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Oral Roentgenology and its Possibilities*
ORAL ROENTGENOLOGY AND ITS POSSIBILITIES* By LE R O Y M . EN N IS, D .D .S ., Philadelphia, Pa.
O T long ago there came to consult a A n easily arrived at interpretation of roentgenologist tw o men, a dentist the film indicated no pathologic condition and a physician, each of whom had to justify the extraction of the first bi a seemingly good practice in his pro cuspid. T o the contrary, it showed a strong, normal structure w ith good pulp, fession in a fairly populous community. Presenting tw o very fair looking roent free of caries and any trace of degenerated genograms of the right maxillary bicuspid tissue, abscess or doubtful physiologic ap region th a t showed in succession a full pearance, save a natural, or at least not complement of teeth, and then a film in unusual, calcification surrounding part of dicating the recent removal of the second the apical region and met many hundreds bicuspid, they related the case: A young of times in our regular practice. O ne not pretending to superior attain woman, aged 21 , had been suffering from w hat the physician had diagnosed as a ments in the field could have interpreted form of arthritis. T h e dentist made the the film. Y et th at innocent and vital roentgenograms and the film to them in tooth would have been extracted save for dicated a condition of the second bicuspid the opposition of the patient. T h e more serious side of the situation th at m ight have contributed to the con dition. T herefore the tooth was ex lies in the fact th at the second bicuspid, which had been extracted in vain as far as tracted. But, the suffering of the young patient the accomplishment sought by its removal meeting no amelioration, it was deter is concerned, was of even better structure, mined to remove the first bicuspid, which its surrounding tissues being unquestion to both dentist and physician seemed to able. T h e roentgenogram confirmed this show a condition w arranting the course. deduction. T h is case typifies hundreds met in my T h e only obstacle to the plan was the protest of the tearful owner that the first own experience; and it probably repre removal effected no relief, and, w ith no sents thousands encountered by many at greater assurance from the projected tending this convention. M ultiply the second extraction, she was not going to number by any figure and you may ap undergo the immediate loss and the con proximate the woe th at follows in the sequent cross of a larger bridge for the wake of inaccurate interpretation of even balance of her life w ithout better promise ample roentgenograms and of faulty ap as to when and where the extractions plication of an interpretation of improp erly produced films. were to end. Thousands of cases there are wherein *Read at the Seventy-Fifth Annual Session the less careful and the less trained ob of the American Dental Association in con server attributes as a sign of infection junction w ith the Chicago Centennial Dental shadows in a roentgenogram th at to the Congress, A ug. 9, 1933.
N
Jour. A .D .A ., August, 1934
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The Journal of the American D ental Association
capable clinician show a normal condi tion or, at most, the slightest deviation from the normal, but which indicate neither infection nor a condition con tributing to infection. Perhaps a much greater number of cases there are wherein the practitioner fails to recognize shadows portending danger or to observe evident abnormalities th at indicate infection or threaten to result in or produce infection. Following the orgy of extracting teeth indulged in a few years ago, there are still too many good and vital teeth re moved by dentists who hold themselves out as capable, and not only of the mer cenary cult th at sees in extraction the fatter return from the making and sale of appliances. Physicians are still prone to blame the teeth for all hum an ills failing to respond to orthodox or inexpert medical treatm ent; and so the tooth that the dentist could not observe was harm less and th a t the physician could not diagnose as uninfected comes out. And the plight of the patient is pathetic, to apply no more condemnatory term to the ignorance th at permitted it. B ut to the myriads of cases wherein the flagrant ignorance of dentists allows serious conditions of the teeth and tissues of the oral cavity to persist for years w ithout w arning or attention, the only word applicable is tragic. In this year of grace, no excuse is offerable for thousands of infections remaining unnoticed until immediate surgical operation is required. T h e past ten years have given successive suggestions as to the care of the teeth and ample admonitions as to the dangers of neglect, placing w ithin our grasp the knowledge and the instruments through which to discover oral conditions calling for treatm ent to protect health; and the dentist who deliberately or carelessly re fuses or neglects to employ every known instrum entality and method to detect in dications of disease, who sidesteps science because of an inability or an ineptitude to
keep abreast of the modern speed of prog ress, who continues following the hit-ormiss system of treating suspicious symp toms instead of searching for and treating causes, who, in fine, is smugly satisfied w ith anything less than the most compre hensive method of diagnosing the ills to which the constituent parts of the mouth are subject, is unfair to the patient, the public and the profession. T h e oral surgeon views many cases that may not often come w ithin the pur view of general dental practice; but it would surprise many w ere the surgeon to mention the number of cases th at might have been saved his scalpel and lancet had the dentist but employed early the ordi nary safeguards and methods of examina tion th at lay as close to hand as do our elevators, mirrors and explorers. T h a t a thorough, full-mouth examina tion of everyone seeking the services of the dentist is necessary has been proved by recent research and by very specific con firmation of scientific theories; and to convince the patient of this is the inescap able responsibility of the practitioner. F or where teeth exist or existed, there lies not only the safeguards of health, but also, though so often deeply hidden, un discerned dangers to health. W e understand now how in the unex plored and, except for experimental sur gery, well-nigh unexplorable maxillary and m andibular structures lay for years undiscovered foci of systemic infection. W e had wondered as to w hat undisclosed conditions might lie beneath the surface, often exploring just short of anything of informative value. N o clinical test re vealed more than a justification for fur ther guesses. And when later we noticed arising from a hitherto unsuspected area a dangerous condition, and one develop ment of which consumed not days or months, but years, we bemoaned our helplessness and hoped for knowledge to insure earlier recognition of danger signs
Ennis— Oral Roentgenology
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M any here have probably had an op and for better methods of diagnosis and better systems of determining the etiology portunity similar to the one it has been of dental diseases. A nd through the my good fortune to have enjoyed. For pioneers in all fields of dental science the past five years, each student entering whose study and struggles have made D rexel Institute, Philadelphia, has been dentistry the honored profession it has given a thorough medical and dental become, science responded. W ilhelm examination. D rexel Institute is a school K onrad Röntgen announced the discovery comparing with the average smaller col of the outstanding and striking property lege, w ith students of the average age of the cathode rays, his own named “x- and average intellectual grasp, and of the rays,” through which, as compared to the average family connections and environ darkness wherein dentistry labored before m ent th at attach to the general run of this discovery, the miracles of yesteryear college matriculates of both sexes. are the routine of present practice. T h ere has been a progressive improve Even the younger generation of the ment in the system of making these exam profession have seen the infancy and inations from year to year, for, when grow th of this specialty, and thanks to originated, the plan comprehended merely the interest these younger men have the superficial clinical survey of the teeth, evinced, the application of roentgen rays the idea being limited to a report on the in general practice has proved the greatest more or less obvious conditions. T h e boon th at has come to civilization since medical examiner had no small task in the offering of anesthesia. Those now his own particular broad field. H e was coming into the profession are recognizing anxious to complete the examinations the roentgen rays as the very support th at quickly and the number of students re dental science has sought these many quiring attention led him to present his years, for they have proved the most de first report to the faculty at the earliest pendable aid the clinician can summon possible moment in order to permit for m ulation of plans for the dental or med when in doubt. T h ere was difficulty encountered in se ical treatm ent necessary. Therefore, it curing the recognition of the value of was ordered th at only teeth justifiedly the roentgen rays by the more experienced suspicious should be examined roentgenomembers of the profession. Dentists and graphically. T h is was a system much less than ade physicians, like some business men . who feel their success measured by their in quate; and it required little argument to come and are too satisfied to consider convince the medical examiner th at his changing either methods or standards, records would prove but a part of w hat cling to old ideas and old ideals, smugly he sought to show. H is final report con unaware th at these were being relegated firmed this fact so fully that, in the fol to the dust heap by the progressive and lowing year, and since then annually, a scientific w orld. T h eir preconceptions are comprehensive clinical and roentgenologic rooted very deep, and inertia deters them full-mouth examination has been made of from an effort to understand the newer all freshmen. ideas ; but a few years hence will see them T h e average age of these students is superseded in the estimation of patients 18, and the questionnaire answered by and the public by the younger men who them seems enlightening as more than are keenly alive to the thrilling experi half replied that they had visited the ences th at are making dentistry so im family dentist for examination or for portant and so progressive a science. some specific treatm ent w ithin one month
