THE TRIALS, TRIBULATIONS AND TRIUMPH OF THE DENTIST

                  By  Sy Schechtman

    

     Soonafter the end of World War II  I began my career as a civilian dentist, after a brief but necessary stintin 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 dentistrywas practiced over my professional lifetime did amount to a complete revolution in the way dentalservice was conceived and delivered.  In a sense while we did definitely save the babywe almost threw out all the surrounding bath water and the baby came not only smelling like a rosebut 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 alreadyin practice, beyond the formative protectionof our professional learning in dental school.  That is,we were in the cross fireof the old and the new,and although the new was indeed our salvationit had not yet been accepted gospeland wewere to some extent like the blind leading the haltand the lame,or as in Plato’s cave example,  we saw an image on the cave wall of the external realitybut not until we turned the ultimate corner and actually saw the                     actual daylight were our hopes verified and validated.   Literallyour professionwas 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 renownedfictional 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 standardquavering 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 DaleDr. Kronkheit routines about the toothache and the dentist always pulling the wrong tooth.  “You’re the doctor, you should knowwithout 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 anaesthesiawas 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 drillthat was the chief agent of dental distress.   Rotating seemingly endlessly at about 3500 revolutionsper 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 peoplegreat total discomfort;not pain exactly but a near totalbodily unease.  But waiting in the wings, in the early1950s was the high speed drill,commonlycalled the Borden Air Rotor, after its prime inventor,Dr. Robert Borden. This literallyoverleaped the cumbersome belt and pulley system of providing motive power to the dental drill bitresulting in theinadequate, puny vibration full 3500 to 5000 rpm range.Compressed air in a flexible tube deliveredthe necessary operating force at speeds up to 100,000rpm, far above the vibrationfrequency perception of us mere mortals,and allowing for very rapid, pressure free drilling of the hardeststructures 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 coolantto prevent drastic overheating to the dental nerve (pulp) just a millimeter or so beyond.   Since the dentistwas now intensely involved in controlling this rapidly, though vibration and pressure free, cutting instrumentanother pair of hands to control thewater suctioning became absolutely imperative to realize the full potentialof 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 promotionfrom “ the girl”who was called in toward the end of the dental procedure to prepare the filling materialor just cleanup.  And sinceshe was now in the field of operation for at least half of the total procedureinevitably the rest of the necessarybusiness 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 helpintegrate 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 abouthalf 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 standingand 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 himhe not so mysteriously soon began laughing---all the way to the bank to keep up with the increasing flow of deposits.  For his productionand ease of operation were increased greatly.    And the only negativewas illness that might keephis chairsideassistant away and having to revert to the prior stand up antediluvian mode and fumbling forall 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 somethingcalled the “lack of busyness syndrome” appeared, especiallyin the northeast.  This was a euphemism for the appearance in many dentist’s appointment books ofmore unfilled appointment spaces than most ofus 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.   Butpartly 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 bethe most common untreated disease in the United States.About a market of some 700 hundred million untreatedcavities,mostly in youngsters primary and permanent teeth but also in more mature citizens too.By the early l980’s, however, aremarkableadvance in public health had occurred—the general acceptanceof fluoridationof the municipalwater supplyin the universally safe level of 1 part per million of the existingwater supply.A fluoride level that would safely strengthenthe 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 metwith much alarming counter propaganda;no matter that every reputable public health agency and both the American Medical and American Dental Associationendorsed the extensive scientific research validatingthis major preventive step,similar to the already commonly used chlorination of municipal water for control of bacterial growth.Indeed, one of thesnide, cynical,anti fluoride insinuationsinsisted that some sinister plot was behind the dentist’s insistence on this fluoridationcampaign.  “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 otherdegenerative disease.  

       But graduallythe strong support of both medical and dental professions plus most responsible civic associations won the day.  Either municipal water supplies were fluoridatedor children dutifully drank it orally at home and/or the local dentist and hygienist topically applied it to the teethof 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 waningin 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 dietswhich were also crucial in preventing recurrent decaydue 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 andhygienistsan important asset.  And the dentist, besidesbeing thechief therapist,also becameabusiness 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 dentistswho 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 sortsthen 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 tradesperson, had to go to the bathroom!  Not standing up anymore and producing a much better dental product more comfortablywhile seatedand 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 theirchoice) and a mouth still comfortably open forthe    smoothly continuingdental 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 thancounterbalancing this uncomfortable trend was the geriatric boom, starting in the in the 80’s decade and constantlygrowing. Not more than a trickle at first but gradually a refreshing graying of the dental practice with elderly peopleand compelling the dentist to continually upgrade his restorative ( and creative) skillsbecause of the new techniques to meet the demand ofpeople living beyond   theirallotted three score and tenbiblical time spanand desiring to retain the care free vigor ofchewing a normal diet and the aestheticsof their prior youth.So the dentist had to learn,among other important new concepts, the importance and placementof implants in the mouth for the creation of literally new teeth for enduring service and the cosmetic enhancement of veneersto make anterior teethmuch more attractivewithout   disturbing the natural tooth anatomy.  

       Aiding and abetting this trend and augmenting theimportant geriatric aspect ofmiddle class and more affluent older peoplewas 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 physicianshave 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 generalrising affluence of the middle classand the relatively generous private corporate insurance plans that now seem relatively more generous thanmedicaresponsored medical programs.  This is perhaps theanother triumph of the dentist.  Most physiciansare trapped with a large over 65 medicare patient base.  Even if is legal to refuse to treat these patientsunless they pay privately,this over 65 groupis probablyat 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 landscapeseems brighter than ever!