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The Economic Aspects of Preventive Dentistry*
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The Journal of the American Dental Association
this cave in m y face and fix me so I can eat.”
A fte r explaining the difficulty of such a procedure, I advised him to seek help elsew here. I heard from this m an in Ja n u a ry , 1929, and his condition w as u n changed. I t is m y opinion th a t had the rig h t an g u lar segm ent of bone been le ft in place, new bone w ould have continued to form so th a t, a t the proper tim e, seques tru m could have been removed w ith o u t the bad deform ity and the resu ltan t loss of function. D o not let the p atient or any one else influence you to remove a sequestrum u n til you are sure such a procedure is cor
rect. A pathologic fra c tu re may be the result. See th a t adequate drainage is m aintained and allow n a tu re to assist. I f this is done, w e w ill have less deform ity and b etter fu nctional results in fra ctu re cases. I am sure I have had my share of diffi culty in the h an dling of such cases as are m entioned in this paper. N o t a ll of my patients have been cured nor do I expect all fu tu re patients to be. I do feel th a t w e owe p atients the very best of our efforts and th a t they have a rig h t to expect us to keep ourselves inform ed so th a t w e shall be able to ren d er th a t w hich is best in th eir p articu lar case w hen we are called to serve them .
TH E ECONOMIC ASPECTS OF PREVENTIVE DENTISTRY* By EDWARD J. RYAN, B.S., D.D.S., Chicago, 111.
B
E H I N D all g reat social m ovem ents — be they concerned w ith the w orld of practical affairs, of esthetic in te r est, of ethical concepts— is a philosophy. T h is philosophy represents the attem p t to give m eaning or value to a situation. W h e reas science is concerned w ith analy tic description, philosophy is concerned w ith in terpretation. D u ra n t tells us th a t “to observe processes and to construct m eans is science; to criticize and coordi n ate ends is philosophy. . . . Science gives us know ledge, b u t only philosophy gives us w isdom .” T h e philosophy of the p re vention of disease implies an attem p t to establish an ideal, th a t is, a m ental con *R ead before the Section on D ental Econom ics at the M id w in ter C linic of the C hicago D en tal Society, Feb. 4, 1931. Jour. A . D. A ., M a y , 1931
cept of a hoped-for practical state. T h e ideal of preventive dentistry, then, is the creation of a condition of hum an life w here no d en tal disease exists. T o w a rd this end, o u r philosophy directs and stim ulates o u r science. I f th e prevention of disease needs any justification, it m ight be w ell to tu rn to the w ords of the philosopher Jo h n Locke. In the year 1692, Locke published his m onum ental w ork, “ Some T h o u g h ts C oncerning E d u catio n ,” w hich b eg in s: A sound m ind in a sound body, is a short b ut full description of a happy state in this w orld. H e th a t has these two, has little m ore to w ish fo r; and he th a t w ants e ith e r of them, w ill be but little better for a n ything else.
In short, the prevention of disease is concerned prim arily w ith the preserva-
Ryan— •Economic Aspects of Preventive D entistry
tion of health, from which springs a large measure of men’s happiness. Unfortunately at the now, the present, the contemporary state of dental science, there are few specific causes and still fewer specific cures for dental disease. Of theories and hypotheses, there is no end; of proved facts and uncontrovertible evi dence, there is little. The exact cause of dental caries is unknown, the etiology of much periodontal disease is still ob scure, the causation of mouth-tissue ma lignancies remains a mystery. At the best, our methods of prevention are empiric. That is, our methods are based on experi ence or observation and not on a complete understanding of underlying causes. It is necessary that we make plain to our patients that our services of prevention produce excellent results and much good, but as long as first causes are unknown to dental science, we cannot guarantee ab solute prevention. It is the same old story: indicating to our patients the lim itations of dental treatment and empha sizing that the phenomena with which dentistry deals are biologic. Truth telling is the foundation of all long-term professional and economic success. A critical study of the economic as pects of preventive dentistry requires a great deal more than the mere considera tion of practices profitable to the dentist. The economic advantages to the public— which are measureable in terms of health values, the conservation of time and mon ey saving—must never be lost sight of. If in the health education of the public on dental matters, the major emphasis is on the profit to the dentist, a dismal fail ure may be predicted. On the other hand, if emphasis is laid on the public’s profit from a program of prevention, we may expect a larger measure of success. A study of the economics of preventive dentistry requires much more than the
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presentation of preventive services to the individual patient in the dental office. As in all problems of public health, the battle against the forces of mass ignor ance, fear, superstition and apathy is of great importance. The projection of the idea and the ideal of preventive dentistry into the consciousness of the public is a problem in adult education. C. E. A. Winslow of Yale University has said: T h e public-health cam paign of the p re s ent d a y is, th ere fo re, based on a broadly con ceived p ro g ra m of a d u lt education. It uses, w ith m ore o r less persistence, the new spaper, the health d e p artm e n t bulletin, the special leaflet, the lecture, the radio-talk, the cinem a, the poster, th e exhibit.
A consideration of this important sub ject of adult education is not within the scope of this paper. It is enough to say in passing that, within the next few years, we must break fr.ee from some of our traditions and antiquated ethics and, as an organization, tell the true story of dentistry to the public. Of the dangers that are lurking here, we must be fully aware. A publicity campaign poorly or ganized, blunderingly promoted, undigni fied, might defeat the very purpose tor which it was intended. That is, by crude methods of advertising, we might inno cently enough place ourselves, in the pub lic eye, in the same category as the ad vertising dentists, who have always been anathema to the intelligent public and the ethical members of the profession. Let no one interpret these remarks as a state ment against the basic idea of public edu cation in dental matters. With the idea of public education, we most enthusi astically and whole-heartedly agree: the manner and method of appeal to the pub lic is the important thing. W e should hesitate before we use methods which might jeopardize our position or under mine the public’s confidence in the dental profession.
