•

Pity these busy monsters. by David Owen

David Owen is a free.lance writer living inNew York.

HORACE WELLS, a twenty-six-year-olddentist in Hartford, Connecticut, in-haled a dose of nitrous oxide and per-mitted a colleague to extract a wis-

dom tooth. The operation was painless, andwhen Wells regained sensibility he proclaimed"a new era in tooth-pulling." The year was1844. Medical science had made great stridesin the preceding decades, but tooth extractions,amputations, and all other operations were stillperformed on conscious patients. Despite acenturies-old search for a method of deadeningpain, even minor surgery was torture.

Wells immediately grasped the significanceof his discovery and traveled to Boston to re-peat the experiment before a medical class atMassachusetts Ceneral Hospital. With a Har-vard student acting as patient, he administeredthe gas and clamped' his forceps on a tooth.The student cried out in pain, and Wells was

42

thrown from the lecture hall, accompanied bycries of "Humbug!" Be later abandoned den-tistry and made a fitful living peddling canar-ies, coal-sifters, and shower baths. In 1848, alittle over three years after his bungled dem-onstration, he took his life while imprisonedin New York for assaulting prostitutes withacid, by slashing an artery in his leg-afterfirst anesthetizing himself with chloroform .

Today Wells is recognized as one of severalpioneers in the discovery of anesthesia. Hemight also be viewed as the prototype of themodern dentist, since his biography anticipatesin grotesque form at least two of the enduringthemes of his profession. Like Wells, whoseHarvard guinea pig later confessed to havingfelt no pain, modern dentists regularly facepatients who are irrationally fearful, often tothe point of hostility. Also like Wells, mod-ern dentists undergo enormous occupational

•

stresses, partly as a result of that hostility:according to studies by Dr. William E. Sorrel,former president of the American Associationof Psychoanalytic Physicians, and author of arecent study of professional stress, Americandentists suffer disproportionately (and increas-ingly) from alcoholism, drug abuse, and di-vorce. They also kill themselves at twice therate of the general population, giving them thet highest suicide rate of all the professions.

Which is just fine with almost everybody,one gets the feeling. Little love is lost on den-tists in this country, notwithstanding a recentGallup poll in which they were rated higherthan all but clergymen and pharmacists interms of "honesty and ethical standards." Butwhile it may be true that most of us view ourdentists as honest, how many think of them asinteresting? A dentist is a drudge. Who wassurprised, on seeing Warren Beatty's Reds,that the man Louise Bryant abandoned forJohn Reed was a dentist? Dentists are likebarbers, but without the folksy panache. Theyrefer to the mouth as "the oral cavity" and toteeth-cleaning as "prophylaxis." Their uni-forms look like bowlin~ shirts. Their officeslook like futuristic beauty parlors. Their fin-gers taste of soap (who even knows what alawyer's fingers taste like?). Dentists, accord-ing to the abiding image, are people whowanted to be physicians but weren't smartenough to get into medical school.

Who are these people, and what do theywant? And why don't we like them better thanwe do?

The roots of the profession

DENTISTRY as a formal profession hasexisted only since Horace Wells'sday, the mid-nineteenth century, butits roots stretch back several thou-

sand years. The ancient Egyptians prescribedmedicines for toothaches, the Etruscans craftedfalse teeth and gold bridgework, the Persiansfilled cavities. "Dentistry was practiced,"writes one historian, "but it was considered by

• the Arabs, as by the Greek and Roman doctors,a very inferior branch of the profession, andwas, for the most part, as with ourselves, tillvery recently relegated to uneducated per-sons." One such person, England's King John,recovered money from a debtor by pulling histeeth, one by one, until he paid up. Elsewheredentists were less illustrious. "The only den-tists in Pare's time," writes another historian,"-if we exclude the bathhouse keepers, ped-dlers, and old Women-were the barber sur-geons." Scientific knowledge advanced at a

glacial pace: it was not until the sixteenth "Americancentury that it was definitively proved that worn- dentists sufferen have as many teeth as men. disproportion-

Dentistry was considered a very minor ately frombranch of medicine (if not a somewhat exalted 1 h I'branch of masonry) until the eighteenth cen- adco °b1sm, d

h F h .. d P' rug a use, antury, w en a rene scientist name Ierre, "Fauchard wrote the first substantial treatise on divorce.the subject. Dentistry's separation from med-icine has never been complete; in the SovietUnion, for example, teeth are cared for notby dentists but by stomatologists, physiciansspecializing in diseases of the mouth. But withFauchard the incipient profession began toassume an independent scientific standing. "Ispeak of the care which must be taken to keepthe teeth clean," Fauchard wrote, "how to fillthem, how to cleanse them, to burn or cau-terize them, and to fill them with lead." Mostdental work was still performed by physiciansor lesser craftsmen, but dental specialists be-came more common.

