Sometime within the next couple of years something quite extraordinary will happen in the nation`s dental schools. If current projections are correct, there won`t be enough student applicants to fill up the 58 schools still in operation.
Dentistry traditionally has been an alluring profession for many of the nation`s brightest college students. A degree in dentistry was a virtual ticket to the upper-income bracket, a big house in the best part of town, a membership in the local country club and generous time off to use it.
The degree also brought with it the esteem of being a highly trained professional in health care, the privilege of using the title ”doctor”
before your name. In some ways dentistry has been even more attractive than medicine. Medicine is a profession that has become so fragmented with specialties and subspecialties that most doctors by necessity must attach themselves to hospitals and group practices. Doctors work as members of complexly organized, highly regimented teams. Newly graduated dentists, on the other hand, can and usually do go on to hang up the shingle of a lifelong independent practice, becoming their own bosses, free of the hassles of a large organization.
But something has happened to dentistry in the last five years. Two dental schools, at Emory University and Oral Roberts University, closed their doors in 1984. The University of Mississippi is struggling from year to year for funding to remain open, and other schools periodically discuss merger to save money. In addition, the remaining schools around the country have cut back their admissions by 20 percent. Still, there are so few students interested in going into dentistry these days that by 1987 many schools probably will not be able to fill their first-year classes. And the falling admissions probably will threaten even more schools with closure, according to studies cited by the American Dental Association.
The hard times in American dental schools are a direct reflection of the good fortune of Americans in general. We, as a population, are enjoying the remarkable payoff of an experiment in public health begun more than 40 years ago. What happened was fluoridation. For the past 40 years an increasing number of American communities have been fluoridating their drinking-water supplies. Where drinking water is not fluoridated, many schools have put their pupils on a regimen of fluoridated mouthwash treatments. Dentists have been applying fluoride treatments to children in the dental chair. Americans everywhere brush and gargle with fluoridated toothpastes and mouthwashes.
As a result, a 1981 national dental survey showed some startling statistics: Of the 9-year-old children examined in the 1981 survey, 51 percent had not one single cavity. Of the children aged 5 to 17 examined, 37 percent had no cavities. Cavities used to be so prevalent that dentists had no hope of caring for all the patients who needed work. It used to be that when you wanted a routine dental appointment, you often had to wait weeks or months. Appointment books were always full. ”Drill, fill and bill” was the phrase describing the dentist`s work, especially on children. Now, thanks to fluoridation, fewer and fewer youngsters have cavities to fill. Those who do have cavities tend to have fewer than did children of 30 years ago. Moreover, there are fewer children and teenagers than before. Changing marriage and child-rearing patterns have drastically slowed American population growth.
In the early 1970s, before the effects of fluoridation and new childbearing patterns in America had been recognized, the federal government contributed heavily to what now seems to be a glut of dentists. Economic forecasters then had predicted a serious shortage of dentists, and the government had responded with a program called ”capitation” to help dental schools expand their classes. The program offered federal grants to dental schools for constructing new, larger facilities and for new equipment. The size of the grant increased with the number of students admitted. By 1980 every dental school in the U.S. had a new building, new equipment–and more students.
Somewhere around 1980 dentists in private practice began to notice that their appointment books no longer bulged months in advance. Though they weren`t faced with shutting down, they were having trouble hanging on to their patients. At the same time, they watched dental schools graduate record numbers of new dentists, each eager, of course, to carve a slice out of a pie that seemed to be shrinking.
It used to be that private dentists were major recruiters for the profession. They urged their own children and their brightest young patients to consider dental school. Now they do the opposite.
As a result, many college students who 10 years ago might have considered applying for dental school now look elsewhere for professional training. It is far easier and cheaper to get a master`s degree in business administration or advanced engineering than to go to dental school, and the payoff afterwards is often just as lucrative.
What is happening today to dentistry is unprecedented in the history of health care. Scientific and technological advances in the past were never so effective that they eroded the patient base on which the practitioner depended for his livelihood. Advances in medicine such as compulsory inoculation programs to stamp out polio, measles, diphtheria and other diseases, for example, have had no such effect. Medical evolution has instead widened the demand for medical services, broader medical education–and doctors.