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The road toward the more general practice of preventive dentistry is block aded by two serious obstacles: first, the indifference and the apathy of a large number of the profession; and, second, the ignorance of the public. It would appear almost axiomatic that before we can make progress in public education, we must first do considerable missionary work within the profession. In these times, when one hears so much talk of making the public “dental-minded” and “dental-conscious,” it might be well to hesitate and direct more vigorous effort toward the education of the profession in the importance of preventive dentistry. It is quite conceivable that the public might become educated up to a level of desire for dental services which large numbers of the profession could not or would not satisfy. T o be specific: Mothers, alert and well informed, after reading of the importance of early dental, care, have often taken their children to some dental office, to be met with this sharp rebuff: “Baby teeth need no attention.” And, too often, adults, learning from various sources of the dangers of dental infec tion, have stepped into a dental office to be told that: “X-rays are not necessary,” or “All this talk of infected teeth is a fad of physicians and dental alarmists.” The abysmal chasm that exists between the theory of prevention and the practice of prevention as it relates to the profes sion and to the public is appalling. The professional literature is full of worth while suggestions regarding procedures and practices directed toward prevention and the health significance of dentistry. Our meetings, for the most part, are of a high scientific and professional character. The practice of dentistry has not kept pace with the philosophy of dentistry. Arsenic devitalizations, “tin-can” crowns, amalgam slugs, occult diagnoses still
make up too much of the practice of dentistry. The indifference of the public to prevention is largely the reflection of the apathy and lack of enthusiasm of the profession. The classic slogan of Glenn Frank, “Millions for pills, but not one cent for prevention,” presents a vivid pic ture of a common public attitude. Preventive dental service has an im portant economic aspect. The profession has been slow to grasp the economic self profit of a program of prevention; the public has not been impressed with the economic advantages of preventive dental service. The economic improvement of dentists should follow whenever they escape from the tether of the vicious tri umvirate : materials, merchandise and me chanics, and begin to place the emphasis on health, biologic processes and preven tion. And of this there can be no doubt: the public likewise will profit when the dental profession becomes biologic and prevention minded. The prevention of dental disease is the professional ideal of dental practice. And none have ever found an argument against the ideal of prevention except a few shortsighted dentists who feared that prevention might some day become so nearly perfect that their services might no longer be necessary. But such a dental millennium, unfortunately, is very dimly in the future. The indifference of pa tients is the great obstacle to prevention. In theory, almost every patient accepts the thesis that prevention is far better than cure; but, in practice, most patients are chance-takers and prefer not “to cross the bridge before they come to it.” Pa tients in the throes of dental pain will rush to a dentist for relief and those un fortunates with disabled and crippled mouths will spend large sums of money for restorative dentistry. Dental pain and mutilation are largely preventable;
Ryan— Economic Aspects of Preventive D entistry
it is our duty and to our profit to force these truths on the consciousness of our patients. Like all sound economics, the practice of preventive dentistry is mutually profit able; the patient preserves his denture and the dentist increases his income. Over and beyond the biologic preserva tion of the human denture, the patient enjoys a three-fold profit from preventive measures: he avoids the inconvenience and the drain on efficiency that comes from dental pain and infection; he con serves his time by not being required to spend long hours in dental treatment, and he saves large sums of money by com ing frequently for prophylaxis and the treatment of incipient disease conditions rather than waiting until expensive and extensive restorative dentistry is demand ed. The dentist who practices preventive dentistry is assured of a steady and larger flow of income by the frequent return of patients, and he enjoys the mental sat isfaction that comes from the knowledge of a job well done. As the advertiser says, “Repetition is reputation,” so let us repeat over and over again and drum into our patient’s consciousness this truth: N eg lect costs m ore than trea tm en t; in pain, in tim e a nd in m oney.
There are four general dental condi tions which preventive service is to be di rected toward; namely, malocclusion, dental caries and the possible pulp se quelae, periodontal disease and mouthtissue malignancies. Preventive service is to be carried out from the “cradle to the grave.” In childhood and early adult life, our services are directed toward the prevention of malocclusion and caries. In the middle decades, we are chiefly con cerned with the prevention of disease of the periodontal tissue. In the later years, we are concerned with the dangers of malignant neoplasms. Our services
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are concerned with the whole life span of the individual. W e need never fear that our services will ever be unnecessary; ours is a lifetime job. M A LOCCLUSION
To prevent malocclusion, the child should come to us early and often, de ciduous teeth should be preserved, and the pernicious habits of mouth-breathing, thumb-sucking, pillowing, etc., should be corrected. Our job is not altogether me chanical or manipulative. The child brought to us for observation and exam ination is coming for our knowledge and advice. We are not talking of ortho dontia, but of prevention of the need for orthodontia. The general practitioner should recognize the forerunners of mal occlusion and attempt to intercept it. For his knowledge and judgment, he is entitled to a fee. The advice that we give the mother regarding dietetics and its relationship to the dental structures, the measures which we apply to the cor rection of vicious habits, the great care which we exercise in the treatment of a deciduous tooth to preserve the totality of the deciduous dentition are important services which we cannot give away. If we evaluate our services and set our fees in terms of grains of alloy, pennyweight of gold and quantities of cement, and do not receive pay for our knowledge and advice, we are apt to be inclined to do only the mechanical or profitable thing and let the advisory or unprofitable thing slip. Knowledge and information which it has taken of our time and money to acquire cannot be given away. It is a question of profit and loss. If we give of our knowledge, the patient profits and so should we; if we withhold important information, the patient loses and so do we. Let us give more time and study to the problems of the interception of maloc-
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elusion—and be paid for it. No other professional man gives his “brains” away. D E N TA L CARIES
Caries is one of the prices which man pays for becoming civilized. In these days when scientists speak in terms of emergent evolution, we may look on dental caries as an expression of this prin ciple. As man evolves from the primitive to the civilized, the ratio of caries in creases in direct proportion to his ascent. Witness the comparative freedom from caries in the mouths of the Australian bushman and the Eskimo as the repre sentatives of primitive types, and the ram pant caries in the mouths of our moviegoing, roadster-riding, roadhouse-danc ing, American young people. Dental caries viewed in this light takes on a social significance; and if we may reason by deduction, we may expect the incident of caries to increase as civilization be comes more complex, unless the services of preventive dentistry become more ef fective. Considering this type of dental disease in its broadest light, we under stand it as a condition that appears to at tack man in the higher brackets of civili zation. To defeat these tendencies, we cannot hope nor do we wish to reverse the process of evolution. What we hope to do is to find the thing or things in modern man’s life and habits which make him susceptible to the ravages of dental hard-tissue disease. Somewhere in the domain of bacteriology, immunology, endocrinology, biochemistry, we may find the answer to the riddle. Until we find a specific one, we must continue to prac tice preventive dentistry empirically. We must instruct our patients in mouth hy giene and dietetics; we must practice good surgery in our operative dentistry and prophylactic treatments; for all of which, we must be paid.
