1 The Professions of Dentistry and Dental Hygiene
Dental practice has existed in some form since the dawn of time, but it is only in comparatively recent years that its practitioners in the economically developed nations have achieved the status of a profession. In most of the low-income world, dental practice is still more of a craft. In countries with a moderate level of economic development, dentistry exhibits some aspects of a profession, but not all.
Webster’s dictionary defines a profession as “a calling requiring specialized knowledge and often long and intensive academic preparation” and “the whole body of persons engaged in a calling.” The definition of professionalism is “the conduct, aims, or qualities that characterize or mark a profession or professional person.” These terse dictionary definitions, however, do not fully capture the essence of a profession or of professionalism: commitment to patient welfare, ethics, and other professional ideals are not included. Nor are all aspects of professionalism necessarily high-minded or noble. Admission to some professional groups can be based on self-perpetuation rather than public good, and aspects of “closed shop” practices in professions have not been uncommon.30
Three models of professionalism have been described,25 none of which by itself fully characterizes dentistry, although collectively they may do so. The first is the commercial model, in which dental care is viewed as a commodity sold by the practitioner. The services are thus not based primarily on the client’s needs, but rather on what the client is able or willing to buy. This rather crass view is distasteful to many, although there are aspects of it in dental practice. The second is the guild model, in which dental care is seen as a privilege with the professional dominant in practitioner-patient relations. In the guild model the professional is the repository of all knowledge and wisdom, the patient is a passive recipient, and the practitioner has an ethical trust to provide the best-quality care. This model has probably been dominant in the United States, although it may be slowly merging with the third model, the interactive model, in which dental care is considered a partnership of equals. In this model, practitioner and patient jointly determine care provided through a combination of professional expertise and patient values.
What are the criteria that characterize a profession, and how can a profession be distinguished from, say, a trade union? The first is the criterion given in the dictionary definition, a substantial body of knowledge, a corollary of which is the obligation to keep that knowledge up to date through continuing education. The second is self-regulation, a tradition whereby society delegates to professional groups the legal responsibility for determining who shall join them in serving the public and for disciplining those members who do not meet the profession’s requirements. A third and perhaps the main distinguishing criterion of a profession is a code of ethics, guidelines for professional conduct that are rooted in a moral imperative rather than in law or regulation (see Chapter 3). A profession sets its own code of ethics and its own procedures for dealing with infringements. Taking the various criteria mentioned, one can distinguish a profession by the features listed in Box 1-1.
BOX 1-1 Characteristics of a Profession
A health profession can then be defined by paraphrasing Webster’s definition given earlier: a calling in the health sciences requiring specialized knowledge, and one that meets the other criteria listed. Dentistry meets all the requirements of a profession. Dental hygiene is usually considered a profession within dentistry, although for the most part it is not self-regulating.
Dental diseases have afflicted the human race since the dawn of recorded history.22,29 Dentistry, however, has existed as a vocation only in recent years, historically speaking, and it was not until modern times that any sort of scientific basis was developed for the care of oral diseases. One landmark event was the 1728 publication of Pierre Fauchard, Le Chirurgien Dentiste, ou Traite des Dents, a two-volume book of more than 800 pages. Fauchard, a Frenchman, is looked upon as a seminal figure in the evolution of the dental profession. His work was the first complete treatise on dentistry published in the Western world, and it remained an authoritative document for over 100 years. Fauchard, despite the lack of formal training, was clearly a first-class empiricist with keen powers of observation.
Aspiring dentists of the time served as apprentices. It is worth noting that even the formal education of G. V. Black, one of the profession’s most notable nineteenth-century pioneers, did not exceed 20 months. His introduction to dentistry consisted of “a few weeks” with one Dr. Speers, who was not considered a particularly good dentist and whose dental library consisted of one book.9 Fortunately, Dr. Black was a true professional and followed the precept that “a professional person has no choice other than to be a continuous student.”
The first American dental school was the Baltimore College of Dental Surgery, later part of the University of Maryland, established in 1840. The course was 16 weeks in length after a year or more of apprenticeship. The initial enrollment was five, of whom two graduated. At about the same time, the first national professional dental journal appeared, the American Journal of Dental Science, and the first national dental organization, the American Society of Dental Surgeons, was established. The genesis of the dental profession in the United States can thus be dated fairly precisely to the 1840 period. The path of professional progress was not entirely smooth, however, for the emergence of dentistry as a fledgling profession was followed by an undignified scramble to open proprietary dental schools. In the best American traditions of free enterprise and entrepreneurship, most of these places were run strictly for profit. In the years before public and professional regulation, the proprietary schools turned out thousands of graduates whose professional abilities covered the spectrum from respectable to dreadful.