At first the evolution of dentistry followed much the same course. New techniques, technology and materials in the past created credibility for the profession and increased demand for dental services. In the last century vulcanized rubber, used to simulate gum tissue, made possible the first attractive, durable false teeth, and development of long-lasting silver amalgams for fillings gave dentists a chance to save diseased teeth. In this century the same increase in services occurred following development of sophisticated local anesthetics and high-speed drills that reduced the pain of seeing a dentist.
But the introduction of fluoridation to community drinking water in 1945 has had a dramatically different effect. As in factories and the steel industry, new technology has begun to lessen the need for human labor in dentistry. Because of fluoridation, the country doesn`t need as many dentists as we now have.
The drastic reduction of cavities would seem to rank historically with the development of a polio vaccine as a medical achievement. Polio
vaccinations and fluoridation both became widely available in the 1950s, and both showed immediate, verifiable and stunning success. Jonas Salk and Albert Sabin are justifiably revered names for their work in eliminating polio. But Frederick McKay and H. Trendley Dean, the men most responsible for developing fluoridation, are virtually forgotten.
In 1901 Frederick McKay, freshly graduated from dental school in Pennsylvania, moved to Colorado Springs, Colo. He chose the city for his first practice because he suffered from tuberculosis and thought the mountain air would restore his health. A city of 23,000, Colorado Springs at that time boasted of being the wealthiest city per capita in the nation because of the vast fortunes that many of its citizens had acquired from the gold and silver in the surrounding mountains.
Within weeks of his arrival, the young dentist noticed that his patients who had been born and reared in Colorado Springs had a peculiar permanent brown tinge on their teeth and that some teeth were misshapen. The
discoloration was known locally as ”Colorado Brown Stain,” but nobody, even other local dentists, paid it much heed. Only lifelong residents of the community had discolored teeth. People born and reared just outside the town boundaries did not.
Curious, McKay studied his dental school notes and reference books to find out what the staining was and where it came from. Not a word had been written about it, and he couldn`t raise much local interest in the phenomenon. In 1905 McKay moved to St. Louis, practicing there for three years without seeing a single case of the stain. Forced by ill health to move back to Colorado Springs in 1908, he was again struck by the nearly universal discoloration of his patients` teeth.
A man of redoubtable persistence, McKay vowed to find the cause of the mysterious stain. At a statewide meeting of dentists in 1908, he exhibited one of his patients who had severe discoloration. The exhibition paid off. Other dentists from communities scattered around Colorado said they, too, had patients with the same sort of stain and that as in Colorado Springs the staining occurred within definite geographic boundaries. Still, the other dentists shrugged off the condition as a local curiosity. McKay suspected that the staining existed in communities all over the country but that it had never been considered worthy of scientific attention. He realized he needed somebody with national stature to take the problem seriously if other dentists were to do the same. The most renowned dental researcher in the world at the time, and also the world`s authority on tooth pathology, was Greene Vardiman Black, dean of the Northwestern University Dental School in Chicago. McKay wrote to Black in 1908, describing the mysterious stain.
G.V. Black is generally considered the father of modern dentistry. Born in Downstate Scott County in 1836, the son of a rural cabinetmaker, Black`s only formal education was 20 months of grammar school. After the Civil War, he became a dentist by apprenticing himself for four years, as was the fashion of the day. He set up practice in Jacksonville, Ill., began reading widely in the current dental and medical literature and established a laboratory to conduct his own experiments in dental techniques and pathology. His work and the books he wrote about it served to systematize dental knowledge as a science, lifting it out of the gray world of quackery. Under Black, dentistry became a legitimate arm of the health sciences.
When he was appointed dean of the dental school at Northwestern in 1897, Black also revolutionized dental education, making it as rigorous a discipline as medicine. By 1908 he was the reigning sage of dentistry. When he received a letter from a young unknown dentist from Colorado Springs, he immediately dismissed McKay`s description of the stains as an unrecorded dental abnormality. He knew more about dental lesions than anyone in the world, and he was sure McKay was mistaken.