All programs of prevention emphasize the importance of education. Through the medium of the written word and the spoken word and by pictorial methods, the public is appealed to. The public is asked to help in the prevention of forest fires, traffic accidents, disease. Even now, the effort in the field of dentistry is more commercial than professional. The den tifrice, mouth-wash and toothbrush manufacturers are using tons of paper, gallons of ink and nationwide radio broadcasts to sell the public their products and, incidentally, to preach the doctrine of prevention. Fortunately, with the ex ception of a few manufacturers who gar bled facts, some who used the fear appeal and several who distorted scientific truths, the advertising has been of a high type. The fact stands that dentists and the pro fession of dentistry have depended on sec ond-hand, but not second-rate, advertis ing to tell their story. But we still enjoy the greatest of all educational opportuni ties, the opportunity to tell the patient, direct, man to man, personalized, the story of dentistry. In the presentation of the case of pre ventive dentistry, this personal relation ship between buyer and seller is of funda mental importance. In general advertis ing, which is directed toward thousands of people, the appeal must be general or abstract; in the relationship between dentist and patient, we may educate the patient to a general or abstract idea, the idea of prevention, and then personalize the idea to make it specific and concrete — the application of the idea of preven tion to the individual case. Because the terms “selling,” which suggests commer cialism, and “propaganda,” which sug gests the unpleasantness of the late war, are opprobrious to most dentists, we may call this appealing to and teaching the patient education. And like all manner
Ryan— Economic Aspects of Preventive Dentistry and kinds of education, there are tuition fees required. W h e n w e in stru ct the patient in the technic of proper brushing of the teeth, in the use of dental floss, in th e require m ents of the safe and sane dentifrice, in the essentials of dietetics, w e are teachers of physiology. I f w e are to prepare o u r selves to be good teachers, w e m ust read and study and attend society meetings, all of w hich takes tim e, effort and money. F u rth erm o re, if w e are to be good teach ers, w e m ust be patient, take tim e and be repetitious in the presentation of our sub ject. I f w e are to be vigorous, convinc ing, interesting in the presentation of the subject of prevention, the p atien t is going to profit. A nd shouldn’t w e ? I should suggest fo r those w ho consider it too much of an innovation to set dow n a sep arate fee fo r advice, consultation and edu cation th a t they m ake sufficient provision in th eir estim ates to cover the tim e spent in patient-teaching. I f th e roentgenographic, prophylactic, operative and pros thetic fee fo r a given case is, say, $ 1 0 0 , I should put dow n an additional $5 or $ 1 0 to cover the tuition fee fo r the dental education of the patient. T h e technical aspect of the prevention of the com plications from caries may be divided into the roentgeriographic and the operative. T h e use of bite-w ing films at freq u ent intervals fo r every case to dis cover the beginning of proxim al caries is very im p o rtan t. T h e early opening and filling of the occlusal fissures in m olars afte r the m anner of prophylactic odontot omy, as described by H y a tt, is an excel len t procedure. T h o ro u g h and careful prophylactic trea tm e n t to remove plaques and deposits is an operative procedure of first im portance. T h e early recognition of caries, the proper suigery of cavity preparation an d the placem ent of m e chanically and scientifically sound restor
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ations represent the d en tist’s effort to p re vent the vicious sequelae of dental ca rie s: pulp involvem ent, periapical disease and systemic com plications. T h e tim e and effort w ill be m u tu ally profitable w hich w e spend in explaining to patients the ad vantage of correct roentgenographic ex am inations over guessw ork in the search for incipient ca ries; of prophylactic odon totom y over the severe excavations neces sary in advance caries; of th e value of prophylactic trea tm e n t over “teeth clean ing” ; of th e proper surgery of cavity prep aration w ith extension fo r prevention, etc., over “ d rillin g a hole” ; of resto ra tions of proper contour, contact an d oc clusal form over fillings or m etal slugs. PERIODONTAL DISEASE
In the consideration of th e prevention of periodontal disease, w e m ust rem em ber th a t th e clinical m anifestations of this condition are varied and of apparently many different sources. W e observe the periodontitis of mechanical origin, the perverted mechanics of occlusion; perio dontal irrita tio n from im proper dental restorations, open contacts, e tc .; m arginal irritatio n from calcarious deposits; the im proper use of tooth picks, toothbrushes, etc. W e fu rth e r observe the periodontal disease of b acterial o rig in : the residual in fection of th e periodontium as a resu lt of such an active condition as V in cen t’s in fection ; th e soft tissue irritatio n th a t comes from h ab itu al unacquaintance w ith the toothbrush. A m ong the periodontal disease of general, systemic or biochemi cal origin, w e find the periodontitis of diabetes an d of the deficiency diseases. T h erefo re, w hen w e think in term s of the prevention of periodontal disease, we m ust consider the m echanical, bacterial and m etabolic n atu re of the condition. W e m ust perform our m echanical opera tions of operative and prosthetic dentistry
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w ith both a technologic and a biologic point of view. W e m ust restore parts to form and function and avoid the lurking dangers to the supporting tissues th a t come from im proper .contour, overhanging m a r gins and occlusal stress and strain . W h a t w e do m echanically, if done w ell, may prevent the com ing of periodontal dis ease; w h a t w e do m echanically, if done poorly, may sometimes resu lt in serious diseases of the su pporting tissues. T o present the picture graphically to the pa tient, it is perfectly proper to present the h o rrible exhibit of “ tin can” crow ns, of the roentgenographic evidence of am al gam slugs pushed w ith a generous thum b into the gingival tissue, of clasps th a t pry teeth loose by th e ir too affectionate em brace. W h e n the p atient views this rogues’ gallery of dental crim inals, he w ill be m ore receptive to the idea of m e chanical dentistry done w ith the idea of prevention; th a t is, he w ill be ready for good dentistry. T h e re is no specific bacterium th a t has been dem onstrated as the causative agent in chronic periodontal disease. Amebas have had th eir d a y ; various form s of the streptococcus have been indicted as the agent responsible fo r periodontal disease. N ow , w e hear of detoxifying the m outh b acteria and the consequent antigenic use of the bacterial cells to produce a form of im m unity. In the conquest of periodon titis of suspected bacterial origin, w e m ust follow the fundam ental principles of pathology ra th e r th a n the enthusiasm s of d ru g an d chemical m anufacturers. W e should rem em ber th a t “ the probability of a successful infection varies directly w ith the num ber of organism s introduced, the virulence of the invaders and the resist ance offered by th e individual.” L ike wise, w hen w e th in k in term s of the pre vention of periodontitis of bacterial and m etabolic origin, w e m ust keep close to
