(C) Peter Meiers - http://www.fluoride-history.de

   

The birth and rise of dentistry

 

"We and our predecessors have brought this profession up from the gutter of tooth pulling in the market place by Tom, Dick and Harry, to the heights of scientific achievement and recognition. We have pulled ourselves up almost literally by our own boot straps, toiling upward while other learned professions and sciences looked askance at us and pooh-poohed our efforts."

David W. McLean, D.D.S., member ADA Board of Trustees, 1938

 

When in Europe chemists and physicians started their investigations on the presence of fluoride in bones and teeth and speculated about any possible implications of this find, the dental profession, which later took advantage of this work, was still not organized as we know it today. Although books and reviews on the history of dentistry usually start with a description of the evolution of medicine and dentistry during the existence of Sumeria, Babylon and Ancient Egypt, and the practice of dentistry among Hebrews, Phoenicians and Chinese, Greeks and Romans (1,2), those then practicing the three ill´s ("drill, fill and bill") business (essentially some kind of micro-carpentry) were lay people without the academic education required for a modern dentist. And this was still the case during the early part of the 19th century (3,4). Teeth are part of the body and, therefore, should have been a matter of medical interest. But while some physicians dedicated considerable time to dental research, the medical profession in general apparently neglected the treatment of dental disorders which they regarded as rather superficial troubles of short duration and very rarely life-threatening. Thus, dental treatment became also a matter of Tom, Dick and Harry. As almost everybody is afflicted by dental caries, from time to time, and the uncomfortable situation it creates, it is easy to imagine that their job was a flourishing business. The lay people practicing it had acquired what knowledge they possessed either through unguided experience or by learning in the office of some practitioner of the day (preceptorial training). They were called unqualified and incompetent "craftsmen" by those with a medical education who choose to regard themselves as a "better class of dentists" (5). In 1834 some physicians felt a need to separate themselves from the craftsmen and to set professional standards and therefore started an attempt to make the trade a medical specialty. They organized the "Society of Surgeon Dentists of the City and State of New York" (3,6). But to realize the tripod upon which every profession must be built if it is to be firmly established, remained for two physicians interested in dental problems, Horace Hayden and Chapin A. Harris. Their mutual efforts, i.e. the first publication of the "American Journal of Dental Science" (1839), the founding of the "Baltimore College of Dental Surgery" (1840), and the organization, in the same year, of the first dental society of national scope, the "American Society of Dental Surgeons", finally marked the birth of dentistry as an organized profession (3,5,7-10), yet essentially as a medical specialty. However, there soon developed some dissension in the Society´s ranks accentuated by the "amalgam war" of that time (11). Amalgam opponents viewed mercury as dangerous and considered the use of amalgam fillings as quackery. The dispute drastically  reduced the Society´s membership. It finally disbanded in 1856 (5).

The next step determined the new profession´s first century to consist primarily of squabbling to establish once and for all the separation from medicine! In August 1859, twenty-six dedicated men met at Niagara Falls to organize the "American Dental Association" (ADA; later called the "National Dental Association" for some years), a national syndicate upon a representative basis (5,12,13). It was open not just to the surgeon dentists but also the craftsmen who made up the great majority of its members. The desire to elevate the profession in public esteem and to advance it in the social scale as compared with other professions (notably medicine), was one of its two fundamental motives, the other -a prerequisite to achieve the first- being to improve the professional qualifications of the dentist (12).

The ADA´s efforts to bring all dental education under the authority of colleges (13) soon led to the passage of dental laws by several states, which forced the change from apprenticeship training to organized instruction (7). Twenty-five years after the first dental school had been established there were but four colleges. In 1900 their number had increased to 57 and this served to usher in the commercial era in dental education (8,9). Many of these schools were founded primarily for profit, with little regard for educational and professional standards. Even when under university supervision, the teaching of basic biological sciences was mere window dressing and -in view of the primarily mechanical art to be performed later- was not regarded as essential, neither by dental teachers nor students. In anatomy, physiology and bacteriology classes dental students were regarded as unwelcome guests, and their instruction was relegated to teachers who were not considered quite good enough to teach the medical students (9). So, many dentists with a medical education persisted in urging that a medical degree should be a preliminary requirement for the practice of dentistry and thus - to the chagrin of the ADA - "determined to place dentistry under the control of medical authority and to make it an accredited specialty of medicine" (13). To oppose the proposed way of education, claims were published in 1904 and 1910, and revived in the 1930´s (14,15), that the medical school of Baltimore refused in 1839/40 to accept the responsibility for dental education and training on the ground that it was not of sufficient importance to warrant such recognition and, thus, necessitated the founding of a separate dental college. According to biochemist William John Gies, of Columbia University, founder of the International Association for Dental Research (IADR) and editor of the Association´s journal (the "Journal of Dental Research"), this claim was without foundation (4).