From the middle of the nineteenth centuryon, the principal advances in dentistry havebeen made not -in Europe but in the UnitedStates (although not without plenty of falsestarts; on the American frontier, settlers pre-served their dental health by gargling withurine). The forerunner of the American Den-tal Association was established in 1839, eightyears before the founding of a comparablebody for physicians. The Baltimore College ofDental Surgery, the world's first dental school,opened the following year. Dentistry's statusas a true profession can be said to date fromthen.

Today there are sixty American dentalschools, in thirty-three states and in PuertoRico. The newest· one is at Oklahoma's Oral[sic] Roberts University, which will graduateits first class in the spring. The sixty schoolscombined will turn out roughly 5,500 newdentists this year, bringing the total numberof active practitioners in America to approx-imately 140,000.

DENTAL EDUCATION in the UnitedStates typically involves four yearsof study divided between classroomwork in the basic medical sciences

and hands-on clinical experience. The first twoyears are generally analogous to the first twoyears of medical school, and in some casesidentical. At Harvard, which runs the nation'sonly five-year program, dental students spend'their first two years at the medical school.Dental students usually begin treating patientsin the second or third year, performing as-signed procedures on clinic patients under the

43

David OwenTHE SECRET

LIVES OFDENTISTS

supervision of their professors.Unlike medical students, who must undergo

several years of hospital residency before strik-ing out on their own, dental students aredeemed competent to set themselves up inpractice immediately following graduation,assuming they pass their state licensing exams.(A limited number of one-year residencies areavailable, but they are optional.) Contrary topopular perception, all licensed dentists areentitled to perform all dental procedures-they can make braces, operate on oral tissues,extract teeth, fit dentures, and so on-but ifthey wish to limit their practice to one of theseareas they are required to receive further train-ing and special certification from a profes-sional board overseeing that field. The numberof dentists who do so is likely to get smallerin the next few years; general practitionerswho find themselves strapped for patients arebeginning to do more of the work they oncereferred to specialists.

Economic pressures have had a dramaticand disturbing effect on dental education.Between 1975 and 1980, the number of first-year places in American dental schools in-creased from 5,763 to 6,030; over the sameperiod, the number of applicants for thoseplaces decreased from 15,734 to just 9,601.In 1981, the New York University dental

Home Dentistry

44

school was actually unable to fill its freshmanclass. The primary reason for the drop in ap-plications is the rising cost of dental education.Tuition at NYU is now $13,000 a year. Instru-ments and books for first-year students cost$5,000, and fees and living expenses have tobe added in as well. It's not unheard of fordental students to graduate with $100,000 ineducational debts, assuming they can find •someone to lend them the money.

The most important effect of rising costs isnot seen until after graduation, when youngdentists face the double burden of paying offtheir debts and earning a living. Equippingan office can cost $100,000, to say nothing ofthe expense of buying a house, feeding a fam-ily, educating a: child. And even when youngdentists are wealthy enough to buy their owndrill bits and X-ray machines, many of themfind that the most attractive areas to practicein are already overserved. They are furtherhampered by the fact that most people viewdental care as a luxury. Although tooth decayaffects 98 percent of all people, making it thenation's most common health problem, at leasthalf of all Americans don't visit dentists reg-ularly. In 1976, the most recent year for whichfigures are available, more than 20 percent ofall dentists said they had fewer patients thanthey wished.

Because of the traditional preference forsolo practice in dentistry (well over half ofall practitioners work without partners or cost-sharing), finding an older dentist willing totake on an inexperienced associate can be ex-tremely difficult. As a result, a growing num-ber of dental-school graduates have beenforced to seek salaried or even part-time orcommissioned employment in discount clinicsor in health programs associated with tradeunions, insurance companies, or corporations.An advertised opening for a dentist in NewJersey, offering wages of twelve dollars anhour, drew 300 applicants from New York.

The rise of so-called "retail" dentistry hasbeen perhaps the most important developmentin the profession in recent years. A number ofdepartment-store chains now offer discountdental services in some of their outlets. Othercut-rate offices, known in the profession as"advertising clinics," have opened in shoppingcenters in order to take advantage of relaxedrestrictions on professional advertising. Oneclinic lures timid patients with the promisethat its dentists will clean teeth without even

~ looking for decay. Others offer "bargain" pro-~ cedures at special prices, including same-day

. ~ denture service and discount root-canal work.~ Quality in such offices is sometimes (if not

always) greatly reduced. Because all discount

•

operations depend for their profitability onmaintaining enormous patient turnover, thedentists they employ are under constant pres-sure to work fast. If a young dentist is rightout of school, his most recent experience offilling a tooth may have been in his state li-censing exam. In New York, license candidatesare given half a day to perform that proce-

.••• dure; in a discount clinic, they may be allowed.•• only a few minutes. A reporter from Dental

Economics magazine paid twelve dollars for asix-minute cleaning at one clinic, then visitedhis own dentist, where a hygienist spent halfan hour scraping off tartar that the retail den-tist had missed or ignored. The ADA has beenkeeping an eye on department-store operationsfor some time, but it has yet to issue a defini-tive assessment. The reason for the delay isn'thard to understand: for too many youthfulmembers of the profession, retail dentistry maybe the only thing standing between them andbankruptcy.

