The anti-fluoridation movement might explain in part the explosion in recent decades of single-issue political movements. Special-interest groups, small but highly organized around a single objective, have proven over and over that they can sway votes in local elections and affect legislation on both state and national levels. Groups that now lobby so effectively against gun control and abortion or for the right to pray in public schools, may well owe some of their success to the tactics of early anti-fluoridationists.
But closing dental schools, directly attributable to fluoride, also attests to the success of a new technology upon the ills of society. Though it serves roughly half the population of this country, fluoridation is so wildly successful that it is undermining the patient base of the entire dental industry.
New technology, once proven useful, spawns further technological development. That is simply part of the most basic evolution of civilization, a fact we may overlook in an age when we are awed by and sometimes fearful of the audacious changes that new technology brings to our society.
Fluoridation may be a new idea in public health policy. But public health policy itself is an old idea, as old as the ancient Roman aqueducts that still gracefully span parts of Europe. The aqueducts represent the first time the political will of any civilization committed manpower and tax money to improve the general welfare of all citizens. In that case it was to bring in fresh, pure water to the polluted, rapidly growing cities of the empire.
If fluoridation is a new dental technique that helps fight the ravages of modern diets on the human tooth, it is part of a technological revolution as old as civilization itself. Human remains dating back to prehistoric Egypt show very little evidence of dental disease.
When humans first began to gather into enclaves of villages and towns, division of labor was born. Not everyone had to hunt, gather or raise food for survival anymore. Some people, the earliest politicians, assumed godlike powers and called themselves pharaohs. Others became artisans to serve the pharaohs, fashioning their jewelry or building their temples. Inevitably, eating habits became refined, and diets changed. Bread was invented, for instance, baked from coarsely ground grains containing grit that lodged between the teeth.
Thus civilization brought something new and damaging to the human experience–tooth decay. The mummies of ancient Egypt are ample proof that those people suffered many of the same tooth problems we endure today. Their skulls are filled with evidence of cavities, periodontal disease and loose and missing teeth.
With the onset of tooth decay, the ancient Egyptians had to make adjustments in the way they lived. A plaque erected about 3000 B.C. by the pharaoh Zoser in honor of Hesi-Re, called him ”chief of the toothers,” the first recorded dentist in history. People began using the fibrous ends of pounded sticks, the forerunner of toothbrushes, to
remove the grit between their teeth. A 4,500-year-old mummified Egyptian skull is evidence of the first known dental bridge, in which two molars were bound together with a piece of gold wire. Scholars believe that one of the molars, loosened by periodontal disease, was strengthened by attaching it to a healthier tooth.
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In 1986 dentists similarly make adjustments to a world made far different –at least for them–by fluoridation. If fluoridation has been a cavity-reducing blessing to Americans, dentistry in the post-fluoridation era promises even more blessings.
In the next century most Americans routinely will go to their graves after a full life with their natural teeth. That was unheard of even 30 years ago, when most people expected to lose some teeth by age 35.
Anybody who has been to the dentist even once recently has heard ”the lecture” the dentist earnestly delivers at the end of every visit: ”The responsibility for keeping your teeth healthy is largely your own;
meticulously brush and floss daily and come back in six months.” One can almost hear Hesi-Re giving the pharoah Zoser similar instructions 5,000 years ago.
”There is no reason anymore for anybody to lose his teeth,” says Edgar Mitchell, secretary of the American Dental Association`s Council on Dental Therapeutics. ”We can pretty well guarantee right now that anybody can keep his own teeth all his life. We today have all the necessary techniques and know-how. All that we need are patients willing to follow carefully their dentists` instructions on dental care at home, interspersed with regular visits to a dental office for a routine exam and cleaning.”
The advice is good, but a surprising number of people never listen to it. There still is more dental disease in the U.S. than American dentists have time to treat if all the people suffering from the diseases would come in to see them. The American Dental Association is scrambling to attract the 50 percent of the population that doesn`t visit a dentist routinely.
Fluoride has worked in reducing cavities, but it can`t completely eliminate them, so there are a lot of people walking around with cavities and other dental diseases. For the last few years the ADA has allowed dentists to advertise and has launched its own series of public health advertising messages extolling the benefits of good dental care. For the patients who regularly come in to see them, dentists are pushing services other than tooth filling. It is no accident, for instance, that suddenly many Americans in their 30s and 40s are walking around with braces on their teeth. Dentists now have the time and impetus to work on other long-neglected dental problems, including crooked teeth. That is why more than 20 percent of the braces and retainers installed today are in adults, including such notables as TV interviewer Barbara Walters and Nancy Kissinger, wife of the former secretary of state.