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to six months just prior to leaving home for college. Eleven hundred and twenty-seven students formed the first group examined in 1929; males, 723, and females, 404. O nly teeth suspected of periapical in volvement were roentgenographed, and of the 723 males examined, only 200 proved free of caries under the rather limited method followed. Five hundred and twenty-three of these young men, am bitious to attain an education, interested in preserving health and knowing the im portance of a sound body for a reasoning mentality, carried in their mouths the well springs of disease, of which they were totally unaware and which were as threatening as poisoned and polluted springs supplying drinking w ater to the T
able
1.— C o m p a r i s o n of A t te m
of
cent of the mouths examined by the roent gen rays exhibited conditions probably more dangerous than those treated by the family dentist just a few short months earlier cannot be a happy thought for those same dental practitioners to con template, particularly w ith the possibility of these young students returning to the home town w ith the report that D r. Slip shod or D r. Careless certainly overlooked some menacing conditions when pro nouncing the patient perfect, w ith no oral condition to w orry him or hinder his studies. And th at is a threat that hangs over the heads of all who are satisfied w ith only the merest clinical examination of the teeth of a patient, and the threat grows larger each day. T he 249 definite carious conditions so
C l in ic a l a n d R o e n t g e n o g r a p h ic F in d in g s , S h o w in g P r e d ic t t h e P r e se n c e o f G r a n u l o m a fr o m t h e C l in ic a l A p p e a r a n c e o f T e e t h
the
R
esults
p t in g t o
C ases
T
eeth
Granuloma suspected clinically; found by roentgen rays................... 91 106 Granuloma not suspected clinically; found by roentgen rays.............100 126 Total number of granulomas.................................................................................... 232 Granuloma suspected clinically; not found by roentgen rays............. 333 495 Percentage of proved granulomas suspected clinically................................... 45.2 Percentage of suspected teeth showing granulom a............................................ 17.6
home. Seventeen hundred and twelve cavities were discovered, not to mention 691 missing teeth that should have been replaced by substitutes to protect coffiplementary vital teeth, in danger of earlier degeneration were such action deferred unduly. B ut only 294 of these 723 mouths were examined roentgenographically, because, to repeat, this method was applied only to those conditions indicating periapical involvement; yet in these 294 cases, there were disclosed 249 carious conditions that the m irror and instrument failed to find, A full roentgenographic examination of every mouth would have disclosed much th a t the method employed had missed; but that approximately 85 per
discovered constitute a sufficient justification for the roentgenographic examinatio n ; but, in addition to these conditions, there was undetected by the clinical tests but discovered by the roentgen rays in the same 294 mouths, more than 100 cases of granuloma, one cyst, fourteen residual roots, ten well-developed cases of periostitis, and thirty-eight instances of root absorption; conditions that should have been treated earlier, N or is it amiss to interpolate here a rather illuminating presentation of data showing the results of the roentgenographic examination of twenty-five young ladies constituting the class in oral hygiene in the D ental D epartm ent of the University of Pennsylvania, this year. I t
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Ennis— Oral Roentgenology is unnecessary to recite the educational qualifications these students are required to possess, but they are extensive. M ore, these students are certainly interested in the maintenance of their own teeth, and surely since first contemplating the field they subsequently entered, they had probably looked after them more zealously than the average person looks after the teeth. N or should we lose sight of the fact th at many of the young ladies entering the course are the daughters, sisters or close relatives of dentists. T h e mouths of these embryo oral hygienists should show a healthful state, a well-attended set of teeth, an absence of infection and threatening growths. B ut the films, checked and rechecked w ith the greatest care and certitude, disclosed T a b le
2.— I n c i d e n c e
T o revert to the result of the examination of the Drexel Institute students, but avoiding the detailed statistics pertaining to the 160 young women selected to undergo the roentgen-ray examination, let it suffice to state that the roentgenographic survey revealed a great amount of infection or pathologic lesions that clinical examination did not disclose and never would have disclosed, So startling were the revelations among both male and female groups that the school authorities determined quickly on a complete roentgenographic examination for all future freshmen on entering college. T h e examination of the class that entered last September revealed a greater prevalence of caries than the average
o f E l e c t r o c a r d io g r a p h ic C h a n g e s in
160
W o m an S tu d e n ts
w ith a n d W i th o u t D e n t a l G ra n u lo m a
W ith W ithout Dental Granuloma Dental Granuloma Number Per Cent Number Per Cent Women electrocardiographed...........................................27 133 Normal tracings..................................................................23 85.2 109 82 Tracings showing some departure from n o rm a l.. . . 4 14.8 24 18
among the twenty-five students these con- found in earlier classes studied; but as to ditions: other conditions, practically similar proCaries ....................................................... 79 portions of infectious conditions were Rarefying osteitis with granulation found as those prevailing in preceding tissue ...................................................12 classes. T h e excess of caries may be atIm pactio n s................................. ............ 13 tributed to the economic conditions of Root absorption ................................... 1 the past three or four years. Less than Condensing o s te itis ............................... 1 sufficient dental treatm ent might easily Perforated r o o t ...................................... 1 be incident to the depression. Residual r o o t s .......................................... 1 T h ere is much to ponder over in reRetained t e e t h ........................................15 viewing the figures just offered. T o apMissing te e th .......................................... 41 proach a consideration of conditions W ith such impressive data collected shown, it may easily be conceded that from sources of unmistakable knowledge some of the students failed to adhere of the value of hygienic and healthful strictly to the tru th when, during the oral conditions, we may pause to consider examination, they were asked, “W hen the gravity of conditions that might be did you last have the services of your found generally among people in all dentist?” ; for too many replied, “Ju st walks of life were every inhabitant of our prior to my departure for school,” to city subjected to a similar examination.deserve complete credence; for the
The Journal of the American D ental Association
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plainly evident conditions observed through the m irror alone negatived many of these assertions and gave reason to suspect the credibility of the student. B ut the veracity of the student be comes an issue only when considered w ith the lesson the entire picture presents: If the conditions discovered among these students seem as threatening to you as they seem to me, and also to John H . A rnett, the medical director, and the faculty of the D rexel Institute, how are we to protect the growing generation against similar danger? F o r it is logical to deduce that similar conditions exist all over the country. I t is a fair assump tion that there would be even more proT a b l e 3.— S e x
and
A g e o f S u b je c ts
A ge Women 16 9 17 76 18 158 19 67 20 26 21 6 22 6 23 3 24 1 25 0 Over 25 5 not stated ..2 4
Men 12 83 153 100 73 29 27 14 5 2 4 0
Total 21 159 311 167 99 35 33 17 6 2 9 24
T o t a l.. , .381
502
883
nounced findings among younger persons not preparing for further studies and not undergraduate college students or pro spective oral hygienists. A nd among older persons, it may be said confidently, the infectious conditions that a complete ex amination would disclose might be double or treble the number found among col lege and university freshmen. Every school and college w ill soon be doing w hat has been tried at Drexel In stitute. Institutions not so w ell equipped w ith forces to handle the examinations w ill require either a complete report from the dentist who latest examined the stu
dent or a report from some reliable den tist in the college town. A nd accuracy will be expected of these examinations. Let dentists attend th at no discoveries be made to discredit the profession. T able 3 presents data on sex and age draw n from the examination of one fresh man class of 833 students a t Drexel In stitute when 27,398 teeth were under ob servation, in 2,797 of which caries was revealed. W hile the combined clinical and roent genologic examinations disclosed 3,034 carious spots, the clinical method revealed only 1,662. T h e roentgen-rays revealed 1,372. T h e roentgen-ray and clinical ex aminations agreed only in 237 cases, which represent the comparatively small proportion, about 10 per cent, of the ca rious conditions revealed, which was du plicated by the joint disclosures. (Table 4.) A nd if, however often we repeat a similar experiment on a large group of people, our findings approximate such a result, it is evident th at to exclude either of these methods in examining teeth is to shirk responsibility. N ot only is there a responsibility upon the dentist to ex amine roentgenologically the clinically suspicious teeth, but also th at attention should be given to the entire mouth, the teeth and edentulous areas th at have no obviously suspicious appearance. In the tables presented, regardless of the number of cavities, a tooth was counted as but one carious tooth. Sound filled teeth are not included. F or no longer is the chief concern of the dental profession merely repair, re placement, the treatm ent of the obvious. Prevention of disease looms as important, and the sphere of the dentist embraces completely the minutely conceived func tion of prophylaxis. W e know of sys temic diseases originating in caries and other hidden areas of oral putrefaction.
