THE TRIALS, TRIBULATIONS AND TRIUMPH OF THE DENTIST

                    By   Sy Schechtman

    

      Soon  after the end of World War II   I began my career as a civilian dentist, after a brief but necessary stint  in the army dental corps. As happened with most of my generation the war discombobulated most of our lives greatly until peace brought relative stability and confidence. But  the changes that did occur in the way dentistry  was practiced over my professional lifetime did amount to a complete revolution in the way dental  service was conceived and delivered.   In a sense while we did definitely save the baby  we almost threw out all the surrounding bath water and the baby came not only smelling like a rose  but fresh as a daisy, after we finally adapted to its new configuration.

        But not until we were able to understand the shock of the new concepts and technology that came into being when we were already  in practice, beyond the formative protection  of our professional learning in dental school.   That is,  we were in the cross fire  of the old and the new,  and although the new was indeed our salvation  it had not yet been accepted gospel  and we  were to some extent like the blind leading the halt  and the lame,  or as in Plato’s cave example,   we saw an image on the cave wall of the external reality  but not until we turned the ultimate corner and actually saw the                      actual daylight were our hopes verified and validated.   Literally  our profession  was in the dark ages as to successful, comfortable treatment.    In the popular folklore of   the time  the common perception of dental treatment was that of extreme discomfort, to quote that renowned  fictional woman hater, Prof. Henry Higgins,  as sung in My Fair Lady.     “Let a woman in your life?...I’d rather for the dentist to be drilling then let a woman in my life!”.   Or the standard  quavering female joke.  “Oh doctor, I’d rather have a baby than this dental visit!”  And the not too sympathetic somewhat sarcastic response.  “Well, lady,  make up your mind before I adjust the chair!”   Or the standard Smith and Dale  Dr. Kronkheit routines about the toothache and the dentist always pulling the wrong tooth.   “You’re the doctor, you should know   without my telling you.”   And the foolish dentist agrees, extracting all the teeth before the pain disappears.  There was also in the air among the more sophisticated,  the mythic assertion, never substantiated but still eagerly believed,   that the suicide rate in the health field was highest among dentists and    psychiatrists.

        By the time in question local anaesthesia  was quite effective for most dental procedures,  the most popular brand then being novocaine.  It was not pain that built this literal wall of fear around the whole dental establishment.   It was the slow speed drill  that was the chief agent of dental distress.   Rotating seemingly endlessly at about 3500 revolutions  per minute(RPM)  the bodily vibrations were exactly synchronous with the the greatest tooth vibration perceptible to human awareness.  While not everyone had exactly the same stress level exacerbation, the 3500 to 5000 rpm range caused most people  great total discomfort;  not pain exactly but a near total  bodily unease.   But waiting in the wings,  in the early  1950s was the high speed drill,  commonly  called the Borden Air Rotor, after its prime inventor,  Dr. Robert Borden. This literally  overleaped the cumbersome belt and pulley system of providing motive power to the dental drill bit  resulting in the  inadequate, puny vibration full 3500 to 5000 rpm range.  Compressed air in a flexible tube delivered  the necessary operating force at speeds up to 100,000rpm, far above the vibration  frequency perception of us mere mortals,  and allowing for very rapid, pressure free drilling of the hardest  structures in the human body,  enamel and dentin.

        But, alas!   There seemed to be one insurmountable new problem created.   This ultra high speed drill—now made of more expensive carbide steel and not the  less durable stainless steel—needed a copious flow of water coolant  to prevent drastic overheating to the dental nerve (pulp) just a millimeter or so beyond.    Since the dentist  was now intensely involved in controlling this rapidly, though vibration and pressure free, cutting instrument  another pair of hands to control the  water suctioning became absolutely imperative to realize the full potential  of the air rotor high speed drill---and to guard the tongue and surrounding tissue from this new, more dynamic bur.  Thus, in the dental opertory almost automatically there came to be the dental chairside assistant, a full and impressive promotion  from “ the girl”  who was called in toward the end of the dental procedure to prepare the filling material  or just clean  up.   And since  she was now in the field of operation for at least half of the total procedure  inevitably the rest of the necessary  business of the dental opertory visit became part of her logical purview.

        Stationed on the other side of the patient, across from the operating dentist, she was able to help  integrate and expedite the operation, essentially handing him and retrieving all needed instruments and allowing him to keep his concentration on the tooth in question; all of  which in the human oral cavity have about  half an inch between the chewing surface and the crucial internal tooth nerve tissue.(dental pulp)   And make it inevitably logical for both dentist and his assistant to sit while working,  and thus free the protagonist—the dentist—from the distorted, half hunched over position of working, while standing  and inevitably straining all day.  The patient was supine but with utterly no salacious intent.   Adjusting the dental chair had only the pure capitalist greedy intent of being more productive and every one being more comfortable at the same time.  So while the dentist may have been initially begrudging the additional overhead that a full time chairside assistant was costing him  he not so mysteriously soon began laughing---all the way to the bank to keep up with the increasing flow of deposits.   For his production  and ease of operation  were increased  greatly.    And the only negative  was illness that might keep  his chairside  assistant away and having to revert to the prior stand up antediluvian mode and  fumbling for  all the needed instruments himself.    