fundam ental biologic conceptions and shun th e fallacious claim s of the nostrum m a n u factu rer. A b ottle of T h is or T h a t or a tube of Such and Such from the cor ner dru g sto re m ay have a certain psycho therap eu tic value, b u t w ill do little to de crease th e dosage an d virulence of p atho genic bacteria o r increase the resistance of the host, an d still rem ain a safe agent to the no rm al tissue cells. T h is certainly is not intended to m ean th a t drugs have no place in th e prevention or treatm en t of periodontal disease. V arious m edicam ents — m ild antiseptics, astringents, etc.,— have a definite place in the treatm en t of certain periodontal conditions. I am attem p tin g to say th is : P atien ts cannot buy prevention of periodontal dis ease at a d ru g store in a glass bottle or a m etal tube. T h e y can buy prevention from dentists w h o apply the fundam ental principles of bacteriology, pathology and surgery to each individual case by opera tive procedures w hich improve the hygiene of the m outh, th ro u g h scaling and polish ing of th e teeth and hygienic restorative dentistry, an d by in stru ctio n in the proper use of th e toothbrush, soft-tissue m as sage an d the essentials of dietetics. A gain, standard ized m ethods and proprietary products cannot prevent periodontal dis turbance. In d iv id u al attention, personal case study, a consideration of the organic wholeness of th e patien t by the dentist constitute the only intelligent m ethod of preven tin g periodontal disease. A nd so let U S tell our patients. M A LIG N A N C IE S
M a lig n a n t neoplasms are apparently on the increase. In the prevention of can cer of th e m outh and environm ental tis sues, the dentist can be of first im portance. In an address on “ C ancer as a W o rld P roblem ,” before th e N e w Y o rk A cad emy of M edicine, Joseph C o lt Bloodgood,
Ryan— Economic Aspects of Preventive D entistry professor of clinical surgery of Johns H opkins U niversity, said: P ra c tic a lly every lesion of the m outh can be fe lt w ith the finger, seen w ith the eye, or p h otographed w ith the x-rays. A s the cause of cancer of the m outh is due to ragged, d irty teeth, ill-fitting plates, tobacco in any form , a n d th e re is alw ays first a non-cancerous lesion easily recognized, the dentist, w hen people a re educated to come to him fo r p e ri odic exam ination, should, w ith ra re excep tions, find the local lesion in a stage in w hich it can be cured by the rem oval of the causes.
C om plete and frequent exam ination by the dentist, education of the patient to the dangers of w h a t lurks in unclean m ouths and of im proper dental appli ances, a suspicion of all prolonged inflam m ation and lesions about the m outh— persistent “ canker” sores, soreness of the tongue, leukoplakia of the soft tissues of th e m outh— and the insistence on early surgery for unknow n grow ths w ill do m uch to prevent precancerous lesions from becoming cancerous, and for those th a t have already undergone m alignant degeneration, w e, by o u r insistence on early trea tm e n t, may prevent m etastasis and so save lives. I f w e are to fulfil our health obligation to the com m unity, the dental exam ination m ust be som ething m ore th a n a h u n t for holes and spaces, and o u r a ttitu d e m ust be different from th a t of the mechanic. In a biologic and biomechanical approach to ou r problems, w e w ill find fulfilm ent, th e larg er life, and profit to our patients and to ou r selves. T h e entire case for prevention may be sum m arized in the w ords of Bloodgood, who, discussing the problem s of the pro fession of journalism in public health w ork, said: W e cannot expect m uch m ore of this p ro fession (jo u rn alism ) until the dental, m edi cal, and n u rsin g professions take up m ore seriously the ideas of p rev en tiv e m edicine. T h e n w e w ill be in a b e tte r position to recom
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m end to the jo u rn alists th a t the d aily p ress is the best m eans of info rm in g the people on rules of health, the necessity o f p rev en tiv e m edicine; a n d not only of the new d isc o v er ies, but o f th e ir application.
T h e w ages of neglect are payable in pain, in tim e, and in money. A n u n d erstan d in g of the economic ad vantage to the dentist th a t comes from the practice of preventive d en tistry is contingent on the d en tist’s a ttitu d e to w ard his profession. F o r the m an w ho is forever seeking th e “big cases,” the one w ho constantly talk s of “big con tra c ts” an d thousand dollar reconstruc tions, the economic aspects of the practice of preventive den tistry may have no ap peal. T h e “ thousand d o llar cases,” most of us w ill agree, are w indfalls th a t come once in a lifetim e, if at all. M o st of us m,ust depend fo r o u r livelihood o n the frequent re tu rn of patients, th e o rdinary and nonspectacular fees and routine d en t istry. A nd, fu rth erm o re, few of our patients are prepared o r w illin g to be the other party to these spectacular “ th o u sand d o lla r” transactions. W e have gone a long w ay to w ard economic im prove m ent w hen w e succeed in im pressing en ou r patients th e saving to them in tim e and money th a t comes from freq u en t vis its to the d en tal office for exam ination, prophylaxis and the trea tm e n t o r correc tion of simple carious defects or gingival inflam m ation. T h e steady flow of re tu rn ing patients, each paying a fair fee for dental treatm en t, in the long ru n shows a m ore favorable business office rep o rt th an th e trea tm e n t of th e occasional and spectacular case and th e atten d in g in ter vals of idleness. C h ild ren ’s dentistry, prophylaxis, simple operative procedures w hich are of the greatest value to the patient can likewise be m ade profitable to the dentist. T h e shunning of the sim ple things w hich are producible in great volume, in the fruitless search for the
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w ill-o ’-the-w isp of a spectacular and high fee case, is a common d ental economic fallacy. A m erica is an insurance-m inded nation. W e insure our lives, ou r incomes against the inroads of ill-health and accident, our homes and our goods against fire and rob bery; w e insure against the liability of an autom obile accident, a misplaced golf shot and a suit for m alpractice. B u t in surance for dental health rem ains u n know n. M en w ho spend freely of their money for every conceivable form of in surance still too com monly begrudge m oney spent to “ insure” their dental mechanism. L e t us present the case of preventive service to our patients as a form of insurance. T h e analogy is strik ing. T h e money spent each year for d en tistry represents the “ prem ium ” neces sary for the hazards, risks and responsi
bility of a p articu la r case. A nd like all other form s of insurance, the rate is higher in relation to th e h azard s of the p articu lar case: th e person w ith a great susceptibility to caries, for instance, m ust pay a higher “ prem ium ” rate, represented in a g reater yearly outlay fo r dentistry, th an the person w ith g reater im m unity. In common w ith life insurance alone, dental h ealth insurance pays a “ divi dend.” T o recover the money spent for accident, health, fire, burglary, or lia bility insurance, it is necessary th a t w e suffer a loss of some kind. N o t so w ith dental h ealth insurance. T h e “ divi dends,” w hich are large and generous, begin the day th a t the patien t subscribes for preventive d ental service, and they are payable, n o t in script, n o r in stock nor in cash, b u t in the greatest of all m un dane rew ards— health.