The anarchic events of the time, however, led to dentistry’s development in the United States as a profession separate from medicine, a position that has been maintained to the present day. This separate development actually occurred more by chance than by deliberate policy, for it was originally intended that the Baltimore dental school be established within the medical school. It was not, but only because of lack of space and internal friction among medical school faculty. The separation of dentistry from medicine was standard in the English-speaking world, Scandinavia, and some other European countries, but in central and southern Europe, by contrast, there was a division between stomatologists (physicians with specialty training in clinical dentistry) and dentists, who in this context were second-level providers. This division of labor is thought not to have benefited oral health in most of the countries concerned13 and has been abandoned in most of them as the European Community moves toward standardization of professional training. On the other hand, whether American dentistry benefited from its evolution on a branch that grew out of the main medical trunk, rather than being more closely allied to medicine during its formative years, can be debated. By the early twenty-first century, there were signs that dentistry might be evolving into something closer to the medical model.
The era of modern dentistry could be said to date from the closing of the last proprietary school in 1929, which came shortly after the landmark Gies report on dental education. Gies collected information from the dental schools of the time and concluded that the dental profession would only progress when dental education became university based and subject to the maintenance of high standards through accreditation. Despite the adoption of Gies’s recommendations, however, dental practice during the economic depression of the 1930s was largely a matter of survival, with few patients able to afford dental care. World War II followed, during which dentists, along with other health professionals, were drafted into the armed forces. As part of the national mobilization for the war effort, American dental schools compressed the curriculum of four academic years into three calendar years. This expedient was dropped when the war ended in 1945, although it was flirted with again for a short time in the 1970s.
The 1930s and 1940s were a hard time for dental education. The teaching of basic science was often perfunctory and the emphasis in the clinical sciences was almost entirely on restorative dentistry and prosthetics. Subjects such as radiology, oral diagnosis, endodontics, periodontics, and pediatric dentistry were neglected in many dental schools, and full-time faculty were the exception rather than the rule. There were few educational programs for the preparation of specialists, and the few that did exist varied in quality and length.20 One of the few bright spots during this difficult period was the beginning of the first controlled water fluoridation projects in 1945 (see Chapter 25).
With a rapidly expanding postwar economy and population, added to accelerating technologic growth and a spirit of optimism, dentistry entered what some saw as a golden age during the 1950s. New dental materials expanded treatment horizons, and the arrival of the high-speed air-turbine engine in 1957 revolutionized dental practice. Dental research, stimulated by the establishment of the National Institute of Dental Research (now the National Institute of Dental and Craniofacial Research) in 1948, grew rapidly, and the publication of The Survey of Dentistry in 196118 led to improvements in education and practice. Stagnating dental schools were revitalized with the passage of the Health Professions Educational Assistance Act in 1963. This act authorized federal funds for construction and student aid. Later renewals in 1971 and 1976 included per capita funding to support the basic instructional program. In the 15 years from 1963 to 1978, the addition of federal monies to state, local, and private sources spurred the reconstruction of the entire physical plant of dental education.16 New schools were built too; the 39 dental schools in 1930 had increased to 59 by 1980.1
The 1960s and 1970s saw the emergence of comprehensive care, growth in use of auxiliaries, the beginnings of prepaid dental insurance, and the development of a community outlook in dentistry. Growth in the number of dentists and in dental business was sharp, in retrospect perhaps too sharp. The economic downturn following the Vietnam War (1964–75), added to the decline in dental caries among children (see Chapter 20), led to a growing perception of an oversupply of dentists, despite increasing public utilization of services (see Chapter 2) and continued growth of dental insurance (see Chapter 7). During the 1980s, enrollment in dental schools dropped substantially from its peak during 1977–79 and rose only a little from these levels through the mid-1990s (see Chapter 8). In response, seven dental schools closed during this period (Emory, Fairleigh Dickinson, Georgetown, Loyola of Chicago, Northwestern, Oral Roberts, Washington University). Applications to dental schools picked up again in the late 1990s, and new dental schools opened in Arizona, Florida, and Nevada. In the early twenty-first century there were 56 dental schools in the United States.6
In the new century, the major oral diseases are better controlled than ever, and dental practice will evolve accordingly. Research in molecular biology is promising a new understanding of many diseases, including those oral diseases that currently are poorly understood and that to date have not been treated in dental practice. Other features that will shape dental practice in the new century are the changing demographic profile (see Chapter 2), disease patterns (see Chapters 19–23 Chapter 19Chapter 20Chapter 21Chapter 22Chapter 23), developments in dental insurance (see Chapter 7), and new restorative materials. Infection-control procedures and their associated regulations had become standard practice by the 1990s (see Chapter 10).
Dr. Alfred Fones, an 1890 graduate of the New York College of Dentistry, developed a technique for scaling and polishing teeth and also taught his patients to carry out home-care procedures. By 1906, acting under the preventive dictum that “a clean tooth never decays,” Dr. Fones was sure that the oral health of his patients was improved through his oral prophylactic practices. He trained his assistant to practice dental hygiene, and in 1907 he was instrumental in having dental hygiene legally recognized in Connecticut as an adjunct to dental practice. Fones went on to establish the first school of dental hygiene in 1913. Accepting only “young ladie/>