In 1910, the English physician William Hunter further aggravated the problems in the medico-dental relationship (16,17) when he forcibly called the attention of both medicine and dentistry to the fact that diseases of the mouth and the things done in the name of dentistry bear a very definite relationship to general health (18):

 

The patient is quite willing to describe and discuss with the doctor all his other troubles and complaints, to which, as he says, he is a "martyr" - his indigestions, headaches, liver troubles, his rheumatism, his gout, and his "neuritis". But the subject of his teeth is his own affair - one between himself and his dentist. And the doctor regards it as such. "It is a matter of teeth and dentistry," with which he cannot deal. ... It is not "a matter of teeth and dentistry". It is an all-important matter of sepsis and antisepsis that concerns every branch of the medical profession, and concerns very closely the public health of the community. It is not a simple matter of "neglect of the teeth" by the patient, as is so commonly stated, but one of neglect of a great infection by the profession ...

No one has probably had more reason than I have had to admire the sheer ingenuity and mechanical skill constantly displayed by the dental surgeon. And no one has had more reason to appreciate the ghastly tragedies of oral sepsis which his misplaced ingenuity so often carries in its train. Gold fillings, gold caps, gold bridges, gold crowns, fixed dentures, built in, on, and around diseased teeth, form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine or surgery. The whole constitutes a perfect gold trap of sepsis of which the patient is proud and which no persuasion will induce him to part with. For has it not cost him much money, and has he not been proud to have his black roots elegantly covered with beaten gold, although no ingenuity in the world can incorporate the gold edge of the cap or crown with the underlying surfaces of the root beneath the edges of the gums. ... Such are the fruits of this baneful so-called "conservative dentistry". ... Conservative it is, but only in one sense. It conserves the sepsis which it produces by the gold work it places over and around the teeth, by the satisfaction which it gives the patient, by the pride which the dentist responsible for it feels in his "high-class American work", and by the inability or unwillingness to recognise the septic effects which it produces. ... The medical ill effects of this septic surgery are to be seen every day in those who are the victims of this gilded dentistry ... In no class of patients and in no country are these, in my observation, more common than among Americans and in America, the original home of this class of work.

   

After Hunter´s lecture, even those physicians not interested in the engulfment of the dental profession started to care about dental matters, but were heavily criticized by dentists, especially when they were concerned about "infection carried into the circulation from the apices of pulpless teeth" (see also Miller´s statements). One of the charges then raised by dentists against those with holistic views reads like this (19):

 

In medicine and surgery the same tendency to faddism and over-enthusiasm is abundantly evident. The vermiform appendix, the coccyx, tonsils, ovaries and various other human appurtenances and hereditaments have been severally condemned to exstirpation as the cause of a long list of human ailments ... Just now the human teeth are receiving their full share of attention, and some are finding in dental infections the solution of all etiological problems. 'Teeth cause rheumatism, my doctor tells me,' is the reflex of this later fad in the mind of the layman; and if the doctor says so, teeth must go like their whilom criminal predecessors the coccyx, vermiform appendix, ovaries and tonsils.

 

While, according to some critics, in not a few instances the "extreme attitude on the part of a modicum of the medical profession" has received aid and encouragement from a "similar class of extremists in the dental profession", some dentists more than once declined to remove teeth "at the dictate of the physician" (20), and an editorial in the "Dental Cosmos"  of July 1916 (19) urged to be laid down as one of the fundamental articles of the professional ethical code

 

...that the question of the removal or retention of a tooth is a dental question and one to be decided ultimately by the dentist and not by the physician.

 

To possibly end this discussion, an editorial in the Journal of the American Dental Association of 1938 proposed the following treatment for Hunter´s followers: "The one great lesson to be learned from our detractors is to ignore them. This is not always easy, but it becomes necessary if we are to cope successfully with them"  (21).