All these developments taken together havecast a certain pall over dental students. WhenI spoke informally with a roomful of youngresidents at NewYork's Mount Sinai Hospital,they were unanimously bitter about depart.ment-store clinics. "With prices so low," onesaid, "just think how much work you have todo in order to make a decent living. The den-tists may actually be good, but you're goingto start getting sloppy, you're going to startoverlooking things, you're going to start tak-ing shortcuts. You wouldn't want somebodydoing that in your mouth, would you?"

If only because of the enormous obstaclesthey have to overcome simply to get throughschool, dental students tend to be extremelydedicated. But maintaining that dedicationonce they enter the job market is another mat-ter altogether. And for the first time in thehistory of the profession, a lot of prospectivedentists are weighing the costs and benefitsand wondering if it's all worthwhile.

"If I had it all to do over again," one recentgraduate told me as he sipped a stiff, four-dollar cocktail at a dental-convention openhouse, "I'd become an engineer."•

Chewed fingers

GIVEN ALL of this, why in the worldwould anyone even consider becominga dentist? Some people, certainly, ap-ply to dental school simply because

they want to be doctors but can't get intomedical school. But there are many otherreasons. Dentists typically work shorter daysthan physicians do (the average work week in

1976 was just over forty hours), which meansthey can spend more time with their families.They also find satisfactions in their work thatare in many cases unique to the profession.Unlike physicians, who spend much of theirtime treating diseases that either never goaway or go away all by themselves, dentistscan usually see concrete results from what theydo. A filled tooth, properly done, is a finishedpiece of work. And because dental diseasestypically don't go away all by themselves, den-tists take satisfaction in the knowledge thatwithout their intervention their patients wouldnot get better.

Dentists also speak of an artistic element inthe work they do. A restored tooth can be apiece of sculpture, a root canal a feat of en-gineering. The raw materials are exotic-gold,silver, mercury, porcelain-and the instru-ments have the sturdy sort of beauty commonto all well-made tools. At professional meet-ings dentists hover like children around tablesof gleaming curettes and margin trimmers,excavators and explorers, pluggers and probes.A dentist, at the most functional level, has asmuch in common with a jeweler as with aphysician.

Even for established and skillful practi-tioners, though, dentistry holds an inordinatenumber of stresses and disappointments. Work-ing in a patient's mouth, one dentist says, "islike repairing a fine watch while someone isspitting on your fingers." Or chewing on them,which is something anxious patients have beenknown to do. Some people are so afraid oftheir dentists that they have to be completelyanesthetized before their teeth can even becleaned ("Total dental care while you sleep,"advertises one Manhattan dentist). Others sitfrozen, their faces drained of blood, ready tocry out the instant the dentist administers somesecret, lethal wound to the back of the throat.Despite the fact that dentistry today has thepotential to be completely painless, most peo-ple feel at least some foreboding on climbinginto the chair.

"There's a sort of constant rejection asso-ciated with what we do," says Dr. MorrisYarosh, a general practitioner in New YorkCity. "Dentists who don't have a good self-image to begin with are going to feel the im-pact of this very severely. Dentists work inan area that is associated with pain, andthey're constantly being told by patients, 'Doc,don't take this personally, but I hate den-tists.' "

Some dentists go to great lengths to courttheir patients' affections. Dr. William Schmidtof San Jose, California, who calls himself the"Plaque Invader," sometimes wears blue tights

"Working ina patient'smouth is 'likerepairing a finewatch whilesomeone isspitting onyour fingers.' "

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David OwenTHE SECRET

LIVES OFDENTISTS

and an enormous tooth-shaped helmet when hetreats children. He also keeps a hot tub bub-bling in his office for grownups who need tocalm themselves down. Other dentists supplytheir patients with everything from Sony Walk-mans to color TVs and video games in the hopeof keeping them distracted. Threatening wordslike "pain" and "drill" have been replaced by"sensitivity" and "handpiece." Some dentistsallay patients' fears by making liberal use ofthe nitrous-oxide tank: the Manhattan Yellow.Pages carries one dentist's ad for "pleasurableexperiences at moderate fees."

Most people would probably be surprised tolearn that dentists are sometimes as afraid oftheir patients as their patients are of them.Some dentists brood for hours before appoint-ments with especially hostile people. Even den-tists who might not otherwise be fearful willoften pick up unconsciously on the moods oftheir patients. Waves of anxiety can pass backand forth between them, each making the otherfeel increasingly uncomfortable. In the eyesof the patient-flat on his back and defense-less, with a stranger's fingers in his mouth-the dentist is an intimate intruder. Oral tissuesbristle with nerve endings whose sensitivity isheightened by the real and symbolic signifi-cance of everything we do with our mouths:eating, speaking, kissing. The dentist, mean-while, is left to carryon a necessarily one-sided conversation and to ponder the thought

Dentistry in History

46

that most of the people he sees every daywould rather be anywhere else than with him.