CAST GOLD ALLOYS: THEIR PHYSICAL PROPERTIES A N D DENTAL APPLICATION* By JO H N S. SHELL, B.S., San Francisco, Calif. H E investigation of the physical properties of gold alloys as related to their use in dentistry has opened a new era in the field of restorative den tistry. T h e em piric m ethods so long practiced by the dentist in selecting m a terials, and the dorm ant attitu d e of many dental m anufacturers, led to so m any failures in com plicated restorations th a t operators w ere forced to m odify their ideas in design to comply w ith the lim ita
T
*R ead before the Section on P a rtia l D e n tu re s ; C row n and B rid g e a t the M id w in ter Clinic o f the C hicago D ental Society, Feb. 3, 1931. Jour. A . D . A . , M a y , 1931
tions of the m aterials. T h e past decade has seen a m arked im provem ent in the physical properties of gold casting alloys fo r dental purposes, and as decided a change in the attitu d e of the progressive dental p ractitioner to w ard th e reception of the accum ulating d ata in the field of physical m etallu rg y as applied to den tistry. T h e science dealing w ith the investiga tion of the in tern al stru ctu re of m etals is of such recent developm ent, w hen com pared w ith m ost other fields, th a t it is not surprising to find its practical applica tion to d entistry slow er th an th a t of the
The Journal of the American Dental Association
this cave in m y face and fix me so I can eat.”
A fte r explaining the difficulty of such a procedure, I advised him to seek help elsew here. I heard from this m an in Ja n u a ry , 1929, and his condition w as u n changed. I t is m y opinion th a t had the rig h t an g u lar segm ent of bone been le ft in place, new bone w ould have continued to form so th a t, a t the proper tim e, seques tru m could have been removed w ith o u t the bad deform ity and the resu ltan t loss of function. D o not let the p atient or any one else influence you to remove a sequestrum u n til you are sure such a procedure is cor
rect. A pathologic fra c tu re may be the result. See th a t adequate drainage is m aintained and allow n a tu re to assist. I f this is done, w e w ill have less deform ity and b etter fu nctional results in fra ctu re cases. I am sure I have had my share of diffi culty in the h an dling of such cases as are m entioned in this paper. N o t a ll of my patients have been cured nor do I expect all fu tu re patients to be. I do feel th a t w e owe p atients the very best of our efforts and th a t they have a rig h t to expect us to keep ourselves inform ed so th a t w e shall be able to ren d er th a t w hich is best in th eir p articu lar case w hen we are called to serve them .
TH E ECONOMIC ASPECTS OF PREVENTIVE DENTISTRY* By EDWARD J. RYAN, B.S., D.D.S., Chicago, 111.
B
E H I N D all g reat social m ovem ents — be they concerned w ith the w orld of practical affairs, of esthetic in te r est, of ethical concepts— is a philosophy. T h is philosophy represents the attem p t to give m eaning or value to a situation. W h e reas science is concerned w ith analy tic description, philosophy is concerned w ith in terpretation. D u ra n t tells us th a t “to observe processes and to construct m eans is science; to criticize and coordi n ate ends is philosophy. . . . Science gives us know ledge, b u t only philosophy gives us w isdom .” T h e philosophy of the p re vention of disease implies an attem p t to establish an ideal, th a t is, a m ental con *R ead before the Section on D ental Econom ics at the M id w in ter C linic of the C hicago D en tal Society, Feb. 4, 1931. Jour. A . D. A ., M a y , 1931
cept of a hoped-for practical state. T h e ideal of preventive dentistry, then, is the creation of a condition of hum an life w here no d en tal disease exists. T o w a rd this end, o u r philosophy directs and stim ulates o u r science. I f th e prevention of disease needs any justification, it m ight be w ell to tu rn to the w ords of the philosopher Jo h n Locke. In the year 1692, Locke published his m onum ental w ork, “ Some T h o u g h ts C oncerning E d u catio n ,” w hich b eg in s: A sound m ind in a sound body, is a short b ut full description of a happy state in this w orld. H e th a t has these two, has little m ore to w ish fo r; and he th a t w ants e ith e r of them, w ill be but little better for a n ything else.
In short, the prevention of disease is concerned prim arily w ith the preserva-
Ryan— •Economic Aspects of Preventive D entistry
tion of health, from which springs a large measure of men’s happiness. Unfortunately at the now, the present, the contemporary state of dental science, there are few specific causes and still fewer specific cures for dental disease. Of theories and hypotheses, there is no end; of proved facts and uncontrovertible evi dence, there is little. The exact cause of dental caries is unknown, the etiology of much periodontal disease is still ob scure, the causation of mouth-tissue ma lignancies remains a mystery. At the best, our methods of prevention are empiric. That is, our methods are based on experi ence or observation and not on a complete understanding of underlying causes. It is necessary that we make plain to our patients that our services of prevention produce excellent results and much good, but as long as first causes are unknown to dental science, we cannot guarantee ab solute prevention. It is the same old story: indicating to our patients the lim itations of dental treatment and empha sizing that the phenomena with which dentistry deals are biologic. Truth telling is the foundation of all long-term professional and economic success. A critical study of the economic as pects of preventive dentistry requires a great deal more than the mere considera tion of practices profitable to the dentist. The economic advantages to the public— which are measureable in terms of health values, the conservation of time and mon ey saving—must never be lost sight of. If in the health education of the public on dental matters, the major emphasis is on the profit to the dentist, a dismal fail ure may be predicted. On the other hand, if emphasis is laid on the public’s profit from a program of prevention, we may expect a larger measure of success. A study of the economics of preventive dentistry requires much more than the
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presentation of preventive services to the individual patient in the dental office. As in all problems of public health, the battle against the forces of mass ignor ance, fear, superstition and apathy is of great importance. The projection of the idea and the ideal of preventive dentistry into the consciousness of the public is a problem in adult education. C. E. A. Winslow of Yale University has said: T h e public-health cam paign of the p re s ent d a y is, th ere fo re, based on a broadly con ceived p ro g ra m of a d u lt education. It uses, w ith m ore o r less persistence, the new spaper, the health d e p artm e n t bulletin, the special leaflet, the lecture, the radio-talk, the cinem a, the poster, th e exhibit.