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E n n is— O r a l R o e n tg en o lo g y
lesions, such as th e granulom a and the cyst, absorbed roots, and m any oth er hid den sources of danger, discovery of w hich is the d u ty of every dentist. W ith o u t the roentgenographic exam ination, w e miss the assurance th a t comes from adopting the m ost scientific system of prophylaxis, of healing, of cure w hich m odern m ethods dem and th a t w e follow for the fullest protection of th e patient.
W e concede th e deleterious influence of septic teeth and tissues; and w e dare not ignore an agency offering to disclose such foci of infection. T o the contrary, w e m ust have such an agency close a t hand to locate and determ ine quickly w here abnorm al conditions exist. Roentgenographic equipm ent should be had in every office. N o extravagant claims are advanced in T
able
4 .— D
ental
C a r ie s ( C
o m p a r is o n o f
C
l in ic a l a n d
R
o e n t g e n -R ay
F in d in g s )
Teeth Caries revealed by clinical exam ination...................................................... 1,662 Caries revealed by roentgen rays....................................................................1,372 Roentgen-ray and clinical examinations agreed..................................... 237 Caries revealed clinically, but not by roentgen-rays.................................. 1,425 Caries revealed by roentgen rays but not clinically.................................. 1,135 T
able
5.— F r e q u e n c y
of
D
C a r ie s a s D e t e r m in e d R o e n t g e n - R a y F in d in g s
ental
and
by
C o m b in in g C l in ic a l
Number of students exam ined................................................................................ 883 Number of students showing caries..................................................................... 733 Percentage of students showing caries................................................................. 83 Approximate number of teeth exam ined.................................................27,398 Number of teeth w ith caries........................................................................ 2,797 Percentage of teeth showing caries.......................................................... 10.3 A verage number of carious teeth per student....................................... 3.2 T
able
6.— F r e q u e n c y
of
G
r a n u l o m a as
D
e t e r m in e d by
U
se o f
R
oentgen
R
ay s*
Number of students examined................................................................................ 883 Students showing granuloma.................................................................................. 175 Percentage of students showing granuloma........................................... 19.8 Approximate number of teeth exam ined................................................. 27,398 Number of teeth showing granulom a................................................................... 232 Percentage of teeth showing granulom a.................................................. 0.8 *Further information regarding this particular group study is presented in the American Journal of the M edical Sciences and the Dental Cosmos, June, 1933.
favor of this conviction, and none need be, for th e self-evident tru th s proclaim to th e w orld sufficient reasons, th e incalcu lable value of the instrum ent. O f course, th e roentgen rays miss m any existing conditions. C aries m ay be in such a posi tion in th e crow n of the tooth as to escape th e roentgen rays, and they w ill miss o th er danger spots th a t the explorer re veals ; b u t w ith o u t them w e miss chronic
P ublic schools, th e radio, the new s papers have carried on widespread educa tional cam paigns reg ard in g th e depend ence of h ealth on good teeth, and the pres ervation and reten tio n of vital teeth. H ence, th e grow ing opposition to ex tractions except as a last resort and the insistence of th e p atien t on the use o f the roentgen rays even afte r th e attending dentist advises extraction. In m any cases,
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T h e J o u rn a l o f th e A m erica n D e n ta l A ssociation
th e sufferer secretly visits the roentgenol ogist before subm itting to extraction of th e teeth. N o te how th e advertising den tist features th e roentgen-rays in his pub licity as a sign of advance, of m odern methods, and how his patients are harangued into believing th a t every pa tie n t should undergo such an exam ina tio n ; an d w e m ust concede th at, in theory, th e argum ent has reason. W ith d entistry th e first support of m odern m edicine to stem the flood of sys tem ic disorders underm ining m ental and physical health, it behooves th e profession to p u t its house in order if it is to be a potent agency in preventing infection th a t may ultim ately spell death. W e cannot stand by u n til forced to recognize the presence of sepsis, w hen the barest outlay of tim e and m oney w ould have detected th e infection and could have aborted or elim inated it before it invaded deeper tis sues and th e blood stream . D entists m ust preach th e gospel of a full-m outh roentgenographic exam ination fo r every patient, th e records to be re tained by th e dentist and filed fo r fu tu re reference. T h e principles of prophylaxis commend th e idea. I t is the logical evo lution of d en tal science tow ard decreas ing dental disease; and in the revelation of pathologic lesions and their location, area and extent, there w ould be a lessen ing of operative labor. W h ile m onetary considerations should hold no place in o u r discussion, it may be v en tured th a t th e equipm ent once owned, th e sm all cost of roentgen-ray films adds little to th e carrying charges of any office. I n fact, instead of an expense, th e m aking and use of roentgenogram s w ill show a p ro fit; for they contribute to building a practice, uncovering conditions th a t w ould otherw ise rem ain unrevealed and so u n treated . T h in k of the tim e, trouble, w orry, u n ce rtain ty saved w hen absolute certainty m ay be had fo r the m ere asking,
the m ere m a tte r of th e atten tio n called for in th e study of roentgenographic technic. N o separate charge should necessarily be m ade patients for the service, w hatever system o f charges m ight be follow ed in an office; and th is fo r several reaso n s: the service should be as incidental to the ex am ination of a p atien t as is now th e very first glance given a w orrisom e to o th or other tro u b le about w hich th e dentist is co n su lted ; and the n a tu ra l reaction of the patient against individual fees for specific necessary trea tm e n t should be considered. T here should be th e desire to impress pa tients w ith the fact th a t th e service is routine practice of th e office, and n ot ex traordin ary , and th a t th e resulting film is for ou r ow n know ledge and inform ation and is n o t the p roperty of th e patien t to display to his fam ily and friends. T h e re seems no b etter reason to ask a separate fee for such an exam ination th an there w o u ld be for th e use of pulp testers and tran sillu m in ato rs in m aking a clinical study, and for the w ear an d te ar on en gines an d explorers. A n d here it seems pertin en t to quote from an article by L. M . W a u g h ,1 entitled “ Radiology as an A d ju n c t in the P ractice of D en tistry .” D r. W a u g h had sent to 325 o u tstan d ing dentists th ro u g h o u t the U n ite d States and C an ad a a series of questions w hich included th e follow ing: Question 5 (a) Do you make a separate charge for each radiograph? Yes, 87; no, 62. (6) If so, does not the patient sometimes question the need of several in a given case? Yes, 74; no, 34. (c) If not in your own practice, do you believe this would be so in a great number of practices? Yes, 116; no, 28. (d) W ould this not be overcome by hav 1. W augh, L. M .: D. Cosmos, (N ov.) 1917.