Cosmetic dentistry has become one of the fastest-growing segments of the profession. Badly discolored, misshapen, chipped or gapped teeth can be repaired readily with new plastic materials applied to the teeth in a process called ”bonding.” The results are natural-looking teeth, giving many patients the sort of dazzling smiles they had only envied on models and movie stars.
Right now, however, the biggest concern in dentistry, both in treatment and in marketing, is periodontal disease, more commonly known as ”gum disease.” It affects more than 75 percent of all Americans over age 35 and is the chief reason for tooth loss after that age. Until fluoridation began showing spectacular success against cavities, dentists in general practice had little interest in gum disease.
Gum disease is largely hidden, a progressive infection working over a period of years out of sight below the gum lines, without noticeable pain. The infection comes from the film of bacterial plaque that forms on teeth. If not removed, the plaque can harden into a deposit called ”calculus” (tartar) on the tooth surface. The bacteria in the plaque slowly attack the gums and jawbone which support the teeth, eventually destroying them. Because of its insidious nature, periodontitis often is not self-diagnosed until it is too late to save the victim`s teeth.
The only proven preventive for periodontitis is regular toothbrushing and flossing and periodic visits to a dentist for thorough cleaning. Unfortunately, dentists in general practice until recently took so little notice of periodontal disease that in many cases they were perplexed to see long-term patients lose otherwise healthy teeth to the disease. Indeed, in a 1972 study on awareness of periodontitis, a researcher discovered that the dentists in the study had worse records of plaque control on their own teeth than their patients. Around 1980 public awareness began to focus on gum disease as the country`s most serious dental problem. That led to lawsuits. Patients who had seen the same dentist for 10, 20 years or longer became enraged when their teeth fell out without warning because of periodontitis. Some dentists who could not prove through their records that they had diagnosed the disease and referred the patients to periodontal specialists were assessed judgments of $20,000 or more.
Understandably, dental schools now spend a great deal of time teaching about periodontal disease, stressing diagnosis and control in its initial stages. Periodontal disease and America`s aging population would seem to fairly describe the future of dentistry in this country. The general population is getting older, and people are keeping their teeth longer, so it would seem natural that treating periodontal disease would become a major part of future dental practice. Ironically, a new technology seems on the verge of attacking periodontal disease, if not as effectively as fluoridation has fought cavities, enough to erode dental business even further.
In 1947 Imperial Chemical Industries of England was looking for an antimalarial agent. Among the materials the company`s chemists looked at was a substance called ”chlorhexidine.” Though the substance had absolutely no useful properties for fighting malaria, one of the scientists noticed that it did have wonderful antibacterial properties. Because it also had a very low toxicity, it was soon developed for several products, including a lotion for burn patients, eyedrops and a surgical scrub soap, Hibiclens.
In 1967 a dental researcher in Norway, Dr. Harald Loe, was studying periodontal disease and looking for antibacterial agents that could effectively fight plaque. He and his colleagues came upon chlorhexidine, which they began experimenting with as the active component in a mouthwash.
Used twice daily, the chlorhexidine mouthwash, they discovered, totally inhibited the formation of new plaque on teeth. It wasn`t long before European drug companies were marketing it over the counter, a practice that has continued for 17 years.
Because of the differences between American and European testing and marketing of new drugs, chlorhexidine has long been ignored in the U.S. as a plaque-fighter. In Europe, new drugs often are developed and tested in a university setting before it is known if a market exists for them.
In America drug development is much more market-driven, research often being directed at new products only after their potential markets are determined.
In the U.S. there was not much concern about periodontal disease until the last few years. Now that there is a lot of concern, it is safe to assume that the many American dental-products manufacturers are doing their homework on chlorhexidine, though most company officials are highly secretive on the subject.
There is another important difference between the American and European way of doing business. The American government is far more cautious in permitting a drug to pass from the experimental stage to the marketplace. The federal Food and Drug Administration has, at least on paper, the most stringent requirements in the world for allowing a new drug to be tested on humans.
Once it gives permission for human testing, the FDA has extremely rigorous rules for multiple independent studies over a long period to make sure the drug is safe for general use. Its stringency seems a cumbersome obstacle at times, but the system has worked well in stopping some potentially dangerous products from reaching the American market. Most notably, it would not allow Thalidomide on the market in the 1950s, though it had already been developed and sold widely in Europe, thus sparing the U.S. from that tragedy. Even so, there have been prominent failures in the system, such as toxic shock syndrome, which resulted from the use of FDA-approved tampon products.