DENTISTS' anxieties don't disappearwhen the final patient of the day goeshome. Because dental school is gen-erally held to be less rigorous than

medical school, many dentists feel like second-class citizens next to physicians. ("Physician,"incidentally, is a word dentists use religiously;"You always hear people refer to 'doctors anddentists,' " one dentist told me, "but actuallyit should be 'physicians and dentists.' A den-tist is a doctor." Physicians, on the other hand,almost always call themselves "doctors," par-ticularly when speaking to dentists.) Severaldentists I talked to said they dreaded beingintroduced to physicians at social gatherings.This may not be all paranoia. "Dental studentsare all a little stupid," one medical studenttold me. "All they ever want to talk about isthe cars they're going to buy when they're inpractice. "

In addition to being an emotionally drain-ing profession, dentistry can be a physicallydebilitating one. Dentists who work standingup-and until the introduction of "sit-down"dentistry several years ago, virtually all ofthem did-can suffer slipped disks, impairedcirculation, foot problems, varicose veins, andcurvature of the spine. Other common ailmentsinclude migraine headaches, muscle spasms,eczema, neurodermatitis, colitis, ulcers, andobesity. The buzzing and whining of officeequipment causes deafness. Mercury used inmaking filling compounds can poison the peo-ple who handle it. Long-term exposure to traceamounts of anesthetic gases can cause mis-carriages, birth defects, liver disease, kidneydisease, and neurological problems in bothdentists and their assistants. (Not to mentiontheir spouses: according to a study publishedin the Journal of the American Dental Asso-ciation (lADA), "a 50% increase in the in-cidence of spontaneous abortion is notedamong wives of male dentists if the male hasbeen heavily exposed to inhalation anestheticsduring the year prior to conception.") •

X rays also pose a health threat to dentists,although nowadays the risk is probably greaterfor patients than for dental personnel. Even

.2 so, dentists with faulty equipment can bathe~ themselves and their assistants in radiation8 day after day, with the usual results. Like any~ number of other physical horrors, this one has

. ~ a long history in the dental profession. Dr.~ C. Edmund Kells, the first dentist to use~ X rays on a patient, developed severe ra-

diation burns on his hands after fourteen years,

t

and was eventually found to have cancer in hisarm. In 1928, after the cancerous arm hadbeen amputated, Dr. Kells committed suicidein his office.

Assuming that a dentist is able to salvageboth body and soul, there remains the problemof meeting his mortgage payments. Dentistryis a comfortable profession, but it is not aregal one. In 1978, the most recent year for

• which figures are available, the average den-tist had a pretax income of $48,000. Physiciansin general practice, by way of comparison,earned $58,000 in the same year; cardiologistsaveraged $96,000. According to Robert Levoy,a professional consultant and author of a bookcalled The $100,000 Practice and How toBuild It, the average income figure for dentistshas risen very little since 1978. The averagedentist, in other words, earns roughly the sameas a top law-school graduate in his first yearwith an established New York firm. And law-yers don't have to buy X-ray machines. Over-head costs, which have always been substantialfor dentists, have skyrocketed in recent years,leaving some practitioners even farther behind.

In the face of rising costs and stagnatingincomes, more and more dentists are seekingprofessional help in running their offices.Thereare now at least two professional magazinesdevoted exclusively to "practice management"in dentistry, and courses in the same subjectare hot tickets at dental meetings, where con-tinuing-education topics range from "Orga-nizing the Dental Staff for Greater Productionand Profit" to "Colored Stones for Invest-ment-The Newest Game in Town." At onelecture I sat in on last year a roomful of reces-sion-weary dentists took careful notes whilethe president-elect of the ADA talked about"marketing" and "patient load" and then·spelled out his personal recipe for SUCCESS (Sstands for Sense of Direction, U stands forUnderstanding, C stands for Courage, and soon).

Sometimes not even Sense of Direction,Understanding, and Courage are enough topull dentists through. The divorce rate in theprofession has risen 12 percent in the last

• decade, and drug abuse, alcoholism, and sui-cide have also been on the rise. Although den-tists have less access than physicians to nar-cotics and other drugs, they can still come intocontact with dangerous substances, most no-tably nitrous oxide. Some dentists find theycan't get through the day unless they relax be-tween patients by inhaling a little laughinggas, a habit that can have disastrous conse-quences. In January 1979, JADA reported thecase of one dentist who became so dependenton nitrous oxide that he sometimes inhaled it

Dentistry in Artfor eight hours a day. He developed a severe'neurological disorder and gradually came torequire a wheelchair. He later took his life byshooting himself in the head.