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Ennis-— O r a l R o en tg en olo g y
ing it understood th a t the necessary radio graphs are a p art of the service, and as such are not charged for separately but are included in the general fee ? Yes, 147; no, 8. ( e) Do you find the time saved by the radiodontic findings compensates for the time required in making them ? Yes, 162; no, 8. T h e answ er to these tw o final queries reflect an interesting attitu d e on the question u n d e r discussion; and w hen w e appreciate th a t the questionnaire dates back to th e alm ost archaic days of dental roentgenography, and surely the infancy of th e system, how could the retu rn s be less impressive if a vote w ere taken at this tim e? In m ore th a n one th ird of the dental offices in our country, w e w ill find some so rt of x-ray ap p aratu s; w hereas, ten years ago, th e appearance of one w as a rarity. T h e profession has learned th a t roentgenology need not be a specialty, and th at, w hile dem anding intensive applica tion w hen studied as seriously as the sub ject w a rra n ts and a profounder know l edge of m any in tricate phases of dental theory, physiology, pathology and etiol ogy, as w ell as a technic akin to art, these very requirem ents are h ard ly m ore th a n every practitio n er is supposed to possess to perform th e usual functions th a t the profession imposes. Capable dentists are counted on to locate and diagnose patho logic conditions of th e teeth, th e m outh and the investing tissues, and it cannot be less th a n disconcerting to p atient or den tist when, fo r a m ere roentgenographic exam ination, reference m ust be m ade to some other dentist. T h e poignancy of this observation appears w hen w e note how advertising quacks and imposters publicize th is service, w hile otherw ise capable and ethical dentists adm it u n preparedness in so abundant a field of endeavor. B ut, you assert, no criticism is leveled
1375
against the physician w ho refers a patien t to a specialist. M a y it be ventured th a t the alm ost antipodean difference in the present day scope and responsibilities of the neighboring b u t distinctly separate professions is th e answ er to the assertion. In analyzing th e respective relations to the p articu la r profession served, it is n ot easy to com pare th e pediatrician, the neurologist, th e psychiatrist or the oph thalm ologist to th e roentgenologist. T h is passes by the th o u g h t of m any physicians th a t th e general p ractitioner has per m itted him self to be erased from the m edical p ic tu re ; b u t know ledge of the terrific course of study and the experience the m edical m an m ust undergo to gain recognition as a specialist of highest re pute, of th e concentration he is required to give his specialty, of the never ending rounds of clinics he m ust attend, cannot be disregarded. T h e degree of know ledge upon w hich th e roentgenologist bases his rig h t to be adm itted a specialist is h ardly in excess of w h a t every dentist is expected to possess. Surely the study incident to learning th e application of th a t know l edge to the m aking of and in terp retin g of the roentgenogram s lies w ith in easy grasp. T h e capable dentist should not allow him self to be forced entirely into the background by th e specialist, becom ing a m ere satellite of the specialist as, in medicine, th e re seems a tre n d ; for his field w ill n ot excuse it, and his patients w ill not p erm it it. Rem em ber th a t sporadic experiments afte r a desultory course of reading, coupled, perhaps, w ith some superficial b u t high pow ered instruction from equip m ent salesmen, w ill n ot constitute one a roentgen o lo g ist; and it is pathetically tru e th a t too m any dentists assume quali fication on such im m ature and pretended preparation. T h e poorly train ed oper ators, advertising charlatans and com m er cial x-ray laboratories m ust be driven to
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cover, and w ill be w hen th e better equipped, ethical dentists enter the field in mass. T h is w ill come to pass w hen w e reach th e ideal adjustm ent, w hereby each cli nician is his ow n roentgenologist. T o a r rive a t this goal, m any may find it ex pedient to re tu rn to th e ir books, to attend num erous clinics, perhaps to seek close personal instruction from th e experienced teachers of our acclaimed schools. B u t brushing up on pathology, physiology, eti ology and th e m odern concepts of prophy laxis m ay n o t prove a poor policy even to the w ell inform ed. N o thoughtlessly m ade or intended de rogatory observation is this, but u n v ar nished tr u th ; for an appalling,deficiency in the fundam entals of dental know ledge is too often exhibited by m any w ith years of practice th a t should have been im proved by continued reading. W e re you to spend a few days w ith some active roentgenologist and hear th e practitioners w ho come to consult him, hear th eir in terpretations of roentgenogram s and of related symptoms, hear th e ir nervously ventured diagnosis o r suggested tre a t m ent, you w ould find m any as w ofully lacking and as w ofully w rong as w ere the physician and the dentist to w hom I have alluded. T h e alert, progressive clinician is ever searching fo r new er, better methods. N o te th e caliber of m en attending the im portant conventions, count th e o u t standing dentists listening intently to val uable discussions, see the ablest of the p ro fession observing closely th e table clinics, in te n t on learn in g anything th a t is an im provem ent in theory o r technic; fo r den tistry is certainly a progressive science, always ready to discard old ideas and substitute th e tested new er th o u g h t; and it is quite easy to believe th a t five years hence w ill see those considered lacking w ho cannot in te rp re t roentgenogram s and
operate th e apparatus producing them . T h a t th is shortcom ing w ill n o t con tinue is w ritte n on th e ever changing sands of science. I n th e very near future, no applicant incapable of qualifying as a roentgenologist w ill be licensed to prac tice dentistry. In Pennsylvania, the state board of d en tal exam iners requires stu dents to m ake a com plete roentgenographic exam ination of a patien t and w rite a fu ll rep o rt of th e roentgenographic findings; and the resu lt of th a t test counts no little for or against th e ap plicant. Pennsylvania recognizes ro en t genology as an o u tstanding factor in the routine practice of th e profession, and the theory th a t none lacking ability and ex perience to perform this routine function should be perm itted to practice dentistry is so w ell founded th a t other states w ill follow this stan d ard , and shortly. J u s t as h a lf-tru th s are often m ore dangerous th a n w hole lies because m ore difficult to confute, in dentistry p a rt or h alf treatm en ts m ay be m ore dangerous th a n none a t a l l ; fo r they m ay cover up and hide fo r too long a period insidious infections th a t m ight have otherw ise dem onstrated th e ir existence earlier. T h e study of d en tistry embraces as im perative the search fo r causes, th e diagnosis and prognosis of suspicious areas. T h e safe practice is to consider all areas suspicious u n til proved o th erw ise; and for this theory, th e clinician as his ow n ro en t genologist is th e ideal arrangem ent. W ith th e th o u g h t th a t com petition usually re sults in th e survival of th e fittest, and recalling th e philosophy th a t self-preservation is th e first law of n ature, th e older practitioners m ay w ell contem plate th a t th e oncom ing dentist w ill be b etter pre pared to m eet th e present need of the profession in th e h ealth preservation p ro gram o f th e n atio n in th a t he w ill be his ow n roentgenologist. 4001 Spruce Street.