In the meantime, many dentists found themselves suffering from the worst kind of an inferiority complex:  

  

"From one direction, we hear that much of the reparative dentistry is responsible for all the ills that flesh is heir to; from another source, we have the criticism that our college teaching is faulty, that we have subordinated the scientific subjects to the practical subjects. We hear much about dentistry failing to keep abreast with other branches of medicine in public service. There are some who declare that dentistry will never be able to give a full measure of health service until we become a specialty of medicine and then there are those pessimists who declare that the great plague, panel dentistry, state commissions, politics, insurance companies and socialization of practice  are threatening. ..."

D. M. Gallie, DDS, ( J. Am. Dent. Assn. 19 (1932) 1617)

  

With the additional impact of the world economic crisis, the problems of the dental profession increased during the 1930´s (17). Already in the former days of prosperity critics said that the dental profession, "through well-conceived and most efficiently conducted propaganda, created a demand for dental service far beyond our present physical capacity to supply," yet at the same time created "educational barriers to entrance to the profession that must necessarily lessen rather than increase this already insufficient physical equipment" (22).

Why would it need all the years of academic education for a dentist just to drill and fill? A discussion along this line had already started in the 1920´s and was illuminated in a report on dental education in the United States, published in 1926, by William John Gies, of Columbia University (23a). When a "Committee on the Cost of Medical Care" was formed in 1927, an editorial in the Dental Cosmos expressed some thoughts on the profession's policy of the past:

"Are we not laying ourselves open to the charge that we are evolving into a close corporation whose services are available only to the wealthy? Are we not unmindful of and have we not ever been derelict in our duty to the masses as a public health service? Is it not true that our present belief in prevention as the only way out had its inception in the realization of our failure to meet the demands we ourselves have created? Are we not creating a condition in this country similar to that in England where the State, realizing the seriousness of the situation, is endeavoring to provide through legislation dental service to the masses?"

(Editorial Department, Dental Cosmos 1927)

 

In 1931, the proposal was made by a senator (23c) and later commended by the "Committee on the Cost of Medical Care" (24-26), to lay the mechanical work on teeth into the hands of dental hygienists and other technicians working under the direction of a physician or a "dentist who is also a physician", and to possibly discontinue the profession of dentistry. But now, as this point was brought up, Gies had an important argument to raise in support of academic education for dentists. He referred to research on "mottled teeth" and their prevention, "a matter of water works engineering and public sanitation under the guidance of the dental profession", emphasizing the "importance of dental membership in health boards" (23):

  

Results of recent biochemical research, as published in papers from an industrial laboratory and an agricultural experiment station, indicate that mottled enamel is caused by excessive proportions of fluoride in drinking water in districts where this dental lesion is endemic. No physician participated in this useful discovery. After important preparatory clinical and scientific work by dentists, the facts were ascertained under industrial and agricultural auspices. These conditions of discovery do not restrict to industry and agriculture the prevention of mottled enamel, nor do these circumstances convert such prevention into "scientific" industry or agriculture. These scientific results "belong" wherever they can be advantageously used.

(1) Physicians will regard the important discovery of the cause of mottled enamel as an addition to a "medical" science, and will use the discovery as such. They will also include the facts in the science of medicine. In the broadest import, however, the discovery signifies that another stone has been placed in the structure of the sciences in which all forms of health service rest - basic sciences that have not in any sense been organized or reserved for the exclusive use or exaltation of any division of health service ("medicine").

(2) The prevention of mottled enamel, while primarily within the scope of scientific dentistry, has become largely a matter of water-works engineering and public sanitation under the guidance of the dental profession. This is one of the many instances that emphasize the importance of dental membership in health boards.  

 

As to the remark that "no physician participiated in this useful discovery", an interesting sentence in one of McKay´s early papers (27) comes to mind:

 

It would seem to me that such work should be done if possible within our Commission, in order to preserve the dental relationship.

 

The need "to preserve the dental relationship" is the more remarkable as McKay himself once realized that "mottled teeth" might be more than just a cosmetic problem (27a):

 

"The constant dosage of fluorine in water in these extremely attenuated concentrations may express itself in mild pathologic lesions of other tissues which, through their inherent vital functions, may be coincidentally repaired. No such function resides within the enamel, as is well understood by dental science. The disturbing influence of fluorine on the process of enamel calcification is never offset; hence, this lesion of the enamel remains as the only index of the toxicity of that element for the individual." 