Guilt and self-hatred

DR. LEON LEFER is a psychiatrist andpsychoanalyst who specializes in psy-chological problems common to den-tistry, an area in which he is uniquely

knowledgeable: before a physical handicapforced him to begin a new career thirty yearsago, he spent six years as a practicing dentist.Although it has been three decades since hechanged professions, mercury stains still dark-en the tips of his fingers, and one of hisshoulders is slightly lower than the other-theresult of long days spent leaning over a dentalchair. I visited Dr. Lefer in his apartmentoffice one morning and asked him why den-tists seem to have such a hard time.

"A normal person needs a certain amountof distance between himself and other people,"he said. "But the dentist has to be very closeto the bodies of strangers all day long. Thiscauses stress. As a result, the dentist has to

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David OwenTHE SECRET

LIVES OFDENTISTS

compensate by having a lot of space aroundhim when he finishes work, which can be di-sastrous if the family and children don't un-derstand and if the dentist doesn't know howto communicate his needs. And most profes-sional people don't know how to communicateemotional needs. Why? Because that's anotherstress. There's a tendency, if you become aphysician or a dentist, to be the kind of per-son who has to deaden his feelings in orderto tolerate the suffering of patients, and thedrawing of blood, and the lacerating and mu-tilating of flesh.

"Most dentists, by the way, are anhedonic,which means they avoid or delay pleasure.Sometimes they delay it so long that they findseveral years have gone by without their takinga vacation. Then, when they do take a vaca-tion, they deal with their leisure time as ifthey were wor-king in the office, because they'reso perfectionist. I think that the number ofdentists who have been successful suicides isgreat because, as perfectionists, if they set out

to kill themselves, they're very likely to suc-ceed."

In addition to maintaining a private psychi-atric and psychoanalytic practice, Dr. Leferteaches classes at both the medical and dentalschools at Columbia University, and at thedental school at NYU. I asked him if he hadnoticed any differences between dental stu-dents and medical students.

"The difference," he said, "is that the med- •ical students seem to have been brought up inan environment that allowed them to makemistakes and not suffer so much guilt and.self-hatred if the least little thing went wrong.As a result they can kill people and blamesomebody else. Whereas if the dentist werereally to hurt somebody, he couldn't live withhimself.

"I've been through both professions, and Ithink that much more is demanded of a den-tal student than of a medical student. Dentalschool is much more difficult, because havingto do something with your hands so that it

How time flies when you're having fun"So .•. what's new?"

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•

Good Times in Dentistry

comes out just so is more difficult than simplystudying something. And, you see, the dentalstudent's natural perfectionism is perpetuatedby his teachers. If a dental student shows ateacher a piece of work that is, let's say, 80-90percent perfect, the teacher, because of hisown inner demands for perfection, seems tohave no latitude between what's perfect andwhat's not good at all. As a result he's likely

• to tell the dental student, 'That's crap,' whichleaves the student feeling that he's worth zero,'instead of 80 percent. And that's how theylive.

"A dentist is always automatically compar-ing himself with someone whom he believesto be more capable. It's an automatic compet-itive process in which he over-competes withhimself and others, and as a result he feelsonly half as good as he should. And that iswhy he's so good for the public. Because any-one who walks around competing with him-self to this tremendous degree is overly com-pulsive about the quality of work he does, andsince the public knows nothing about whatgoes on in their mouths-absolutely nothing-it's really up to the dentist to decide whatkind of quality he'll put in the mouth. Andfortunately for the public, if they pick a verycompulsive dentist, the quality of the work ismagnificent."

T fiE COMPULSIVE dentist may indeed domagnificent work, but how many den-tists are compulsive? More to thepoint, how many dentists, compulsive

or otherwise, do magnificent work?The question is impossible to answer, for

the simple reason that there has never been adefinitive study of quality in the dental profes-sion; nor is there likely to be one. Partly be-cause they tend to work alone, dentists resistthe idea of being evaluated, or even observed,by others. And because inferior dental workmay not be discovered until years after it isperformed, patients are seldom in a positionto make informed judgments.

Nevertheless, dental malpractice suits have• been increasing in both size and number in

recent years. Typical cases involve dentists'failure to diagnose oral disease, mistaken ex-traction of healthy teeth, and injuries arisingfrom careless handling of dental instruments.In one case in 1975, a young woman wasawarded $275,000 after the steel burr of herdentist's drill broke off and lodged in her lip,causing a permanent numbness that reducedthe pleasure she had previously taken in kiss-ing her husband (who was himself awarded$15,000 for "loss of services"). In a much

more serious case, a New York court awarded$750,000 to the family of a three-year-old boywho died when a careless dental hygienist ina city hospital allowed him to swallow a lethaldose of a topical fluoride treatment.