        However, as happens in most human scenarios,  clouds became to appear on the horizon down the line.   About twenty years later something  called the “lack of busyness syndrome” appeared, especially  in the northeast.   This was a euphemism for the appearance in many dentist’s appointment books of  more unfilled appointment spaces than most of  us were happy about.   Partly this was a triumph of their more productive use of operating time, using the high speed drill efficiently, and with a full time chairside assistant, producing more dentistry with less time needed.   But  partly it was also a triumph of another sort,  the conquering or diminution of dental disease.    When I started practice in the early   1950’s dental disease was estimated to be  the most common untreated disease in the United States.  About a market of some 700 hundred million untreated  cavities,  mostly in youngsters primary and permanent teeth  but also in more mature citizens too.  By the early l980’s, however, a   remarkable  advance in public health had occurred—the  general acceptance  of fluoridation  of the municipal  water supply  in the universally safe level of 1 part per million of the existing  water supply.  A fluoride level that would safely strengthen  the tooth enamel and prevent tooth decay and cause no bodily harm.  Flouridation of municipal water, along with the Salk vaccine to prevent infantile paralysis, undoubtedly were the two greatest public health preventive measures of the last century.   In the early 1950’s, however,  this proposal met  with much alarming counter propaganda;  no matter that every reputable public health agency and both the American Medical and American Dental Association  endorsed the extensive scientific research validating  this major preventive step,  similar to the already commonly used chlorination of municipal water for control of  bacterial growth.  Indeed, one of the  snide, cynical,  anti fluoride insinuations  insisted that some sinister plot was behind the dentist’s insistence on this fluoridation  campaign.   “How could they be pushing for this so hard since it will only cut their incomes?”  therefore there was some some subversive plot  to “soften our brains”.    Or cause kidney damage or other  degenerative disease.    

        But gradually  the strong support of both medical and dental professions plus most responsible civic associations won the day.   Either municipal water supplies were fluoridated  or children dutifully drank it orally at home and/or the local dentist and hygienist topically applied it to the teeth  of young tots.   So the maxim of “be careful what you pray for---it may happen!”   seemed too be a little too true for comfort.      The discouraging six month recall visits with children returning with recurrent decay around recent fillings was being eliminated.   Dental disease seemed to be waning  in all those “bread and butter” categories such as cavities, extractions and space maintainers for newly extracted hopelessly decayed teeth.  All these prayerfully hoped for events were being realized—at the expense of short term profit.   There was, of course,  necessary    work in the field of prevention,  as in the afore mentioned field of topical application of fluoride treatments and dental sealants to the chewing surface of molar teeth.   And instruction in non sugar diets  which were also crucial in preventing recurrent decay  due to sugar’s pernicious effects on tooth structure.   While well within the purview of the dentist,  these less skilled but necessary tasks,  as with the chairside assistant,  became the domain of the dental hygienist, who also did the necessary work in preventing dental disease by thoroughly cleaning the teeth every three to six months.    Gradually these prophylactic events also became profit centers in the dental office and  hygienists  an important asset.   And the dentist, besides  being the  chief therapist,  also became  a  business administrator of sorts, employing  several key personnel on his payroll—the receptionist,  the hygienist and chairside assistant at the very least.  Sometimes, too, as the practice continued to grow, a full or part time practice co-ordinator was also added to make certain that all the productive staff were meshing properly!!   (And those dentists  who still clung to the splendid isolation of the solo dental practitioner role,  while having much less initial aggravation in adjusting, also had many less lucrative trips to the bank with the increased “burden”of larger deposits!)   If not a revolution of sorts  then  quite an evolution from the stand up hunched over the patient, solo style dentist of years ago;  who even answered the phone when his sole assistant and jack of all trades  person, had to go to the bathroom!   Not standing up anymore and producing a much better dental product more comfortably  while seated  and probably listening to some soothing music, across from his seated chairside assistant while the patient was comfortably supine and relaxed,  and with the same soothing music.  (or a television program of their  choice) and a mouth still comfortably open for  the     smoothly continuing  dental procedure.

                But while the dentist saw his hitherto  large population base of dental decay shrivel into  mere prevention requiring less of his skilled presence and the disquieting  slowing of profit, he also saw that  more than  counter  balancing this uncomfortable trend was the geriatric boom, starting in the  in the 80’s decade and  constantly  growing.  Not more than a trickle at first but gradually a refreshing graying of the dental practice with elderly people  and compelling the dentist to continually upgrade his restorative ( and creative) skills  because of the new techniques to meet the demand of  people living beyond   their  allotted three score and ten  biblical  time span  and desiring to retain the care free vigor of  chewing a normal diet and the aesthetics  of their prior youth.  So the dentist had to learn,  among  other important new concepts, the importance and placement  of implants in the mouth for the creation of literally new teeth for enduring service and the cosmetic enhancement of veneers  to make anterior teeth  much more attractive  without   disturbing the natural tooth anatomy.  

        Aiding and abetting this trend and augmenting the  important geriatric aspect of  middle class and more affluent older people  was the shift in the funding support for these people and the income streams involved.    In l965 Medicare, federal medical care insurance for all people over 65 became the law of the land.  It did not include dental care.   No one then anticipated that this program would grow to the monster entitlement that it now represents; and the fees for physicians  have been repeatedly scaled back in the last ten years, so that they are far from the”gravy   train” that dentists once envied and were denied the chance to participate in.   Dentists, on the other hand,  have been gradually raising their fees,  supported by the general  rising affluence of the middle class  and the relatively generous private corporate insurance plans that now seem relatively more generous than  medicare  sponsored medical programs.   This is perhaps the   another triumph of the dentist.   Most physicians  are trapped with a large over 65 medicare patient base.   Even if is legal to refuse to treat these patients  unless they pay privately,  this over 65 group  is probably  at least half of many medical practices and certainly would result in a great “lack of busyness syndrome” without them in the practice.  While physician income is still above that of the dentist they have to practice more hours now to maintain the same income level due to the decline in the medicare fee scale.    Here the law of unintended consequences may kick in.  Some older physicians are now chosing to retire sooner than they would have with more attractive financial rewards.   At any rate, on many levels the dental career landscape  seems brighter than ever!