Today's Dentistry: a New Drill

By Claudia Wallis

The ad was a classic of the late '50s: a child runs across a suburban lawn, arms outspread, beaming broadly and shouting, "Look, Mom--no cavities!" That sales pitch, offered when fluoridated toothpastes were introduced, hardly seemed credible. Few American children, nurtured as they were (and still are) on candy bars and other sweets, returned from a dental checkup in triumph. In fact, it was not unusual for a child to have five, six or seven cavities at a time, and just as many the following year. Tooth decay was a perennial national problem that meant a mouthful of silver for patients, and for dentists a pocketful of gold.

No more. Today studies by the National Institute of Dental Research indicate that nearly 40% of children between the ages of five and 17 have nary a cavity. While many medical specialties have promoted the idea of preventive medicine, dentistry, more than any other, has put its money where its mouth is. The results have been astounding. Over the past two decades, the widespread use of fluoridated drinking water and toothpastes, along with improved dental care, has produced a 50% drop in the incidence of tooth decay. A further drop is imminent because of the growing use of sealants, protective resins painted on the biting surfaces of back teeth. According to the American Dental Association (A.D.A.), which recommends sealants for all children, they should virtually eliminate childhood tooth decay.

But good dentistry has not necessarily been good for dentists. As they lose their bread-and-butter work, filling cavities, the nation's 127,000 dentists are scrambling to fill the gaps in their practices. Some fear that they may be going the way of the blacksmith. Says Dr. Ted Gordon, 62, who has been practicing in Chicago for nearly 40 years: "We're one of the few professions in history that has done everything in its power to put itself out of business." Dental schools, which were expanding until the mid-1970s, are now cutting enrollments. Total enrollment is down 20% since 1978, the equivalent of closing twelve dental schools. American dentists, once confident of a comfortable income, are feeling the pinch. As practices dwindle, costs of equipment and office space continue to rise. The lack of business is "depressing," says Dr. Henry Ramsey, 50, of Manhattan. "You talk to other dentists, and they're wringing their hands," he says. "Much as I love this work, I wouldn't go into it again. I really don't see how young people can make it in this business. It has to be hell."

The financial squeeze begins when the average dental student graduates with a debt of $28,000, according to the American Association of Dental Schools. A solo practice is out of the question for most, with start-up costs ranging up to $150,000. And while young dentists used to be able to join the practices of older professionals, today established dentists often do not have enough work to justify taking on a protege. Some graduates find themselves settling for part-time work or relatively low-paying jobs at walk-in clinics in shopping centers and department stores. Several, like Dr. Richard Stein, 32, of Santa Barbara, Calif., resort to moonlighting. For the first two years after graduating from the UCLA School of Dentistry, the 6-ft. 4-in. Stein worked weekends making promotional appearances dressed as Star Wars Archvillain Darth Vader. "I was working just one day a week as a dentist," he recalls. "Old Darth definitely saved my hide."

Despite the difficulties, dentists are not about to hang up their drills and call it quits. Instead, onetime tooth fillers are bolstering their practices with new services. Many general practitioners who once referred patients to specialists for oral surgery or root-canal work are now performing these procedures themselves. Others are diagnosing and treating the early stages of oral cancer and the various stress- or bite-related jaw pains known collectively as TMJ (temporomandibular joint syndrome). Several are offering nutritional counseling. Dental schools are expanding their curriculums to include these areas and other aspects of oral health. "The scope of general dentistry is growing," says Dr. Harold Loe, who runs the National Institute of Dental Research (NIDR) in Bethesda, Md. Instead of being a tooth specialist, he observes, the dentist is rapidly becoming "the physician of the mouth."

These new services are augmented by more sophisticated and aggressive marketing. Dentists hope not only to keep regular patients coming back but also to attract the elusive 50% of Americans who, according to the A.D.A., do not have their teeth cared for regularly. New low-cost, high-volume clinics in shopping malls are catering to lower-income patients who might otherwise see a dentist only in an emergency. Dentists are turning to advertising in newspapers and the Yellow Pages, promising such attractions as "gentle anesthetics," "artistic" cosmetic treatment, 24-hr. service and "friendly staff."

There is a new stress on "internal marketing," which involves creating a pleasant atmosphere to dispel the old image of the dentist as torturer. Offices are decorated in soothing pastels; intimidating, heavy metal dental chairs have been replaced with comfortable lounges. To distract patients, some dentists offer stereo headphones and even videotapes.

Beyond amenities, dentists have made their ministrations less painful. Modern drills revolve 450,000 times a minute, thousands of times as fast as those used 30 years ago. Thus, they are less likely to jar the nerves. Anesthetics are longer-lasting and more precise, delivering local relief without numbing the entire mouth.