Cases of this magnitude are extremely rarein dentistry, however. If what dentists dodoesn't seem terribly important to most lay-men, what they do wrong doesn't seem terriblyimportant to most juries. According to a 1981study by Jury Verdict Research, Inc., the me-dian dental malpractice award is $26,500.That figure is roughly three and a half timeslarger than it was in 1975, but it is still sosmall that most lawyers are reluctant to take ondental cases. (The median award in psychiat-ric malpractice, by comparison, is $200,000).The New York law firm of Fuchsberg & Fuchs-berg, one of the nation's leading professionalmalpractice firms, handled only a dozen dentalcases last year, and all of them were settledout of court. Because the firm's costs run toabout $5,000 or $6,000 per case, and becauseits fee (a third of any award or settlement) ischarged only if the case is successful, a com-plaint has to be not only airtight but also fair-ly substantial before the firm will even con-sider it. "There just isn't any profit in mostof these cases," one lawyer told me.

Whether or not it is profitable to lawyers,shoddy dentistry certainly exists, and there isreason to believe that it is on the rise. Onedentist I spoke to said that 80 percent of thework he does consists of repairing inferiorwork performed by other dentists. As econom-ic pressures on practitioners have increased,more and more dentists have found it neces-sary to work faster than they (or their pa-tients) might wish. Because patients are ex-tremely resistant to increases in dental fees,and because dentists' fixed costs have beenrising at an astonishing rate, many dentistshave had to speed up simply to keep from fall-ing behind. Most dentists, certainly, maintainhigh standards, but the pressure to work fastaffects the entire profession.

Speed is a very popular topic in dentistrythese days. Last July, Dental Economics mag-azine (which in palmier days was known asOral Hygiene magazine) carried an advertise-ment for a three-day seminar on "the success-ful Barnes' practice management technique,"one of whose highlights is "the 90-secondprep" procedure for crowns and bridges. Den-tal equipment companies advertise faster andfaster dental drills and ultrasonic devices thatsupposedly eliminate the need for time-consum-ing manual removal of tartar deposits on pa-tients' teeth. Dr. Burton Press, president-electof the ADA, sometimes piques the interest of

"A peculiar factabout thetraditional feestructure isthat savinga tooth is veryoften lesslucrative thandestroying it."

49

Modern Dentistry

audiences he lectures to by telling them thathe can teach them to do twentv crowns in oneday instead of a mere eight. 'Press is no ad-vocate of substandard work, but he knows howto catch a dentist's attention.

Economic forces can determine not only thespeed at which dentists work but also thekinds of procedures they perform. A peculiarfact about the traditional fee structure in den-tistry is that saving a tooth is very often lesslucrative than destroying it. The average feefor a simple silver filling (known in the profes-sion as a one-surface amalgam restoration) is$19.33; the average fee for a simple nonsur-gical extraction, on the other hand, is $23.41.And because pulling a tooth is typically muchless time-consuming than filling it, the moreradical procedure can seem even more attrac-tive. Consider, too, that an extracted toothshould ideally be replaced by an artificial one,and that crowns, bridges, and partial denturescan cost hundreds of dollars.

Questions about quality in dentistry involvemuch more than matters of speed or cost. Likeany profession, dentistry attracts its share ofquacks, and controlling them can be extremelydifficult. Unlike new drugs, which must be ap-proved by the government before being placedin general use, experimental techniques in den-tistry, as in medicine, are essentially unreg-ulated. "You can do just about any damn

50

thing you want," one dentist told me. "I couldgo into the back room, take a nail, sterilize it,hammer it into a patient's jaw, and say it'san implant, and he couldn't do a damn thingabout it."

The "implant" just referred to is a case inpoint. Implants are artificial anchoring devicesthat are sometimes surgically embedded in apatient's jaw and then used to support falseteeth. Their attraction is that they seem to of-fer toothless patients a functional and digni-fied alternative to ordinary dentures. Theproblem, many dentists say, is simply that irn-plants are dangerous: they can cause rapidand irreversible bone loss, chronic infectionof oral tissues, periodontal disease, puncturedsinuses, and agonizing pain. "I've never seenan implant success," says Dr. Marvin Schissel,a practicing dentist and author of a bookcalled Deruistry and Its Victims. "I've neverheard of an implant success."

Despite the dangers, though, "implantol-ogy" (as practitioners refer to their field) isa thriving business. Implantologists have theirown professional organization (The AmericanAcademy of Implant Dentistry) as well astheir own publication (the quarterly [ournolo]Oral Implantology, a glossy periodical dottedwith typos and grammatical errors). Like mostinhabitants of scientific twilight zones, im-plantologists tend to be messianic in promot-ing their procedure, and also quick to detectconspiracies in nonbelievers.