A consideration of this important sub ject of adult education is not within the scope of this paper. It is enough to say in passing that, within the next few years, we must break fr.ee from some of our traditions and antiquated ethics and, as an organization, tell the true story of dentistry to the public. Of the dangers that are lurking here, we must be fully aware. A publicity campaign poorly or ganized, blunderingly promoted, undigni fied, might defeat the very purpose tor which it was intended. That is, by crude methods of advertising, we might inno cently enough place ourselves, in the pub lic eye, in the same category as the ad vertising dentists, who have always been anathema to the intelligent public and the ethical members of the profession. Let no one interpret these remarks as a state ment against the basic idea of public edu cation in dental matters. With the idea of public education, we most enthusi astically and whole-heartedly agree: the manner and method of appeal to the pub lic is the important thing. W e should hesitate before we use methods which might jeopardize our position or under mine the public’s confidence in the dental profession.
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The road toward the more general practice of preventive dentistry is block aded by two serious obstacles: first, the indifference and the apathy of a large number of the profession; and, second, the ignorance of the public. It would appear almost axiomatic that before we can make progress in public education, we must first do considerable missionary work within the profession. In these times, when one hears so much talk of making the public “dental-minded” and “dental-conscious,” it might be well to hesitate and direct more vigorous effort toward the education of the profession in the importance of preventive dentistry. It is quite conceivable that the public might become educated up to a level of desire for dental services which large numbers of the profession could not or would not satisfy. T o be specific: Mothers, alert and well informed, after reading of the importance of early dental, care, have often taken their children to some dental office, to be met with this sharp rebuff: “Baby teeth need no attention.” And, too often, adults, learning from various sources of the dangers of dental infec tion, have stepped into a dental office to be told that: “X-rays are not necessary,” or “All this talk of infected teeth is a fad of physicians and dental alarmists.” The abysmal chasm that exists between the theory of prevention and the practice of prevention as it relates to the profes sion and to the public is appalling. The professional literature is full of worth while suggestions regarding procedures and practices directed toward prevention and the health significance of dentistry. Our meetings, for the most part, are of a high scientific and professional character. The practice of dentistry has not kept pace with the philosophy of dentistry. Arsenic devitalizations, “tin-can” crowns, amalgam slugs, occult diagnoses still
make up too much of the practice of dentistry. The indifference of the public to prevention is largely the reflection of the apathy and lack of enthusiasm of the profession. The classic slogan of Glenn Frank, “Millions for pills, but not one cent for prevention,” presents a vivid pic ture of a common public attitude. Preventive dental service has an im portant economic aspect. The profession has been slow to grasp the economic self profit of a program of prevention; the public has not been impressed with the economic advantages of preventive dental service. The economic improvement of dentists should follow whenever they escape from the tether of the vicious tri umvirate : materials, merchandise and me chanics, and begin to place the emphasis on health, biologic processes and preven tion. And of this there can be no doubt: the public likewise will profit when the dental profession becomes biologic and prevention minded. The prevention of dental disease is the professional ideal of dental practice. And none have ever found an argument against the ideal of prevention except a few shortsighted dentists who feared that prevention might some day become so nearly perfect that their services might no longer be necessary. But such a dental millennium, unfortunately, is very dimly in the future. The indifference of pa tients is the great obstacle to prevention. In theory, almost every patient accepts the thesis that prevention is far better than cure; but, in practice, most patients are chance-takers and prefer not “to cross the bridge before they come to it.” Pa tients in the throes of dental pain will rush to a dentist for relief and those un fortunates with disabled and crippled mouths will spend large sums of money for restorative dentistry. Dental pain and mutilation are largely preventable;
Ryan— Economic Aspects of Preventive D entistry
it is our duty and to our profit to force these truths on the consciousness of our patients. Like all sound economics, the practice of preventive dentistry is mutually profit able; the patient preserves his denture and the dentist increases his income. Over and beyond the biologic preserva tion of the human denture, the patient enjoys a three-fold profit from preventive measures: he avoids the inconvenience and the drain on efficiency that comes from dental pain and infection; he con serves his time by not being required to spend long hours in dental treatment, and he saves large sums of money by com ing frequently for prophylaxis and the treatment of incipient disease conditions rather than waiting until expensive and extensive restorative dentistry is demand ed. The dentist who practices preventive dentistry is assured of a steady and larger flow of income by the frequent return of patients, and he enjoys the mental sat isfaction that comes from the knowledge of a job well done. As the advertiser says, “Repetition is reputation,” so let us repeat over and over again and drum into our patient’s consciousness this truth: N eg lect costs m ore than trea tm en t; in pain, in tim e a nd in m oney.
