Toward Creation of the Oral Physician

Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America By Mary Otto

New York, NY: The New Press; 2017 288 pp.; $26.95 ISBN-10: 1620971445 ISBN-13: 978-1620971444

Teeth by Mary Otto is less about teeth than a lament of the US dental profession’s failure to adequately address the oral health care needs of poor, underserved populations. Interspersed between anecdotal case histories of poor, excessive, or negligent treatment, described in breathless florid prose, are well-written historical essays of dentistry’s transformation from an unregulated itinerant trade to a learned oral health care profession traditionally separated from medicine.

There are many good reasons, as Otto makes clear, why dentistry should be integrated as a specialty of medicine: most obviously, the head is connected to the body and its diseases and infections are not limited to the oral cavity. But it is arguable that dentistry’s development as a separate profession allowed for more rapid advancement because its schools did not have to compete directly with other medical specialties for space, funding, and recognition.

SERVING THE POOR

Acknowledgment is given to individual dentists and dental hygienists who serve poor and minority populations, especially children who suffer most from the ravages of dental disease. The tragic death of two children from infections spreading from decayed teeth are described in graphic detail. The barriers to accessing dental care are numerous. Poor people cannot afford the high fees of private practice dentists. Few dentists accept the low fees paid for children covered by Medicaid and the Children’s Health Insurance Program. Dentists locate in high-income affluent cities and suburbs that are inaccessible to the poor. There are too few dentists. At least 7000 dentists are needed to meet minimal oral health care needs in the 5550 dental health shortage areas.^1,2

The American Dental Association (ADA) is rightfully criticized for its tight control of dental hygienists and its unconscionable opposition to dental therapists, who in other countries provide care to all children. But the ADA receives scant praise for its role in promoting community water fluoridation, considered one of the 10 greatest public health accomplishments of the 20th century, or for its scientific, educational, and community contributions.³ Considering the emphasis placed on the neglect of children, it is surprising that Otto’s description of dental therapists fails to mention that their greatest success is caring for children, as comprehensively documented in a report sponsored by the W. K. Kellogg Foundation that she neglects to reference.⁴

HUCKSTERISM

The overall impression in Teeth is of a profession dominated by hucksterism. A “practice management” course teaching dentists how to become millionaires with the hard sell is described in such detail that it could serve as instruction for an enterprising dentist. Her critique of the surge in cosmetic dentistry that exploits the public’s vanity is on mark. However, there is no mention of orthodontics—the straightening of crooked teeth—which, except for correction of severe malocclusion, is entirely to improve one’s smile. Dentistry’s annual “Smile” campaigns are intended to promote good dental care, but they also feed into people’s obsession with appearance. Nonetheless, there is good cosmetic treatment that overcomes “social disability” and bad cosmetic treatment that exploits the public’s vanity for trivial gain and sometimes damage to the dentition.

WISDOM TOOTH EXTRACTION

Otto’s emphasis on the hazards of dental neglect is negligently silent on the risks of wisdom tooth extraction. She copied verbatim a statement from a New York Times article on the cost of wisdom tooth extraction without attributing this reviewer, who was quoted in that article. She references a secondary source in the American Journal of Public Health rather than the original article, also published in the Journal, which highlights not only excessive cost but also the harm of excessive surgery.⁵ Tens of thousands of mostly young people suffer iatrogenic injury each year from unnecessary wisdom tooth extraction, which led to the American Public Health Association’s policy opposing prophylactic extraction.⁶ While laboring at length on two tragic deaths of children from dental infections, she makes no mention of the children and adults who succumb each year under unnecessary intravenous sedation or general anesthesia, which is often pushed on patients when a safe local anesthetic injection would suffice.

DENTAL CAPITATION

My close friend and colleague Max H. Schoen did not invent dental insurance, as Otto asserts in the text. He is correctly credited in the book’s index with the “invention of capitated group practice system.” He recognized that fee-for-service is an open invitation to overtreatment and an impediment to poor people accessing health care. Schoen pioneered in developing the first post–World War II dental capitation plan for children of members of the International Longshore and Warehouse Union (ILWU) in conjunction with the Pacific Maritime Association (PMA). The ILWU–PMA Benefit Funds extend across the West Coast from southern California through Oregon to Washington. To provide for all eligible children, and to prevent the spread of closed-panel capitation group practices, such as Schoen’s, that were established for the plan, the dental association in each of the three states formed Service Corporations to administer the innovative fee-for-service open-panel indemnity dental insurance plan, modeled after medical indemnity insurance. (The Service Corporations eventually evolved into Delta Dental Plans.) Max deserves credit as the “father of modern dental capitation,” although he would cringe at the poor programs and corporate group dental practices, with their overemphasis on profits that have since become widespread.

ATRAUMATIC RESTORATIVE TREATMENT

Mention is made of atraumatic restorative treatment, termed intermediate therapeutic restoration by pediatric dentists, which painlessly removes some of the soft decay in a tooth with a small, spoon-shaped instrument. The cavity is then sealed with a decay-inhibiting material. Not mentioned is that atraumatic restorative treatment was developed under the auspices of the World Health Organization for the training of public health workers and nondental health personnel in a five-day [sic] course for service where there are no dentists or hygienists.⁷ Typically, organized dentistry absurdly requires authorization by a dentist before a dental hygienist, much less a trained field health worker, can apply this simple tooth-saving and possibly life-saving procedure in a school, nursing home, or prison.

UNIVERSAL WATER FLUORIDATION

Most dental disease, especially tooth decay, could be prevented. All we have to do is fluoridate the entire community water supply, apply fluoride varnish to every baby tooth, and eliminate sugar from the diet. Universal water fluoridation is conceivable despite the opposition of a small but influential number of “antis.” Baby teeth could and should be varnished in pediatricians’ offices. But eliminating sugar entirely defies comprehension. Tooth decay and periodontal disease that cannot be prevented will require hands-on technical treatment, most of which could be provided by dental therapists, dental hygienists, orthodontic technicians, and denturists (prosthetic technicians) for replacement of missing teeth. Thus, there would be less need for traditional dentists, which might lead to the integration of dentistry with medicine and creation of the oral physician, as envisioned by progressive dental educators in the past and advocated by many public health dentists today.

“FIRST, DO NO HARM”

Teeth covers many of the issues confronting the dental profession, both past and present. To her credit, Mary Otto is highly critical of organized dentistry and of the commercialization of dental practice. But with all its shortcomings, the dental profession is composed of many dentists in private practice and in public health who adhere to the basic Hippocratic oath, “First, do no harm,” and then do a lot of good in service to those in need of preventive and curative oral health care.