Nobody knows much about the effects of chlorhexidine on periodontal disease in Europe, even though it has been available as a nonprescription treatment for nearly two decades. Because it is a nonprescription product, there is no reliable way to know who uses it and what its effect has been. And unlike their U.S. counterparts, European drug companies do not readily publicize how much of the market share their products command, so it is difficult to tell even how much chlorhexidine mouthwash is sold there. Likewise, no statistics are available on the number of people with periodontal disease.
In the U.S. one company seems to be slightly ahead of its competitors in developing chlorhexidine. Early this year Procter & Gamble Co. of Cincinnati published results of extensive tests it has done on humans under FDA monitoring, using a chlorhexidine mouthwash. Their results showed that the mouthwash caused significant reductions in plaque accumulation on teeth and a reduction in gum infection of 45 to 61 percent.
Obviously Procter & Gamble is looking at chlorhexidine
mouthwash as a possible new product, though the company refuses to discuss its plans. Industry insiders believe that the FDA is on the verge of approving a chlorhexidine mouthwash for general consumption and that it will be placed on the market before the end of the year but probably only as a prescription drug.
Whether chlorhexidine mouthwash comes into the American marketplace, nobody, including Dr. Harald Loe, the scientist who pioneered studies of it for dental use, thinks it is capable of wiping out periodontal disease. Some years ago Loe emigrated to America from Norway. He is now head of the National Institute of Dental Research in Washington, D.C., a position first held by H. Trendley Dean when the institute was created in 1948.
”Periodontal disease is a quiet, insidious disease that doesn`t get much attention until it is in a very advanced state in the patient,” Loe says. ”A chlorhexidine mouthwash treatment will not be of any use treating the disease when it is at the advanced stage because the disease by then is in deep pockets beneath the gum lines, where the mouthwash could not reach it. ”But chlorhexidine does seem to be a wonderful weapon in the arsenal to stop periodontal disease at its initial stages, before it gets too serious. It does that by eliminating plaque before it builds up, before the gums become swollen and begin bleeding. Used properly under supervision of a dentist, it promises to be a wonderful preventive measure.”
Loe says he believes that if the FDA approves chlorhexidine for general use, it should be only by prescription. It is a drug, he says, with two slight drawbacks. One is a foul taste, which presumably would be masked by other flavorings. The other is a slight tooth staining that occurs among 15 percent of the people who use it; the stains can be removed by a dentist. Because it probably will be used as a limited treatment under controlled conditions, chlorhexidine wouldn`t have nearly the impact on periodontal disease as fluorides have had on cavities.
”The beauty of fluoridation,” Loe says, ”is that it is administered passively. Every time you open the tap water at home, you are receiving the benefit of fluoridation. The success of a chlorhexidine mouthwash would depend on the patient getting to a dentist to get a prescription and then making a conscious effort to use it according to a prescription.”
Even as Procter & Gamble and other companies investigate chlorhexidine and other microbicides to combat periodontal disease, other researchers are looking for even bigger guns that would really knock out the disease once and for all. Already scientists are studying successful nonsurgical treatments for advanced cases of the disease that stop its damage to roots of teeth and the jawbone. One promising treatment is in the human-testing stage at Boston`s Forsyth Dental Center. Researchers there are placing strings impregnated with the antibiotic tetracycline under the patients` gumlines to kill off the destructive periodontal bacteria. Other researchers are experimenting with placing nonharmful ”protective” bacteria under the gumlines that would outnumber and replace the destructive strains of bacteria. If successful, the treatments promise to eliminate another large segment of dentists` work.
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In fact, much dental research today centers on new technologies and medications that would diminish the caseloads of individual dentists even further. One of the more astonishing experiments is a 10-year study at the University of Connecticut of the ”glue” produced naturally by sea mussels. Dr. J. Herbert Waite has been able to re-create artificially the sticky substance with which barnacles attach themselves to underwater structures.
His glue can be applied either in or out of water and adheres to any surface, including rocks, metal, glass and wood. Because it works in a wet saline solution, it promises enormous benefits for dentistry, in which it could be used as tooth filling, as a permanent sealant or for bonding gums to teeth in battling periodontal disease. The research, funded by the NIDR, is also attracting attention in medicine and other fields, particularly from the U.S. Navy, which is exploring its use for repairing ship hulls underwater instead of dry-docking them.