There are four general dental condi tions which preventive service is to be di rected toward; namely, malocclusion, dental caries and the possible pulp se quelae, periodontal disease and mouthtissue malignancies. Preventive service is to be carried out from the “cradle to the grave.” In childhood and early adult life, our services are directed toward the prevention of malocclusion and caries. In the middle decades, we are chiefly con cerned with the prevention of disease of the periodontal tissue. In the later years, we are concerned with the dangers of malignant neoplasms. Our services
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are concerned with the whole life span of the individual. W e need never fear that our services will ever be unnecessary; ours is a lifetime job. M A LOCCLUSION
To prevent malocclusion, the child should come to us early and often, de ciduous teeth should be preserved, and the pernicious habits of mouth-breathing, thumb-sucking, pillowing, etc., should be corrected. Our job is not altogether me chanical or manipulative. The child brought to us for observation and exam ination is coming for our knowledge and advice. We are not talking of ortho dontia, but of prevention of the need for orthodontia. The general practitioner should recognize the forerunners of mal occlusion and attempt to intercept it. For his knowledge and judgment, he is entitled to a fee. The advice that we give the mother regarding dietetics and its relationship to the dental structures, the measures which we apply to the cor rection of vicious habits, the great care which we exercise in the treatment of a deciduous tooth to preserve the totality of the deciduous dentition are important services which we cannot give away. If we evaluate our services and set our fees in terms of grains of alloy, pennyweight of gold and quantities of cement, and do not receive pay for our knowledge and advice, we are apt to be inclined to do only the mechanical or profitable thing and let the advisory or unprofitable thing slip. Knowledge and information which it has taken of our time and money to acquire cannot be given away. It is a question of profit and loss. If we give of our knowledge, the patient profits and so should we; if we withhold important information, the patient loses and so do we. Let us give more time and study to the problems of the interception of maloc-
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elusion—and be paid for it. No other professional man gives his “brains” away. D E N TA L CARIES
Caries is one of the prices which man pays for becoming civilized. In these days when scientists speak in terms of emergent evolution, we may look on dental caries as an expression of this prin ciple. As man evolves from the primitive to the civilized, the ratio of caries in creases in direct proportion to his ascent. Witness the comparative freedom from caries in the mouths of the Australian bushman and the Eskimo as the repre sentatives of primitive types, and the ram pant caries in the mouths of our moviegoing, roadster-riding, roadhouse-danc ing, American young people. Dental caries viewed in this light takes on a social significance; and if we may reason by deduction, we may expect the incident of caries to increase as civilization be comes more complex, unless the services of preventive dentistry become more ef fective. Considering this type of dental disease in its broadest light, we under stand it as a condition that appears to at tack man in the higher brackets of civili zation. To defeat these tendencies, we cannot hope nor do we wish to reverse the process of evolution. What we hope to do is to find the thing or things in modern man’s life and habits which make him susceptible to the ravages of dental hard-tissue disease. Somewhere in the domain of bacteriology, immunology, endocrinology, biochemistry, we may find the answer to the riddle. Until we find a specific one, we must continue to prac tice preventive dentistry empirically. We must instruct our patients in mouth hy giene and dietetics; we must practice good surgery in our operative dentistry and prophylactic treatments; for all of which, we must be paid.
All programs of prevention emphasize the importance of education. Through the medium of the written word and the spoken word and by pictorial methods, the public is appealed to. The public is asked to help in the prevention of forest fires, traffic accidents, disease. Even now, the effort in the field of dentistry is more commercial than professional. The den tifrice, mouth-wash and toothbrush manufacturers are using tons of paper, gallons of ink and nationwide radio broadcasts to sell the public their products and, incidentally, to preach the doctrine of prevention. Fortunately, with the ex ception of a few manufacturers who gar bled facts, some who used the fear appeal and several who distorted scientific truths, the advertising has been of a high type. The fact stands that dentists and the pro fession of dentistry have depended on sec ond-hand, but not second-rate, advertis ing to tell their story. But we still enjoy the greatest of all educational opportuni ties, the opportunity to tell the patient, direct, man to man, personalized, the story of dentistry. In the presentation of the case of pre ventive dentistry, this personal relation ship between buyer and seller is of funda mental importance. In general advertis ing, which is directed toward thousands of people, the appeal must be general or abstract; in the relationship between dentist and patient, we may educate the patient to a general or abstract idea, the idea of prevention, and then personalize the idea to make it specific and concrete — the application of the idea of preven tion to the individual case. Because the terms “selling,” which suggests commer cialism, and “propaganda,” which sug gests the unpleasantness of the late war, are opprobrious to most dentists, we may call this appealing to and teaching the patient education. And like all manner
Ryan— Economic Aspects of Preventive Dentistry and kinds of education, there are tuition fees required. W h e n w e in stru ct the patient in the technic of proper brushing of the teeth, in the use of dental floss, in th e require m ents of the safe and sane dentifrice, in the essentials of dietetics, w e are teachers of physiology. I f w e are to prepare o u r selves to be good teachers, w e m ust read and study and attend society meetings, all of w hich takes tim e, effort and money. F u rth erm o re, if w e are to be good teach ers, w e m ust be patient, take tim e and be repetitious in the presentation of our sub ject. I f w e are to be vigorous, convinc ing, interesting in the presentation of the subject of prevention, the p atien t is going to profit. A nd shouldn’t w e ? I should suggest fo r those w ho consider it too much of an innovation to set dow n a sep arate fee fo r advice, consultation and edu cation th a t they m ake sufficient provision in th eir estim ates to cover the tim e spent in patient-teaching. I f th e roentgenographic, prophylactic, operative and pros thetic fee fo r a given case is, say, $ 1 0 0 , I should put dow n an additional $5 or $ 1 0 to cover the tuition fee fo r the dental education of the patient. T h e technical aspect of the prevention of the com plications from caries may be divided into the roentgeriographic and the operative. T h e use of bite-w ing films at freq u ent intervals fo r every case to dis cover the beginning of proxim al caries is very im p o rtan t. T h e early opening and filling of the occlusal fissures in m olars afte r the m anner of prophylactic odontot omy, as described by H y a tt, is an excel len t procedure. T h o ro u g h and careful prophylactic trea tm e n t to remove plaques and deposits is an operative procedure of first im portance. T h e early recognition of caries, the proper suigery of cavity preparation an d the placem ent of m e chanically and scientifically sound restor