O T long ago there came to consult a A n easily arrived at interpretation of roentgenologist tw o men, a dentist the film indicated no pathologic condition and a physician, each of whom had to justify the extraction of the first bi a seemingly good practice in his pro cuspid. T o the contrary, it showed a strong, normal structure w ith good pulp, fession in a fairly populous community. Presenting tw o very fair looking roent free of caries and any trace of degenerated genograms of the right maxillary bicuspid tissue, abscess or doubtful physiologic ap region th a t showed in succession a full pearance, save a natural, or at least not complement of teeth, and then a film in unusual, calcification surrounding part of dicating the recent removal of the second the apical region and met many hundreds bicuspid, they related the case: A young of times in our regular practice. O ne not pretending to superior attain woman, aged 21 , had been suffering from w hat the physician had diagnosed as a ments in the field could have interpreted form of arthritis. T h e dentist made the the film. Y et th at innocent and vital roentgenograms and the film to them in tooth would have been extracted save for dicated a condition of the second bicuspid the opposition of the patient. T h e more serious side of the situation th at m ight have contributed to the con dition. T herefore the tooth was ex lies in the fact th at the second bicuspid, which had been extracted in vain as far as tracted. But, the suffering of the young patient the accomplishment sought by its removal meeting no amelioration, it was deter is concerned, was of even better structure, mined to remove the first bicuspid, which its surrounding tissues being unquestion to both dentist and physician seemed to able. T h e roentgenogram confirmed this show a condition w arranting the course. deduction. T h is case typifies hundreds met in my T h e only obstacle to the plan was the protest of the tearful owner that the first own experience; and it probably repre removal effected no relief, and, w ith no sents thousands encountered by many at greater assurance from the projected tending this convention. M ultiply the second extraction, she was not going to number by any figure and you may ap undergo the immediate loss and the con proximate the woe th at follows in the sequent cross of a larger bridge for the wake of inaccurate interpretation of even balance of her life w ithout better promise ample roentgenograms and of faulty ap as to when and where the extractions plication of an interpretation of improp erly produced films. were to end. Thousands of cases there are wherein *Read at the Seventy-Fifth Annual Session the less careful and the less trained ob of the American Dental Association in con server attributes as a sign of infection junction w ith the Chicago Centennial Dental shadows in a roentgenogram th at to the Congress, A ug. 9, 1933.
N
Jour. A .D .A ., August, 1934
1367
1368
The Journal of the American D ental Association
capable clinician show a normal condi tion or, at most, the slightest deviation from the normal, but which indicate neither infection nor a condition con tributing to infection. Perhaps a much greater number of cases there are wherein the practitioner fails to recognize shadows portending danger or to observe evident abnormalities th at indicate infection or threaten to result in or produce infection. Following the orgy of extracting teeth indulged in a few years ago, there are still too many good and vital teeth re moved by dentists who hold themselves out as capable, and not only of the mer cenary cult th at sees in extraction the fatter return from the making and sale of appliances. Physicians are still prone to blame the teeth for all hum an ills failing to respond to orthodox or inexpert medical treatm ent; and so the tooth that the dentist could not observe was harm less and th a t the physician could not diagnose as uninfected comes out. And the plight of the patient is pathetic, to apply no more condemnatory term to the ignorance th at permitted it. B ut to the myriads of cases wherein the flagrant ignorance of dentists allows serious conditions of the teeth and tissues of the oral cavity to persist for years w ithout w arning or attention, the only word applicable is tragic. In this year of grace, no excuse is offerable for thousands of infections remaining unnoticed until immediate surgical operation is required. T h e past ten years have given successive suggestions as to the care of the teeth and ample admonitions as to the dangers of neglect, placing w ithin our grasp the knowledge and the instruments through which to discover oral conditions calling for treatm ent to protect health; and the dentist who deliberately or carelessly re fuses or neglects to employ every known instrum entality and method to detect in dications of disease, who sidesteps science because of an inability or an ineptitude to
keep abreast of the modern speed of prog ress, who continues following the hit-ormiss system of treating suspicious symp toms instead of searching for and treating causes, who, in fine, is smugly satisfied w ith anything less than the most compre hensive method of diagnosing the ills to which the constituent parts of the mouth are subject, is unfair to the patient, the public and the profession. T h e oral surgeon views many cases that may not often come w ithin the pur view of general dental practice; but it would surprise many w ere the surgeon to mention the number of cases th at might have been saved his scalpel and lancet had the dentist but employed early the ordi nary safeguards and methods of examina tion th at lay as close to hand as do our elevators, mirrors and explorers. T h a t a thorough, full-mouth examina tion of everyone seeking the services of the dentist is necessary has been proved by recent research and by very specific con firmation of scientific theories; and to convince the patient of this is the inescap able responsibility of the practitioner. F or where teeth exist or existed, there lies not only the safeguards of health, but also, though so often deeply hidden, un discerned dangers to health. W e understand now how in the unex plored and, except for experimental sur gery, well-nigh unexplorable maxillary and m andibular structures lay for years undiscovered foci of systemic infection. W e had wondered as to w hat undisclosed conditions might lie beneath the surface, often exploring just short of anything of informative value. N o clinical test re vealed more than a justification for fur ther guesses. And when later we noticed arising from a hitherto unsuspected area a dangerous condition, and one develop ment of which consumed not days or months, but years, we bemoaned our helplessness and hoped for knowledge to insure earlier recognition of danger signs
Ennis— Oral Roentgenology
1369
M any here have probably had an op and for better methods of diagnosis and better systems of determining the etiology portunity similar to the one it has been of dental diseases. A nd through the my good fortune to have enjoyed. For pioneers in all fields of dental science the past five years, each student entering whose study and struggles have made D rexel Institute, Philadelphia, has been dentistry the honored profession it has given a thorough medical and dental become, science responded. W ilhelm examination. D rexel Institute is a school K onrad Röntgen announced the discovery comparing with the average smaller col of the outstanding and striking property lege, w ith students of the average age of the cathode rays, his own named “x- and average intellectual grasp, and of the rays,” through which, as compared to the average family connections and environ darkness wherein dentistry labored before m ent th at attach to the general run of this discovery, the miracles of yesteryear college matriculates of both sexes. are the routine of present practice. T h ere has been a progressive improve Even the younger generation of the ment in the system of making these exam profession have seen the infancy and inations from year to year, for, when grow th of this specialty, and thanks to originated, the plan comprehended merely the interest these younger men have the superficial clinical survey of the teeth, evinced, the application of roentgen rays the idea being limited to a report on the in general practice has proved the greatest more or less obvious conditions. T h e boon th at has come to civilization since medical examiner had no small task in the offering of anesthesia. Those now his own particular broad field. H e was coming into the profession are recognizing anxious to complete the examinations the roentgen rays as the very support th at quickly and the number of students re dental science has sought these many quiring attention led him to present his years, for they have proved the most de first report to the faculty at the earliest pendable aid the clinician can summon possible moment in order to permit for m ulation of plans for the dental or med when in doubt. T h ere was difficulty encountered in se ical treatm ent necessary. Therefore, it curing the recognition of the value of was ordered th at only teeth justifiedly the roentgen rays by the more experienced suspicious should be examined roentgenomembers of the profession. Dentists and graphically. T h is was a system much less than ade physicians, like some business men . who feel their success measured by their in quate; and it required little argument to come and are too satisfied to consider convince the medical examiner th at his changing either methods or standards, records would prove but a part of w hat cling to old ideas and old ideals, smugly he sought to show. H is final report con unaware th at these were being relegated firmed this fact so fully that, in the fol to the dust heap by the progressive and lowing year, and since then annually, a scientific w orld. T h eir preconceptions are comprehensive clinical and roentgenologic rooted very deep, and inertia deters them full-mouth examination has been made of from an effort to understand the newer all freshmen. ideas ; but a few years hence will see them T h e average age of these students is superseded in the estimation of patients 18, and the questionnaire answered by and the public by the younger men who them seems enlightening as more than are keenly alive to the thrilling experi half replied that they had visited the ences th at are making dentistry so im family dentist for examination or for portant and so progressive a science. some specific treatm ent w ithin one month
1370
The Journal of the American D ental Association
