buy an emergency kit from a supermarket or high street pharmacy which includes the cleaning agents, tools and cement to put in a ‘temporary’ filling that can last for months if you chew carefully, while the tooth may continue to rot underneath. There has also been a rise in those who, deciding ‘teeth is just a misery’, perform their own extractions.
Simple measures could make a difference. Only one-tenth of the country has fluoridated tap water, though the Health Security Agency recommends universal fluoridation, which could cut cavities by 25 per cent for the poorest children. More important still is ensuring that children have access to the nutrition needed to lay down strong bones and teeth. In Scotland, free lunches are now available to all primary school pupils, and Wales will launch a similar scheme in the new academic year. The Tories have opposed these interventions on the disingenuous grounds that it isn’t right that ‘the children of millionaires’ should benefit. There’s an easy response: to paraphrase the Beveridge Report, if the rich were taxed appropriately, we could have a functioning dental system and give their children a free jacket potato.
Part of our collective failure to demand a system that protects the poorest from the pain and shame of a sore, malodorous mouth may stem from a misplaced moralism: the idea that we end up with the teeth we deserve, that those who choose cariogenic diets cannot have their cake and eat it. It is true that the more deprived a person is, the more sugar they tend to eat, but solving that problem means offering something better than the consolations of sweetness.
Orwell wrote about cost-of-living debates in the 1930s, referring, in The Road to Wigan Pier, to ‘a disgusting public wrangle about the minimum weekly sum on which a human being could keep alive’. He cites a letter to the New Statesman, in which a reader claims it is possible to live on less than four shillings a week (the equivalent of about £7.70). The letter-writer – Orwell suggests they might be a troll – offers a list consisting largely of bread, dripping and vegetables, eaten raw to save on fuel. Last month Lee Anderson MP claimed that a person can live off 30p meals. Orwell understood what Tory ministers still don’t:
The ordinary human being would sooner starve than live on brown bread and raw carrots … When you are underfed, harassed, bored and miserable, you don’t want to eat dull wholesome food. You want something a little bit ‘tasty’ … White bread-and-marg and sugared tea don’t nourish you to any extent, but they are nicer.
All this neglect and suffering is being quietly recorded. The dentine at the root of each of our teeth is coated in a calcified layer of cementum that is deposited incrementally, in layers whose thickness responds to stressors. Cementum strata can be read like tree rings. In death, our tooth bacteria perish with us, and whatever is left of a person’s teeth remains to tell the story of their life and health, including what they ate, the pain they felt, and whether or not they were cared for.