Implantology even enjoys the support ofsome of its victims. "I know an elderly manwho had implants," says Dr. John Dodes, whois Marvin Schissel's partner. "Two years laterone side of his face was swollen, and he said,'Look at my beautiful implants.' He was soproud of them. His wife said, 'He's crazy. He'slost forty pounds. He's been on penicillin con-stantly for two years now, just to keep theinfection down, and this is the first week thathe's not swollen on both sides.' He eventuallyhad to go to a hospital and have them all re-moved. He lost so. much bone that now hecan't even wear a denture, and he still claimshow great it is, because he says, 'You've gotto be a rich man to have done what I did.'''

•

•PERHAPS the most fertile area for the

cultivation of quackery in the dentalprofession today is a group of ailmentsknown collectively as TMJ disorder.

TMJ stands for temporomandibular joint,which is the hinge that connects the upperand lower jaws. TMJ disease owes its currentvogue in some segments of the professionto the fact that almost anyone, given a little

imagination, can be said to suffer from it. Thisfact suggests enormous possibilities to dentistsbent on beefing up their practices, since theycan add TMJ treatment to their stock of pro-cedures without having to find new patients.The May 1981 issue of lADA carried an ad fora Long Island University continuing-educationcourse called "How To Increase, Revitalizeand Inflation-Proof Your Practice Through

• TMJ" (my italics). The same course was alsodescribed elsewhere as "The only TMJ sem-inar that will show you how to tap unuseddental and medical insurance resources andbuild on your already-existing practice" (theiritalics) .

TMJ disorder is not a single disease but atleast half a dozen distinct conditions that pro-duce pain in the face and jaw. These condi-tions can include osteoarthritis, trigeminalneuralgia, and sustained involuntary contrac-tion of muscles in the faci.' The first of theseis ordinary arthritis, the second is a neuro-logical disorder, and the third is a myofascialsyndrome that is apparently sex-linked (vir-tually all the people who have it are women).Despite the diversity of these ailments, TMJdentists tend to treat them as though theywere the same condition and as though theywere caused by the same thing: a bad bite.Common treatments include pulling teeth,grinding down teeth, capping teeth, insertingremovable "bite plates" to alter occlusion, andeven drilling holes in jawbones. Most of thesetreatments are irreversible, all of them are ex-pensive, and-according to Dr. Joseph Mar-bach, head of Columbia University's highlyrespected TMJ clinic and perhaps the country'sleading researcher in the field of facial pain-none of them works.

"Numerous studies have demonstrated thatthese patients have a normal distribution ofbites when compared with the general popula-tion," says ,Dr. Marbach. "Nevertheless, thevast majority of facial-pain patients are treat-ed exclusively or primarily by bite adjust-ment." Marbach favors conservative (and in-expensive) treatments based on drug therapy,exercise, and an informal sort of counseling

• to relieve the stresses and depression that canaccompany chronic pain. He may also be theonly dentist in the country who thinks dentistsdon't have any real business treating TMJ.

But dentists aren't likely to give up TMJanytime soon. In the words of A. C. Fonder,editor of a curious journal called Basal Facts("The Official Journal of the American Acad-emy for Functional Prosthodontics and theAmerican Academy of Physiologic Dentistry,"both of which, along with Basal Facts itselfand something called Doctor's Dental Service,

share an address in Chicago), TMJ treatmentis "the hottest procedure in the dental field."It is also becoming a hot procedure in anynumber of other fields. Some dentists nowclaim that bite manipulation can cure not onlyfacial pain but also curvature of the spine, em-physema, stuttering, numbness, paralysis, andopen sores on ankles and scalp.

The ADA has yet to take a firm stand onTMJ. A three-day symposium on the .subjectis scheduled for the summer, but there is noreason to expect a substantial result. TMJ, likedepartment-store dentistry, is too useful an em-ployer of dentists to be dismissed out of hand.As a result, it tends to be considered largelyin economic terms. "I think there's a lot of va-lidity in the dentist's involvement in TMJ,"says ADA president-elect Press. "Whether ornot certain dentists are more entrepreneurialin marketing their program, in trying to cap-ture an audience with certain catch phrases-that's just because they've talked to some guyfrom Madison Avenue, or had a better agentin putting together a brochure."

Dr. Press may be right. But there is stillsomething unsettling about dentists who seemto be selling not so much a treatment as adisease.

No future in decay

A'LL OF THIS runs counter to the dis-ease-fighting tradition dentists havemade for themselves. In comparisonwith other health-care professions,

dentistry has been especially successful bothin educating the public and in developing ef-fective treatments for disease. Whether we payattention or not, virtually all of us know howoften to brush our teeth and what kind ofsnacks to avoid and when we're supposed toappear for a checkup. Dental scientists are nowin the process of testing a vaccine that mayconquer tooth decay altogether, an achieve-ment that would be the dental equivalent offinding a cure for the common cold. Even inthe absence of a vaccine, fluoride toothpastesand fluoridated water supplies have alreadybrought about enormous reductions in decay,reductions that would not have been possiblewithout the persistent prodding of dentists,who have championed fluoridation for decades.Treatment of dental disease in all areas hasprogressed to the point where some dentistssay that tooth extraction in most cases oughtto be considered malpractice.