Ultimately, the dentist's principal instrument of agony, the drill, may be used less often because of a substance called Caridex 100, developed at Tufts University in Medford, Mass. Caridex, which is gradually being introduced around the country, is an amino-acid solution that dissolves tooth decay, leaving behind a clean, sturdy area that can be filled with little or no drilling. However, the method is not suitable for all cavities.

Dentists are also profiting from America's enthusiasm for self-improvement: apparently, more people want perfect smiles to go with their Nautilus-toned bodies. In New York City, Dr. Barry Bloom has seen cosmetic dentistry rise to account for more than 70% of his practice. "It used to be only theater types coming in," he says. "Now it's secretaries, businessmen, accountants, policemen." Patients can choose from a variety of cosmetic procedures that include bleaching, which offers a temporary lightening of tooth stains, and the application of veneers, thin porcelain or acrylic facades that have been likened to false fingernails.

By far the most popular cosmetic technique is bonding, in which plastic resins are applied directly to the surface of teeth to mask chips, discolorations and cracks, or even to conceal unattractive gaps between teeth. The procedure is simple, and can be performed by almost any dentist. The resins are painted on teeth that have first been prepared by the application of a mild acid solution. Next a layer of tooth-colored material is applied in the desired shape, then the coatings are hardened with either chemicals or a beam of ultraviolet light and polished. Bonding costs anywhere from $150 to $500 a tooth, one-third to one-half the price of crowns or caps, and can usually be performed without pain or the need to file down teeth. While bonding now lasts only five to seven years before it needs to be redone, the resins are continually being improved. Some are already so durable that dentists use them instead of silver amalgam for fillings in the front teeth.

For those who seek more extensive smile repair or who risk losing their teeth because of overcrowding or bite problems, orthodontics offers a range of alternatives. Clear plastic braces, available for the past ten years, have made orthodontics more palatable to adults, who now account for 20% of the braces business. "Invisible," or lingual, braces, which are applied to the backs of teeth, are even less conspicuous, though some users complain of tongue irritation and mild speech problems.

As the population ages and more people keep their own teeth, periodontics, the specialty that deals with the treatment of gum disease, has become a large portion of the dentist's trade. More than 70% of tooth loss among adults is due to gum disease, which typically remains symptomless until it is well advanced. Says Dr. John Karch of Atlanta: "It is second only to the common cold" in the number of people affected. Gum disease is caused by bacteria that produce a colorless, sticky film called plaque, which, if left undisturbed by a toothbrush or dental floss, leaves a hard residue known as tartar. As plaque accumulates along the gum line, pockets of inflammation form, which eventually loosen teeth and wear away the underlying bone.

The traditional treatment for advanced gum disease is oral surgery, in which the pockets are opened, scraped and drained. Some dentists believe that mild cases can be managed (after tartar deposits and plaque have been removed) with daily home applications of a simple paste made of hydrogen peroxide and baking soda, followed by a rinse of salt water. However, the method is controversial and the A.D.A. questions its effectiveness. Procter & Gamble, Colgate-Palmolive and other companies have joined the battle against gum disease by introducing antiplaque, antitartar toothpastes and rinses. Dentists are divided on how well they work. Says Erwin Barrington, immediate past president of the American Academy of Periodontology: No toothpaste can make much of a difference so long as "people don't like to brush and floss regularly."

Eventually, both plaque and cavities may be prevented by vaccines. Researchers at the NIDR and several universities are developing anticavity vaccines directed against Streptococcus mutans, the bacterium primarily responsible for tooth decay. Because cavities are already disappearing in the U.S., such vaccines may prove more useful in developing countries, notably in Latin America and Africa, where sugary processed foods are increasingly prevalent.

For adults who lose their teeth to gum disease or other problems, modern dentistry offers an alternative to dentures: permanent dental implants. These are artificial teeth, complete sets or small bridges, which are surgically affixed to the jaw bone either by metal frames that grip the bone or by screws or other mechanical means. Though available for more than 30 years, early models tended to loosen easily and caused infections. Many of these problems have now been solved. "Today the debate is not whether the implants work, but which systems are the best," says Leonard Shulman of Boston's Forsyth Dental Center, a leading research institution.

Dentists say that the 23 million Americans who require false teeth of any sort are a vanishing breed. High-speed drills have made root-canal work, the replacement of the inner pulp of a diseased tooth with a rubbery substitute, far easier and less painful. This and other new techniques are enabling dentists to salvage even badly damaged teeth. "Ultimately," says Loe of the NIDR, "we look forward to a time when not just young people but the middle- aged and elderly need never lose a tooth to disease and when the practice of dentistry is largely one of prevention." That glass on the bathroom shelf containing Grandma's teeth may soon be a relic of another age.

With reporting by Kenneth W. Banta/New York, with other bureaus