Contributor: Harris Contos, DDS, WG’80
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The “Open Wide” column went on hiatus about two years ago because I felt that all that could be said about the dental care industry in this country had been said: that it was a small planet far off, and spinning ever further far off, in the healthcare universe, complacently operating undisturbed according to its own rules; that despite gross inefficiencies and disparities in cost control, access, quality, and treatment outcomes, it adhered to a procedure- and technology-focused form of treatment, provided almost exclusively by a dentist, along the terms and conditions of the erstwhile “gold standard” of business models in healthcare, the private, solo, fee-for-service practice. Health policy makers in general didn’t care about the comparatively trifling and frankly quite boring issue of dental care (at $150 billion per year, only about 5% of national health expenditures), and purported dental health policy makers lacked fluency, familiarity, experience, and even interest in the conceptual, organizational, financial, and managerial precepts and initiatives to achieve “value over volume” under health reform. Most tellingly, those shortcomings, even derelictions, about being so disconnected from wider healthcare developments, have amounted to the embarrassing indictment that the dental care industry doesn’t know how to prevent what is often considered a completely preventable disease, that it is content to regard dental disease as inevitable, and organizes itself to profit therefrom. And that is where matters were left to stand.
The interregnum between the last “Open Wide” entry and the present one has not been an idle, however. My observations and comments on the dental care industry have resonated with a few others in the profession, similarly disaffected by the “drill, fill, and bill” doctrine, to the point where I was asked to write the policy chapter for an upcoming book on a wholly new approach – from basic science principles to dental education and training to new dental care delivery models – to addressing the disease of tooth decay. [The book, to be published in October, is titled SMART Oral Health [“SMART” being an acronym for a rather cumbersome term “silver-modified atraumatic restorative technique,” the explanation of which is best kept for another time.] Matters stand differently now – tooth decay and its sequelae (costly treatments like crowns, “root canals,” implants; unnecessary and risky sedation or anesthesia; and serious infection and death resulting from that) can indeed move into the realm of being truly prevented, with the control, reduction, and conceivably even the eradication of tooth decay within a population being possible. The cost for doing so will entail a complete reallocation of the $150 billion spent annually on dental care in this country, the bulk of which goes for reparative and restorative procedures, not prevention; it also means the end of the dental care industry as it has familiarly been known.
First, a bit of history on the disease of tooth decay, which some may find interesting, and then some background on dentistry itself, which fewer might find interesting, but won’t be too long or numbing (ha-ha) and might be worth keeping in mind when dentistry as we have come to know it is compared and contrasted with the way it can be reconfigured to be far more efficient, effective, and equitable lines.
DENTISTRY “BACK THEN”
The dawn of agriculture some 15,000 years ago not only brought generally stable and predictable food supplies to the world’s population, but also tooth decay, a scourge of humankind ever since as a result of inclusion of plentiful carbohydrates into the human diet, which were acted upon by oral bacteria to produce decay-causing acids leading to demineralization of tooth enamel. Today tooth decay is the most common chronic illness of childhood throughout the world, with 60-90% of children, and the majority of adults in most industrialized nations, affected by the disease. The dietary consequences on the extent and severity of the disease have been exacerbated in modern times with the industrialization and commercialization of processed foods involving copious amounts of sugars, e.g., high-fructose corn syrup in inexpensive “super-sized” soft drinks.
As with much else in medicine, knowledge of the causes and treatment of tooth decay over time has entailed folklore (“tooth worms” being an example), conjecture, superstition, and serendipity in the absence of scientific understanding. Treatment eventually centered upon a “surgical” approach, initially the extraction of the diseased tooth practiced centuries – even millennia – ago, to the more recent and commonly accepted drilling away of affected tooth structure, followed by filling or refashioning what remained of the tooth with various materials, from about the mid-17th century to the present day. [The approach is understandable, from the standpoint that teeth are the only visible hard tissue structures of the human body, not counting finger- and toenails, and decayed teeth are readily identifiable as the source of pain, with no recourse to relieve the pain other than extraction or some conjured up medicament to apply, such as an ointment of roasted earthworms, crushed eggs of spiders, and spikenard, a fragrant herb. This would be in contrast to the treatment of a soft tissue cut or laceration, where essentially the body’s self-healing properties worked its wonders over time, assuming no infection, of course.] As little could be done about preventing decay, the “dental arts” centered upon reconstruction and cosmetic efforts to compensate for lost tooth structure. While acids produced by bacteria were first recognized as a cause of decay at approximately the same time, significantly effective prevention did not come about until the advent of community water fluoridation and fluoridated toothpastes in the mid-20th century. That, and the admonition to “see your dentist twice a year,” essentially constituted preventive dentistry to this day.
Modern dentistry remains a descendant of the 17th century. On the clinical level, while it has seen advances in materials, procedures, techniques, and armamentaria, they have been in support of the “surgical” drilling and filling of teeth, essentially the debridement of hard tissue, after the disease has set in, comparatively scarce resources are allocated to prevention (Note: the definition of “debridement” is “the usually surgical removal of lacerated, devitalized, or contaminated tissue,” as such the surgical drilling of teeth would be analogous to removal of part of a lung to treat pneumonia). On the organizational level, for many and various reasons, dentistry has historically been apart from medicine, with a notable schism or failure to integrate the two coming about in the mid-19th century with the founding of the Baltimore College of Dental Surgery, the first dental school in the United States established to professionalize the discipline through a degree-conferring curriculum (the DDS, doctor of dental surgery) and remove the practice of dentistry from non-professionals such as barbers, who since medieval times were the traditional dental practitioners (hence the red and white barber’s pole). The Baltimore College of Dental Surgery was a separate school, not a part of an existing medical school, as medicine wouldn’t deign to put the mouth on a par with the rest of the body. The first university-affiliated dental institution, The Harvard University Dental School, was founded in 1867, but again not a part of the Harvard Medical School. Interestingly, dentistry has mimicked medicine in its hierarchical arrangement of providers, the proliferation of specialties, and the pursuit of more sophisticated technology for the treatment of disease.
Apart from what this says about the integration and comprehensiveness of care – two parallel universes that essentially do not interact with one another – medicine has had to undergo changes in organization, financing, and management of care so as to meet policy demands for cost control, access, quality, and, to a lesser degree, effectiveness. Dentistry, seen as being on a discretionary and cosmetic fringe, with little bearing on overall health or quality of life and resorted to mostly as a result of perceived failed personal behavior in taking care of one’s dental health, has been only marginally involved in those policy issues. It remains largely a private, solo, fee-for-service cottage industry, oriented toward the volume and intricacy of the specialized restorative procedures refined over the centuries it offers, and using that as a proxy for quality of care and dental health status. The shininess of the gold crown or the natural appearance of the ceramic veneer is looked upon as an indicator of quality care and good dental health, rather than the expensive failure to intercept disease early on. With this as an implicit summation of dental care in the United States, it is no wonder it is little involved in and remains unaware and unresponsive to developments arising from health reform.
Thus ends Part 1 of this revisiting of “Open Wide” with a recapitulation of where things left off, of why dentistry is where it is today in the healthcare cosmos. Part 2 will pick up with a reexamination of the scientific basis for the present-day practice of dentistry, the latest understanding of the causes, treatment, and prevention of tooth decay is – essentially, we’ve been practicing dentistry the wrong way for the past 400 years – and what this then means for developing a more responsive, flexible, effective, and integrated dental care system, not only attuned to the imperatives of health reform, but also consigning one of humanity’s scourges to the dust bin. Please stay tuned.
Contact Harris at: email@example.com