But McKay knew Black shared his own passion for fishing, and he lured the scientist from Chicago to Colorado with the proposal of a summer of sloshing through mountain streams. The agreement was that Black would also spend a few days looking at the dental stains McKay had discovered. So it was that Black arrived in Colorado Springs in the summer of 1909, bringing his wife and family.
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McKay prepared carefully for the impending visit. With the help of another local dentist, he examined the teeth of all 2,945 school-aged children in Colorado Springs. The dentists were shocked to discover that 87.5 percent had the stain.
On arrival Black began performing his own examinations and reviewing McKay`s data. In an account he later wrote about his Colorado visit, Black described the disturbing condition: ”The teeth are of normal form but not of normal color. When not stained with brown or yellow, they are a ghastly opaque white that comes prominently into notice whenever the lips are opened, which materially injures the expression of the countenance of the individual. . . In very many cases the teeth appear absolutely black as one sees them in ordinary social intercourse.
”I spent considerable time walking on the streets, noticing the children in their play, attracting their attention and talking with them about their games, etc., for the purpose of studying the general effect of the deformity. I found it prominent in every group of children. One does not have to search for it, for it is continually forcing itself on the attention of the stranger by its persistent prominence. This is much more than a deformity of childhood. If it were only that, it would be of less consequence, but it is a deformity for life.”
After several days of such observations, Black announced that McKay had discovered a new tooth lesion previously unreported in dental literature. Something present in Colorado Springs and other communities in the state was causing a mottling malformation in the tooth enamel of children as they developed their adult teeth (the new teeth already were stained when they came in).
Now the quest was on to find out what caused the stain. Most local people who had stained teeth just assumed it was ”something in the water,” and McKay was inclined to agree. Black strongly disagreed, though he had no firm alternate theory, but he insisted that McKay investigate the water theory first, if only to dispel the local theory.
McKay and Black began their research, corresponding through the mail. It culminated in a landmark series of papers identifying the condition published in a national dental journal in 1916, a year after Black died. It was, incidentally, the only time in Black`s illustrious career that he conceded to share authorship of a research paper. McKay was the first he considered his equal in dental research.
Black`s prestige and his interest in the mottled teeth of the Colorado Springs schoolchildren had the effect McKay desired. The articles he and Black wrote together and subsequent papers McKay wrote himself brought the problem to light in more and more areas around the country. McKay received reports of staining in the Dakotas, in Iowa, on the Eastern seaboard and especially in Texas, where the condition was widespread and long known as ”Texas teeth.”
Black`s death meant McKay was now the leading authority on the staining condition, and it became a lifelong obsession. For the next 20 years, when he received letters from dentists reporting the presence of mottling in their communities, he dutifully got on a train and went to see it firsthand, paying for the trips himself.
The more he traveled, the more McKay was convinced that whatever caused the staining was in the drinking water of the communities where it occurred. The existing technology for assaying the mineral content of water was crude, however. McKay had water samples examined in each community he visited, but he could never discover a specific element in the water common only to communities with stained teeth.
Though he was almost exclusively concerned with finding the cause of the stain, McKay, along with Black, also made another startling observation about the dental health of people with mottled teeth: They had no more cavities than anybody else and, in fact, perhaps had fewer cavities than people with unstained teeth.
”This mottled condition, in itself,” McKay wrote in 1916, ”does not seem to increase the susceptibility of the teeth to decay. . . .” In an address in 1928 to the Chicago Dental Society he noted that reports from around the country suggested that mottled tooth enamel was often ”free from caries (cavities). One of the first things noted by Dr. Black . . . was the singular absence of decay, and it can hardly be said that his faculty for observation was superficial.”