In view of these achievements, dentists couldplausibly be accused of trying to put them-selves out of business. In the space of a very

"A child whomakes it all theway to adult-hood withouta filling maydecide thatdentists aren'tterriblyimportant. "

51

David OwenTHE SECRET

LIVES OFDENTISTS

HARPER'SMAR CH 1982

52

few decades, they have come close to elimi-nating the traditional mainstay of their live-lihood. One dentist I talked to said that in thepast it was not uncommon for children to ap-pear for regular appointments with as manyas ten new cavities. "Now," he said, "theycome back and often it's just a checkup, every-thing's fine, and we'll see you next year." Noone knows yet what wiII happen when thesechildren reach adulthood. Will they send theirown children to dentists? Will they go them-selves? A child who makes it all the way toadulthood without a filling may decide thatdentists aren't terribly important.

Dentists are quick to point out that toothdecay isn't the only, or even the most devas-tating, oral problem. Periodontal disease-s-which attacks the tissues that surround andsupport the teeth and which is popularly knownas "gum disease"-is and always has been theleading cause of tooth loss in adults. In thefuture, dentists say, periodontal disease wiIIreplace tooth decay at the center of dental at-tention. To a certain extent the change hasalready begun: general practitioners, who havetraditionally referred most periodontal casesto specialists, are now doing more and more ofthe work themselves; dental schools are be--ginning to shift the emphasis of instructionever so slightly in the direction of periodontia;dentists who never paid much attention to thedisease are learning about it now.

The "problem" with periodontal disease,from the dentist's point of view, is that al-though it can be prevented with careful oralhygiene, once it gets started it's very difficultto control. Treating it requires painstakingscraping of plaque beneath the gum line, com-bined with conscientious maintenance care bythe patient himself, and sometimes surgery.Periodontal disease, in other words, is expen-sive, and dental patients fear expense evenmore than they fear pain. And because thedisease typically. begins in adolescence andprogresses for years without tangible symp-toms, there is no guarantee that the peoplewho suffer from it will ever get around to vis-iting their dentists in the first place.

As decay replacements go, periodontal dis-ease doesn't sound like a very sure bet. Evenso, one gets the feeling that the future of theprofession may depend on it.

ASK A PHYSICIAN whether medicine hasa future and he'll laugh in your face;ask a dentist whether dentistry has afuture and he'll give you a cautious,

reasoned reply."Dentistry wiII remain a profession for

which there is a need," Dr. Sidney L. Horowitzof the Columbia University dental school toldme one afternoon. It was an extraordinarystatement, all things considered. Have we pa-tients got our dentists so intimidated that theyactually wonder whether they deserve to exist?Is the entire profession contemplating suicide?"A physician friend of mine came over yes-terday," says Marvin Schissel, "and we weretalking about the cost of dental education, •and he said, 'You're lucky you're a dentistnow, because in ten or fifteen years I don'tthink there'll be any dentists left.'" At a dentalmeeting in New York last year, Burton Pressasked a roomful of dentists, "Do you thinksome dentists are going to end up like aero-space engineers?"

Of course, to describe a problem like thisis necessarily to exaggerate it. Dentistry isn'tabout to fold up its tent and disappear. Noris it locked in some great mad upheaval thatwill leave thousands of dentists hungry andhomeless, their driII bits rusting in their emptyoffices. As virtually any dentist will tell you,there is enough untreated dental disease al-ready in existence to keep the world's dentistsbusy from now until they all drop dead. ("Un-treated dental disease" is the holy grail of thedental profession; dentists get sparks in theireyes when they talk about it.) Still, there arechanges afoot in dentistry, changes that takentogether amount to something of a revolution.

"What we will see is a different emphasisin general dentistry, as has been the casefor a number of years," says Dr. I. LawrenceKerr, a practicing dentist in Endicott, NewYork, and a former president of the ADA."We're talking more about periodontia, whichis the least treated of all diseases in dentistry.In fact, I would say that only one or two per-cent of all periodontal disease is being treated.We are emphasizing more the concept of thetotal body; we're emphasizing jaw problems;we're talking to people more about nutrition-and we were way ahead of all the other pro-fessions when it came to nutrition, because itwas so involved in dental decay. We talk topeople more about muscle use, muscles of theface. We're talking more about the validity of •vitamin therapy, if it is valid. We talk moreabout pain reduction, biofeedback: And likeeverybody else we're getting more into geneticcounseling, because we have been able to stepback a bit from just filling cavities to knowthat as a profession we've been trained to doa hell of a lot more."

There's not much mention of teeth in Dr.Kerr's catalogue of the future. But then, who-ever said that being a dentist had anything todo with teeth? 0