to six months just prior to leaving home for college. Eleven hundred and twenty-seven students formed the first group examined in 1929; males, 723, and females, 404. O nly teeth suspected of periapical in volvement were roentgenographed, and of the 723 males examined, only 200 proved free of caries under the rather limited method followed. Five hundred and twenty-three of these young men, am bitious to attain an education, interested in preserving health and knowing the im portance of a sound body for a reasoning mentality, carried in their mouths the well springs of disease, of which they were totally unaware and which were as threatening as poisoned and polluted springs supplying drinking w ater to the T
able
1.— C o m p a r i s o n of A t te m
of
cent of the mouths examined by the roent gen rays exhibited conditions probably more dangerous than those treated by the family dentist just a few short months earlier cannot be a happy thought for those same dental practitioners to con template, particularly w ith the possibility of these young students returning to the home town w ith the report that D r. Slip shod or D r. Careless certainly overlooked some menacing conditions when pro nouncing the patient perfect, w ith no oral condition to w orry him or hinder his studies. And th at is a threat that hangs over the heads of all who are satisfied w ith only the merest clinical examination of the teeth of a patient, and the threat grows larger each day. T he 249 definite carious conditions so
C l in ic a l a n d R o e n t g e n o g r a p h ic F in d in g s , S h o w in g P r e d ic t t h e P r e se n c e o f G r a n u l o m a fr o m t h e C l in ic a l A p p e a r a n c e o f T e e t h
the
R
esults
p t in g t o
C ases
T
eeth
Granuloma suspected clinically; found by roentgen rays................... 91 106 Granuloma not suspected clinically; found by roentgen rays.............100 126 Total number of granulomas.................................................................................... 232 Granuloma suspected clinically; not found by roentgen rays............. 333 495 Percentage of proved granulomas suspected clinically................................... 45.2 Percentage of suspected teeth showing granulom a............................................ 17.6
home. Seventeen hundred and twelve cavities were discovered, not to mention 691 missing teeth that should have been replaced by substitutes to protect coffiplementary vital teeth, in danger of earlier degeneration were such action deferred unduly. B ut only 294 of these 723 mouths were examined roentgenographically, because, to repeat, this method was applied only to those conditions indicating periapical involvement; yet in these 294 cases, there were disclosed 249 carious conditions that the m irror and instrument failed to find, A full roentgenographic examination of every mouth would have disclosed much th a t the method employed had missed; but that approximately 85 per
discovered constitute a sufficient justification for the roentgenographic examinatio n ; but, in addition to these conditions, there was undetected by the clinical tests but discovered by the roentgen rays in the same 294 mouths, more than 100 cases of granuloma, one cyst, fourteen residual roots, ten well-developed cases of periostitis, and thirty-eight instances of root absorption; conditions that should have been treated earlier, N or is it amiss to interpolate here a rather illuminating presentation of data showing the results of the roentgenographic examination of twenty-five young ladies constituting the class in oral hygiene in the D ental D epartm ent of the University of Pennsylvania, this year. I t
1371
Ennis— Oral Roentgenology is unnecessary to recite the educational qualifications these students are required to possess, but they are extensive. M ore, these students are certainly interested in the maintenance of their own teeth, and surely since first contemplating the field they subsequently entered, they had probably looked after them more zealously than the average person looks after the teeth. N or should we lose sight of the fact th at many of the young ladies entering the course are the daughters, sisters or close relatives of dentists. T h e mouths of these embryo oral hygienists should show a healthful state, a well-attended set of teeth, an absence of infection and threatening growths. B ut the films, checked and rechecked w ith the greatest care and certitude, disclosed T a b le
2.— I n c i d e n c e
T o revert to the result of the examination of the Drexel Institute students, but avoiding the detailed statistics pertaining to the 160 young women selected to undergo the roentgen-ray examination, let it suffice to state that the roentgenographic survey revealed a great amount of infection or pathologic lesions that clinical examination did not disclose and never would have disclosed, So startling were the revelations among both male and female groups that the school authorities determined quickly on a complete roentgenographic examination for all future freshmen on entering college. T h e examination of the class that entered last September revealed a greater prevalence of caries than the average
o f E l e c t r o c a r d io g r a p h ic C h a n g e s in
160
W o m an S tu d e n ts
w ith a n d W i th o u t D e n t a l G ra n u lo m a
W ith W ithout Dental Granuloma Dental Granuloma Number Per Cent Number Per Cent Women electrocardiographed...........................................27 133 Normal tracings..................................................................23 85.2 109 82 Tracings showing some departure from n o rm a l.. . . 4 14.8 24 18
among the twenty-five students these con- found in earlier classes studied; but as to ditions: other conditions, practically similar proCaries ....................................................... 79 portions of infectious conditions were Rarefying osteitis with granulation found as those prevailing in preceding tissue ...................................................12 classes. T h e excess of caries may be atIm pactio n s................................. ............ 13 tributed to the economic conditions of Root absorption ................................... 1 the past three or four years. Less than Condensing o s te itis ............................... 1 sufficient dental treatm ent might easily Perforated r o o t ...................................... 1 be incident to the depression. Residual r o o t s .......................................... 1 T h ere is much to ponder over in reRetained t e e t h ........................................15 viewing the figures just offered. T o apMissing te e th .......................................... 41 proach a consideration of conditions W ith such impressive data collected shown, it may easily be conceded that from sources of unmistakable knowledge some of the students failed to adhere of the value of hygienic and healthful strictly to the tru th when, during the oral conditions, we may pause to consider examination, they were asked, “W hen the gravity of conditions that might be did you last have the services of your found generally among people in all dentist?” ; for too many replied, “Ju st walks of life were every inhabitant of our prior to my departure for school,” to city subjected to a similar examination.deserve complete credence; for the
The Journal of the American D ental Association
1372
plainly evident conditions observed through the m irror alone negatived many of these assertions and gave reason to suspect the credibility of the student. B ut the veracity of the student be comes an issue only when considered w ith the lesson the entire picture presents: If the conditions discovered among these students seem as threatening to you as they seem to me, and also to John H . A rnett, the medical director, and the faculty of the D rexel Institute, how are we to protect the growing generation against similar danger? F o r it is logical to deduce that similar conditions exist all over the country. I t is a fair assump tion that there would be even more proT a b l e 3.— S e x
and
A g e o f S u b je c ts
A ge Women 16 9 17 76 18 158 19 67 20 26 21 6 22 6 23 3 24 1 25 0 Over 25 5 not stated ..2 4
Men 12 83 153 100 73 29 27 14 5 2 4 0
Total 21 159 311 167 99 35 33 17 6 2 9 24
T o t a l.. , .381
502
883
nounced findings among younger persons not preparing for further studies and not undergraduate college students or pro spective oral hygienists. A nd among older persons, it may be said confidently, the infectious conditions that a complete ex amination would disclose might be double or treble the number found among col lege and university freshmen. Every school and college w ill soon be doing w hat has been tried at Drexel In stitute. Institutions not so w ell equipped w ith forces to handle the examinations w ill require either a complete report from the dentist who latest examined the stu
dent or a report from some reliable den tist in the college town. A nd accuracy will be expected of these examinations. Let dentists attend th at no discoveries be made to discredit the profession. T able 3 presents data on sex and age draw n from the examination of one fresh man class of 833 students a t Drexel In stitute when 27,398 teeth were under ob servation, in 2,797 of which caries was revealed. W hile the combined clinical and roent genologic examinations disclosed 3,034 carious spots, the clinical method revealed only 1,662. T h e roentgen-rays revealed 1,372. T h e roentgen-ray and clinical ex aminations agreed only in 237 cases, which represent the comparatively small proportion, about 10 per cent, of the ca rious conditions revealed, which was du plicated by the joint disclosures. (Table 4.) A nd if, however often we repeat a similar experiment on a large group of people, our findings approximate such a result, it is evident th at to exclude either of these methods in examining teeth is to shirk responsibility. N ot only is there a responsibility upon the dentist to ex amine roentgenologically the clinically suspicious teeth, but also th at attention should be given to the entire mouth, the teeth and edentulous areas th at have no obviously suspicious appearance. In the tables presented, regardless of the number of cavities, a tooth was counted as but one carious tooth. Sound filled teeth are not included. F or no longer is the chief concern of the dental profession merely repair, re placement, the treatm ent of the obvious. Prevention of disease looms as important, and the sphere of the dentist embraces completely the minutely conceived func tion of prophylaxis. W e know of sys temic diseases originating in caries and other hidden areas of oral putrefaction.
