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
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!