 

Of vital importance was the fact that dentistry, in the course of that project, learned to appreciate cooperation by industrial circles which finally identified the culprit that was also a cause of major trouble due to certain industrial activities. Support of this kind, in addition to funds for related research,  served to give the dental profession a certain recognition. In summary, as McKay put it (28), research on mottled teeth "had a profound effect in helping to raise dentistry from the general level of skilled technology to that of the exact sciences". Yet the original dream of water works engineering had to be somewhat modified - along with the description of the dental defect, mottled teeth.
 

References:

(1) Ring M.: "History of dentistry", undated; (2) Perine G. H.: "Geschichte der Zahnheilkunde von fruehester Zeit bis zur Gegenwart", Correspondenz-Blatt fuer Zahnaerzte (C. Ash & Sons) 13 (1884) 113-124; (3) Merritt A. H.: "The progress of American dentistry", J.Am. Dent. Assn. 27 (1940) 1103; (4) Gies W. J.: "Dental education. Including a study of the alleged influence of derogatory medical opinion on its institutional initiation in 1840", J. Am. Dent. Assn. 27 (1940) 99; (5) Dittmar G. W.: "Presidents address", J. Am. Dent, Assn. 20 (1933) 1941; (6) Bear H.: "Dental organizations in the United States. A century of achievement", J. Am. Dent. Assn. 27 (1940) 425; (7) Black A. D.: "The rise and progress of dentistry", J. Am. Dent. Assn. 20 (1933) 1933; (8) Wright W. H.: "The dentist, the dental technician and the public", J. Am. Dent. Assn. 27 (1940) 1932; (9) Holyday H.: "Dentistry´s place in a health service program", J. Am. Dent. Assn. 29 (1942) 1608; (10) Casto F. M.: "The transition in the art and science of dentistry", J. Am. Dent. Assn. 22 (1935) 1097; (11) Dittmar G. W.: "A résumé of the development of organized dentistry in America and the present status of the American Dental Association", J. Am. Dent. Assn. 20 (1933) 1428; (12) "A synoptic history of the American Dental Association", J. Am. Dent. Assn. 58 (June 1959) Special Issue "100 years American Dental Association"; (13) Robinson J. B.: "1859-1897", p. 21 in Ref. 12; (14) Henshaw F. R.: "Dental education as related to medicine", J. Am. Dent. Assn. 19 (1932) 1607; (15) "A brief consideration of the report on medical education, 1925-1932", J. Am. Dent. Assn. 20 (1933) 348; (16) Bunting R. W.: "President´s address. Certain Trends in Dental Research", J. dent. Res. 13 (1933) 175; (17) "Editorial: Cooperation between the physician and the dentist", J. Am. Dent. Assn. 19 (1932) 1231; (18) Hunter W.: "An address on the role of sepsis and antisepsis in medicine", The Lancet, (Jan. 14, 1911) 79; (19) "Editorial: The swing of the pendulum", Dental Cosmos 58 (1916) 823; (20) Fergus O.: "The swing of the pendulum", Dental Cosmos 58 (1916) 1166; (21) Editorial "Our detractors", J. Am. Dent. Assn.  25 (1938) 952; (22) "Editorial: Noblesse oblige", Dental Cosmos 69 (1927) 744; (23a) Gies W.J.: "Dental education in the United States and Canada", A report to the Carnegie Foundation, New York, 1926; (23b) E. L. Bernays: "Propaganda", New York/London 1928, p.24; (23c) Gies W. J.: "The status of dentistry. Notes on the question whether dental practice should be included in medical practice, with comment on a substitute for state medicine", J. dent. Res. 12 (1932) 945; (24) "The report of the committee on the costs of medical care", J. Am. Dent. Assn. 20 (1933) 141; (25) "That fatuous footnote", J. Am. Dent. Assn. 20 (1933) 1721; (26) Gies W. J.: "The final report of the Committee on the Costs of Medical Care", J. dent. Res. 13 (1933) 81; (27) McKay F.S.: "Investigation of mottled enamel and brown stain", J. Natl. Dent. Assn. 4 (1917) 273; (27a) McKay, F.S.: J. Am. Dent. Assoc. 20 (1933) 1137-1149; (28) McKay F.S.: "Fluorine and mottled enamel" in "Fluorine in dental public health" (ed.: W. J. Gies; chairman: A. H. Merritt), A symposium at the 94th monthly conference of the New York Institute of Clinical Oral Pathology, New York, Oct. 30, 1944, publ. 1945, p. 10

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