In 1923 McKay was called to Oakley, Idaho, by parents distressed over the ugly staining present in every child in the small frontier village. The stain had not been present before 1908, the year Oakley residents constructed a communal pipeline to a warm spring five miles away. McKay could find nothing suspicious in the water, but he convinced the village to abandon the pipeline and take its water from another nearby spring used by a family who had reared four children free of the dreaded brown stain. Within a couple of years, as younger Oakley children began sprouting their first adult teeth, they, too, were free from the stain.
That was enough to prove to McKay that water carried the culprit. McKay`s final breakthrough came in 1928, when he was called to Bauxite, Ark. Bauxite was a company town built in 1901 next to a bauxite ore mine owned by the Aluminum Company of America (ALCOA). In 1909 the community began to take its drinking water from a 297-foot deep well. Shortly thereafter, the children in Bauxite began developing teeth with deep chocolate-brown stains.
McKay visited Bauxite with a medical officer from the United States Public Health Service, and the two men coauthored a paper on their visit published in 1930. The paper mentioned in passing that standard water analysis of Bauxite water supplies threw ”little light whatever on the probable causal agent” of the staining.
The appearance of the paper deeply alarmed ALCOA. For several years the company had suffered from a whispering campaign charging that cooking with aluminum pots and pans caused diseases. Now McKay`s paper confirmed the existence of hideously stained teeth among children growing up in an ALCOA company town where aluminum ore was extracted. Publicity could only lend fodder to the campaign.
Early in 1931 ALCOA had a sample of Bauxite`s drinking water sent to its headquarters in New Kensington, Pa. By then a more sophisticated technology was available to detect trace elements in water samples–photospectrographic analysis. As luck would have it, ALCOA`s own laboratories had a device that could detect trace elements.
H.V. Churchill, ALCOA`s chief chemist, asked an assistant to assay Bauxite`s water. The assistant reported a high level of fluoride in the sample.
”Whoever heard of fluorides in water?” thundered Churchill. ”You have contaminated the specimen. Rush another specimen.”
The hapless assistant came back with the same results as the first test
–high fluoride content. Churchill was convinced that the entire water sample sent from Bauxite to the ALCOA headquarters had been accidentally contaminated, so he ordered another sample sent from Arkansas. When the second sample arrived and also showed a high fluoride content, Churchill changed his tune. ”Well then,” he concluded, ”I guess there must be fluoride in the water,” and he reported the findings to Frederick McKay in a letter written Jan. 20, 1931.
”We . . . have discovered the presence of hitherto unsuspected constituents in this water,” he wrote. He asked McKay to begin arranging for other water samples from other towns ”where the peculiar dental trouble has been experienced. . . We trust that we have awakened your interest in this subject and that we may cooperate in an attempt to discover what part
`fluorine` may play in the matter.”
Within a few months, the mystery that had so baffled McKay for 30 years was solved: Fluorine caused the stain. Fluorine is a gaseous element that exists in nature only in combination with other elements–as a ”fluoride”– and is found in rocks, sand and soil almost everywhere. When water from natural springs and watersheds flows through or over rocks and soil where fluorine is overly abundant, it may eventually show up in community water supplies in the form of fluoride ions. That is what had happened in Colorado Springs, Bauxite and all the other towns that McKay had visited where children suffered from the brown stain. This new knowledge galvanized the U.S. Public Health Service. It assigned a dentist from its San Francisco office to survey the nation and determine where the staining occurred so that it could be eliminated. The dentist was H. Trendley Dean.
In his travels Dean became increasingly intrigued by another of McKay`s earlier observations–that those people with the stain seemed to have fewer cavities than normal. Within a couple of years Dean, working at times with McKay, compared levels of fluoride in the cities he had surveyed and determined that drinking water containing one part fluoride per million did not cause staining. Dean turned to several Illinois communities that had naturally fluoridated water within the range of one part per million and began to study the incidence of cavities in children in those communities. First he studied Galesburg and Monmouth, where the water was naturally fluoridated, comparing them with Macomb and Quincy, which had no fluorides in their water. From the dental histories of 885 children in the four towns, he discovered that children in the unfluoridated communities had more than twice as many cavities.