1373
E n n is— O r a l R o e n tg en o lo g y
lesions, such as th e granulom a and the cyst, absorbed roots, and m any oth er hid den sources of danger, discovery of w hich is the d u ty of every dentist. W ith o u t the roentgenographic exam ination, w e miss the assurance th a t comes from adopting the m ost scientific system of prophylaxis, of healing, of cure w hich m odern m ethods dem and th a t w e follow for the fullest protection of th e patient.
W e concede th e deleterious influence of septic teeth and tissues; and w e dare not ignore an agency offering to disclose such foci of infection. T o the contrary, w e m ust have such an agency close a t hand to locate and determ ine quickly w here abnorm al conditions exist. Roentgenographic equipm ent should be had in every office. N o extravagant claims are advanced in T
able
4 .— D
ental
C a r ie s ( C
o m p a r is o n o f
C
l in ic a l a n d
R
o e n t g e n -R ay
F in d in g s )
Teeth Caries revealed by clinical exam ination...................................................... 1,662 Caries revealed by roentgen rays....................................................................1,372 Roentgen-ray and clinical examinations agreed..................................... 237 Caries revealed clinically, but not by roentgen-rays.................................. 1,425 Caries revealed by roentgen rays but not clinically.................................. 1,135 T
able
5.— F r e q u e n c y
of
D
C a r ie s a s D e t e r m in e d R o e n t g e n - R a y F in d in g s
ental
and
by
C o m b in in g C l in ic a l
Number of students exam ined................................................................................ 883 Number of students showing caries..................................................................... 733 Percentage of students showing caries................................................................. 83 Approximate number of teeth exam ined.................................................27,398 Number of teeth w ith caries........................................................................ 2,797 Percentage of teeth showing caries.......................................................... 10.3 A verage number of carious teeth per student....................................... 3.2 T
able
6.— F r e q u e n c y
of
G
r a n u l o m a as
D
e t e r m in e d by
U
se o f
R
oentgen
R
ay s*
Number of students examined................................................................................ 883 Students showing granuloma.................................................................................. 175 Percentage of students showing granuloma........................................... 19.8 Approximate number of teeth exam ined................................................. 27,398 Number of teeth showing granulom a................................................................... 232 Percentage of teeth showing granulom a.................................................. 0.8 *Further information regarding this particular group study is presented in the American Journal of the M edical Sciences and the Dental Cosmos, June, 1933.
favor of this conviction, and none need be, for th e self-evident tru th s proclaim to th e w orld sufficient reasons, th e incalcu lable value of the instrum ent. O f course, th e roentgen rays miss m any existing conditions. C aries m ay be in such a posi tion in th e crow n of the tooth as to escape th e roentgen rays, and they w ill miss o th er danger spots th a t the explorer re veals ; b u t w ith o u t them w e miss chronic
P ublic schools, th e radio, the new s papers have carried on widespread educa tional cam paigns reg ard in g th e depend ence of h ealth on good teeth, and the pres ervation and reten tio n of vital teeth. H ence, th e grow ing opposition to ex tractions except as a last resort and the insistence of th e p atien t on the use o f the roentgen rays even afte r th e attending dentist advises extraction. In m any cases,
1374
T h e J o u rn a l o f th e A m erica n D e n ta l A ssociation
th e sufferer secretly visits the roentgenol ogist before subm itting to extraction of th e teeth. N o te how th e advertising den tist features th e roentgen-rays in his pub licity as a sign of advance, of m odern methods, and how his patients are harangued into believing th a t every pa tie n t should undergo such an exam ina tio n ; an d w e m ust concede th at, in theory, th e argum ent has reason. W ith d entistry th e first support of m odern m edicine to stem the flood of sys tem ic disorders underm ining m ental and physical health, it behooves th e profession to p u t its house in order if it is to be a potent agency in preventing infection th a t may ultim ately spell death. W e cannot stand by u n til forced to recognize the presence of sepsis, w hen the barest outlay of tim e and m oney w ould have detected th e infection and could have aborted or elim inated it before it invaded deeper tis sues and th e blood stream . D entists m ust preach th e gospel of a full-m outh roentgenographic exam ination fo r every patient, th e records to be re tained by th e dentist and filed fo r fu tu re reference. T h e principles of prophylaxis commend th e idea. I t is the logical evo lution of d en tal science tow ard decreas ing dental disease; and in the revelation of pathologic lesions and their location, area and extent, there w ould be a lessen ing of operative labor. W h ile m onetary considerations should hold no place in o u r discussion, it may be v en tured th a t th e equipm ent once owned, th e sm all cost of roentgen-ray films adds little to th e carrying charges of any office. I n fact, instead of an expense, th e m aking and use of roentgenogram s w ill show a p ro fit; for they contribute to building a practice, uncovering conditions th a t w ould otherw ise rem ain unrevealed and so u n treated . T h in k of the tim e, trouble, w orry, u n ce rtain ty saved w hen absolute certainty m ay be had fo r the m ere asking,
the m ere m a tte r of th e atten tio n called for in th e study of roentgenographic technic. N o separate charge should necessarily be m ade patients for the service, w hatever system o f charges m ight be follow ed in an office; and th is fo r several reaso n s: the service should be as incidental to the ex am ination of a p atien t as is now th e very first glance given a w orrisom e to o th or other tro u b le about w hich th e dentist is co n su lted ; and the n a tu ra l reaction of the patient against individual fees for specific necessary trea tm e n t should be considered. T here should be th e desire to impress pa tients w ith the fact th a t th e service is routine practice of th e office, and n ot ex traordin ary , and th a t th e resulting film is for ou r ow n know ledge and inform ation and is n o t the p roperty of th e patien t to display to his fam ily and friends. T h e re seems no b etter reason to ask a separate fee for such an exam ination th an there w o u ld be for th e use of pulp testers and tran sillu m in ato rs in m aking a clinical study, and for the w ear an d te ar on en gines an d explorers. A n d here it seems pertin en t to quote from an article by L. M . W a u g h ,1 entitled “ Radiology as an A d ju n c t in the P ractice of D en tistry .” D r. W a u g h had sent to 325 o u tstan d ing dentists th ro u g h o u t the U n ite d States and C an ad a a series of questions w hich included th e follow ing: Question 5 (a) Do you make a separate charge for each radiograph? Yes, 87; no, 62. (6) If so, does not the patient sometimes question the need of several in a given case? Yes, 74; no, 34. (c) If not in your own practice, do you believe this would be so in a great number of practices? Yes, 116; no, 28. (d) W ould this not be overcome by hav 1. W augh, L. M .: D. Cosmos, (N ov.) 1917.
