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.
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
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!