Other researchers appear close to a lifetime vaccine against cavities. Such a vaccine, made of protein produced by bacteria that cause tooth decay, has already been tested successfully on rats, hamsters and monkeys, and human testing has begun. If it works and isn`t harmful, it probably will eliminate the need for fluoridation.
Given so much research aimed at eliminating the need for dentists, it would seem that dentistry is an endangered profession, bound for the ash heap of history like buggy-whipmaking. That does not seem likely, however. ”There will always be a need for dentists,” says Loe, ”but we all agree there will be less need for so many dentists in the future. There is a gradual decline in need for complicated dental work as we make new technological advances. To keep up with it all, the scope of emphasis in dentistry is changing, and most dental schools are shifting and adjusting emphasis on what they teach and why.”
There is a problem, however, with packing new knowledge into the standard four-year dental-school curriculum. Because of all the new technology and techniques, many dental schools are considering expanding their programs from four to five years, as Harvard University already has done. Adding a fifth year may eventually discourage even more prospective dental students from entering the profession. Going to dental school is an expensive proposition, often costing $15,000 a year or more. To graduate, students must perform actual work on patients in university clinics, and they don`t get credit until their patients pay for the work. (Payment is required because schools, though they charge less for dental services, do not wish to drain too many patients from practicing dentists.) If the patients can`t pay (many patients at university clinics are indigent and are reimbursed only partially by the government for dental procedures), many students say they find themselves borrowing money to pay the fees themselves to earn the necessary credits, though administrators discourage the practice. The average graduating dental student leaves school $40,000 to $50,000 in debt.
The schools in recent years have added course work in treating periodontal disease and elderly patients, for example, without cutting back on course work already in the curriculum. Much of the older standard dental curricula is outdated, students argue, such as learning Greene Vardiman Black`s classic century-old procedure for installing gold foil fillings, rarely used in actual practice today.
”When a dental student graduates,” says Norman Olson, dean of the Northwestern University Dental School, ”we have to guarantee he is a finished product. Our student must learn by doing the actual work in a clinical setting (so that he is) ready after graduation and passing his boards to go out and start practice immediately. A medical student is educated in a hospital environment. After he graduates and passes his boards, he still has to go into residency under the tutelage of experienced physicians for four or five years before he can set up a practice of his own. The dental schools keep adding new techniques but are reluctant to take out any of the older ones, for pretty good reasons. The gold-foil technique is a perfect example. Dentists have to be people with extraordinary manual dexterity to be able to work with exact precision in very small places, and the gold foil technique is probably still the best way we have of testing and training an individual`s dexterity. Our classes may be smaller now than a few years ago, but we cannot afford to compromise our exacting standards.”
Class sizes of first-year students at the three dental schools in Chicago reflect the waning interest in dentistry as a profession. At Northwestern University the first-year classes have dropped from 120 students in the 1970s to 90. At Loyola University and the University of Illinois at Chicago, they have dropped respectively from 145 to 125 and from 165 to 135.
Dr. Aidan Stephens, dean of the Loyola School of Dentistry, says newly graduated dentists still can look forward to lucrative practices, though perhaps not as wildly expansive as they were 20 years ago. ”Dentistry in the 1960s and 1970s was the golden age,” he says. ”It seemed like you couldn`t fail to be very successful because of the huge demand for dental care in those days due to caries (cavities). Dentists from those days now feel things are difficult because they have fewer patients, even though they continue to make quite a good living by most anybody`s standards. New dentists do quite well, too, though now they probably have to choose the area where they are going to practice quite carefully and perhaps work some odd hours, such as a couple of evenings a week, to suit their patients.”
Indeed, the average income of dentists continues to rise, though not as fast as a decade ago. Nationally, the take-home income of dentists rose from $61,200 in 1983 to $65,460 in 1984. That fact, in itself, seems to be a continuing lure for prospective dental students. ”It might take a little longer to get a practice established to compete effectively with senior dentists than it did a few years ago,” says a student graduating from the University of Illinois College of Dentistry this year. ”But eventually we`ll be the senior dentists, and there will always be a lot of work to perform. I`m banking on two things. First, because people are living longer and keeping their own teeth longer, there are going to be more cavities and more periodontal disease to treat in older people. Second, I`m hoping there`s going to be more cosmetic work to be done as people become more aware of dental health.”