59:1105
Ennis-— O r a l R o en tg en olo g y
ing it understood th a t the necessary radio graphs are a p art of the service, and as such are not charged for separately but are included in the general fee ? Yes, 147; no, 8. ( e) Do you find the time saved by the radiodontic findings compensates for the time required in making them ? Yes, 162; no, 8. T h e answ er to these tw o final queries reflect an interesting attitu d e on the question u n d e r discussion; and w hen w e appreciate th a t the questionnaire dates back to th e alm ost archaic days of dental roentgenography, and surely the infancy of th e system, how could the retu rn s be less impressive if a vote w ere taken at this tim e? In m ore th a n one th ird of the dental offices in our country, w e w ill find some so rt of x-ray ap p aratu s; w hereas, ten years ago, th e appearance of one w as a rarity. T h e profession has learned th a t roentgenology need not be a specialty, and th at, w hile dem anding intensive applica tion w hen studied as seriously as the sub ject w a rra n ts and a profounder know l edge of m any in tricate phases of dental theory, physiology, pathology and etiol ogy, as w ell as a technic akin to art, these very requirem ents are h ard ly m ore th a n every practitio n er is supposed to possess to perform th e usual functions th a t the profession imposes. Capable dentists are counted on to locate and diagnose patho logic conditions of th e teeth, th e m outh and the investing tissues, and it cannot be less th a n disconcerting to p atient or den tist when, fo r a m ere roentgenographic exam ination, reference m ust be m ade to some other dentist. T h e poignancy of this observation appears w hen w e note how advertising quacks and imposters publicize th is service, w hile otherw ise capable and ethical dentists adm it u n preparedness in so abundant a field of endeavor. B ut, you assert, no criticism is leveled
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against the physician w ho refers a patien t to a specialist. M a y it be ventured th a t the alm ost antipodean difference in the present day scope and responsibilities of the neighboring b u t distinctly separate professions is th e answ er to the assertion. In analyzing th e respective relations to the p articu la r profession served, it is n ot easy to com pare th e pediatrician, the neurologist, th e psychiatrist or the oph thalm ologist to th e roentgenologist. T h is passes by the th o u g h t of m any physicians th a t th e general p ractitioner has per m itted him self to be erased from the m edical p ic tu re ; b u t know ledge of the terrific course of study and the experience the m edical m an m ust undergo to gain recognition as a specialist of highest re pute, of th e concentration he is required to give his specialty, of the never ending rounds of clinics he m ust attend, cannot be disregarded. T h e degree of know ledge upon w hich th e roentgenologist bases his rig h t to be adm itted a specialist is h ardly in excess of w h a t every dentist is expected to possess. Surely the study incident to learning th e application of th a t know l edge to the m aking of and in terp retin g of the roentgenogram s lies w ith in easy grasp. T h e capable dentist should not allow him self to be forced entirely into the background by th e specialist, becom ing a m ere satellite of the specialist as, in medicine, th e re seems a tre n d ; for his field w ill n ot excuse it, and his patients w ill not p erm it it. Rem em ber th a t sporadic experiments afte r a desultory course of reading, coupled, perhaps, w ith some superficial b u t high pow ered instruction from equip m ent salesmen, w ill n ot constitute one a roentgen o lo g ist; and it is pathetically tru e th a t too m any dentists assume quali fication on such im m ature and pretended preparation. T h e poorly train ed oper ators, advertising charlatans and com m er cial x-ray laboratories m ust be driven to
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T h e J o u rn a l o f th e A m erica n D e n ta l A ssociation
cover, and w ill be w hen th e better equipped, ethical dentists enter the field in mass. T h is w ill come to pass w hen w e reach th e ideal adjustm ent, w hereby each cli nician is his ow n roentgenologist. T o a r rive a t this goal, m any may find it ex pedient to re tu rn to th e ir books, to attend num erous clinics, perhaps to seek close personal instruction from th e experienced teachers of our acclaimed schools. B u t brushing up on pathology, physiology, eti ology and th e m odern concepts of prophy laxis m ay n o t prove a poor policy even to the w ell inform ed. N o thoughtlessly m ade or intended de rogatory observation is this, but u n v ar nished tr u th ; for an appalling,deficiency in the fundam entals of dental know ledge is too often exhibited by m any w ith years of practice th a t should have been im proved by continued reading. W e re you to spend a few days w ith some active roentgenologist and hear th e practitioners w ho come to consult him, hear th eir in terpretations of roentgenogram s and of related symptoms, hear th e ir nervously ventured diagnosis o r suggested tre a t m ent, you w ould find m any as w ofully lacking and as w ofully w rong as w ere the physician and the dentist to w hom I have alluded. T h e alert, progressive clinician is ever searching fo r new er, better methods. N o te th e caliber of m en attending the im portant conventions, count th e o u t standing dentists listening intently to val uable discussions, see the ablest of the p ro fession observing closely th e table clinics, in te n t on learn in g anything th a t is an im provem ent in theory o r technic; fo r den tistry is certainly a progressive science, always ready to discard old ideas and substitute th e tested new er th o u g h t; and it is quite easy to believe th a t five years hence w ill see those considered lacking w ho cannot in te rp re t roentgenogram s and
operate th e apparatus producing them . T h a t th is shortcom ing w ill n o t con tinue is w ritte n on th e ever changing sands of science. I n th e very near future, no applicant incapable of qualifying as a roentgenologist w ill be licensed to prac tice dentistry. In Pennsylvania, the state board of d en tal exam iners requires stu dents to m ake a com plete roentgenographic exam ination of a patien t and w rite a fu ll rep o rt of th e roentgenographic findings; and the resu lt of th a t test counts no little for or against th e ap plicant. Pennsylvania recognizes ro en t genology as an o u tstanding factor in the routine practice of th e profession, and the theory th a t none lacking ability and ex perience to perform this routine function should be perm itted to practice dentistry is so w ell founded th a t other states w ill follow this stan d ard , and shortly. J u s t as h a lf-tru th s are often m ore dangerous th a n w hole lies because m ore difficult to confute, in dentistry p a rt or h alf treatm en ts m ay be m ore dangerous th a n none a t a l l ; fo r they m ay cover up and hide fo r too long a period insidious infections th a t m ight have otherw ise dem onstrated th e ir existence earlier. T h e study of d en tistry embraces as im perative the search fo r causes, th e diagnosis and prognosis of suspicious areas. T h e safe practice is to consider all areas suspicious u n til proved o th erw ise; and for this theory, th e clinician as his ow n ro en t genologist is th e ideal arrangem ent. W ith th e th o u g h t th a t com petition usually re sults in th e survival of th e fittest, and recalling th e philosophy th a t self-preservation is th e first law of n ature, th e older practitioners m ay w ell contem plate th a t th e oncom ing dentist w ill be b etter pre pared to m eet th e present need of the profession in th e h ealth preservation p ro gram o f th e n atio n in th a t he w ill be his ow n roentgenologist. 4001 Spruce Street.