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ations represent the d en tist’s effort to p re vent the vicious sequelae of dental ca rie s: pulp involvem ent, periapical disease and systemic com plications. T h e tim e and effort w ill be m u tu ally profitable w hich w e spend in explaining to patients the ad vantage of correct roentgenographic ex am inations over guessw ork in the search for incipient ca ries; of prophylactic odon totom y over the severe excavations neces sary in advance caries; of th e value of prophylactic trea tm e n t over “teeth clean ing” ; of th e proper surgery of cavity prep aration w ith extension fo r prevention, etc., over “ d rillin g a hole” ; of resto ra tions of proper contour, contact an d oc clusal form over fillings or m etal slugs. PERIODONTAL DISEASE
In the consideration of th e prevention of periodontal disease, w e m ust rem em ber th a t th e clinical m anifestations of this condition are varied and of apparently many different sources. W e observe the periodontitis of mechanical origin, the perverted mechanics of occlusion; perio dontal irrita tio n from im proper dental restorations, open contacts, e tc .; m arginal irritatio n from calcarious deposits; the im proper use of tooth picks, toothbrushes, etc. W e fu rth e r observe the periodontal disease of b acterial o rig in : the residual in fection of th e periodontium as a resu lt of such an active condition as V in cen t’s in fection ; th e soft tissue irritatio n th a t comes from h ab itu al unacquaintance w ith the toothbrush. A m ong the periodontal disease of general, systemic or biochemi cal origin, w e find the periodontitis of diabetes an d of the deficiency diseases. T h erefo re, w hen w e think in term s of the prevention of periodontal disease, we m ust consider the m echanical, bacterial and m etabolic n atu re of the condition. W e m ust perform our m echanical opera tions of operative and prosthetic dentistry
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w ith both a technologic and a biologic point of view. W e m ust restore parts to form and function and avoid the lurking dangers to the supporting tissues th a t come from im proper .contour, overhanging m a r gins and occlusal stress and strain . W h a t w e do m echanically, if done w ell, may prevent the com ing of periodontal dis ease; w h a t w e do m echanically, if done poorly, may sometimes resu lt in serious diseases of the su pporting tissues. T o present the picture graphically to the pa tient, it is perfectly proper to present the h o rrible exhibit of “ tin can” crow ns, of the roentgenographic evidence of am al gam slugs pushed w ith a generous thum b into the gingival tissue, of clasps th a t pry teeth loose by th e ir too affectionate em brace. W h e n the p atient views this rogues’ gallery of dental crim inals, he w ill be m ore receptive to the idea of m e chanical dentistry done w ith the idea of prevention; th a t is, he w ill be ready for good dentistry. T h e re is no specific bacterium th a t has been dem onstrated as the causative agent in chronic periodontal disease. Amebas have had th eir d a y ; various form s of the streptococcus have been indicted as the agent responsible fo r periodontal disease. N ow , w e hear of detoxifying the m outh b acteria and the consequent antigenic use of the bacterial cells to produce a form of im m unity. In the conquest of periodon titis of suspected bacterial origin, w e m ust follow the fundam ental principles of pathology ra th e r th a n the enthusiasm s of d ru g an d chemical m anufacturers. W e should rem em ber th a t “ the probability of a successful infection varies directly w ith the num ber of organism s introduced, the virulence of the invaders and the resist ance offered by th e individual.” L ike wise, w hen w e th in k in term s of the pre vention of periodontitis of bacterial and m etabolic origin, w e m ust keep close to
fundam ental biologic conceptions and shun th e fallacious claim s of the nostrum m a n u factu rer. A b ottle of T h is or T h a t or a tube of Such and Such from the cor ner dru g sto re m ay have a certain psycho therap eu tic value, b u t w ill do little to de crease th e dosage an d virulence of p atho genic bacteria o r increase the resistance of the host, an d still rem ain a safe agent to the no rm al tissue cells. T h is certainly is not intended to m ean th a t drugs have no place in th e prevention or treatm en t of periodontal disease. V arious m edicam ents — m ild antiseptics, astringents, etc.,— have a definite place in the treatm en t of certain periodontal conditions. I am attem p tin g to say th is : P atien ts cannot buy prevention of periodontal dis ease at a d ru g store in a glass bottle or a m etal tube. T h e y can buy prevention from dentists w h o apply the fundam ental principles of bacteriology, pathology and surgery to each individual case by opera tive procedures w hich improve the hygiene of the m outh, th ro u g h scaling and polish ing of th e teeth and hygienic restorative dentistry, an d by in stru ctio n in the proper use of th e toothbrush, soft-tissue m as sage an d the essentials of dietetics. A gain, standard ized m ethods and proprietary products cannot prevent periodontal dis turbance. In d iv id u al attention, personal case study, a consideration of the organic wholeness of th e patien t by the dentist constitute the only intelligent m ethod of preven tin g periodontal disease. A nd so let U S tell our patients. M A LIG N A N C IE S
M a lig n a n t neoplasms are apparently on the increase. In the prevention of can cer of th e m outh and environm ental tis sues, the dentist can be of first im portance. In an address on “ C ancer as a W o rld P roblem ,” before th e N e w Y o rk A cad emy of M edicine, Joseph C o lt Bloodgood,
Ryan— Economic Aspects of Preventive D entistry professor of clinical surgery of Johns H opkins U niversity, said: P ra c tic a lly every lesion of the m outh can be fe lt w ith the finger, seen w ith the eye, or p h otographed w ith the x-rays. A s the cause of cancer of the m outh is due to ragged, d irty teeth, ill-fitting plates, tobacco in any form , a n d th e re is alw ays first a non-cancerous lesion easily recognized, the dentist, w hen people a re educated to come to him fo r p e ri odic exam ination, should, w ith ra re excep tions, find the local lesion in a stage in w hich it can be cured by the rem oval of the causes.
C om plete and frequent exam ination by the dentist, education of the patient to the dangers of w h a t lurks in unclean m ouths and of im proper dental appli ances, a suspicion of all prolonged inflam m ation and lesions about the m outh— persistent “ canker” sores, soreness of the tongue, leukoplakia of the soft tissues of th e m outh— and the insistence on early surgery for unknow n grow ths w ill do m uch to prevent precancerous lesions from becoming cancerous, and for those th a t have already undergone m alignant degeneration, w e, by o u r insistence on early trea tm e n t, may prevent m etastasis and so save lives. I f w e are to fulfil our health obligation to the com m unity, the dental exam ination m ust be som ething m ore th a n a h u n t for holes and spaces, and o u r a ttitu d e m ust be different from th a t of the mechanic. In a biologic and biomechanical approach to ou r problems, w e w ill find fulfilm ent, th e larg er life, and profit to our patients and to ou r selves. T h e entire case for prevention may be sum m arized in the w ords of Bloodgood, who, discussing the problem s of the pro fession of journalism in public health w ork, said: W e cannot expect m uch m ore of this p ro fession (jo u rn alism ) until the dental, m edi cal, and n u rsin g professions take up m ore seriously the ideas of p rev en tiv e m edicine. T h e n w e w ill be in a b e tte r position to recom
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m end to the jo u rn alists th a t the d aily p ress is the best m eans of info rm in g the people on rules of health, the necessity o f p rev en tiv e m edicine; a n d not only of the new d isc o v er ies, but o f th e ir application.
T h e w ages of neglect are payable in pain, in tim e, and in money. A n u n d erstan d in g of the economic ad vantage to the dentist th a t comes from the practice of preventive d en tistry is contingent on the d en tist’s a ttitu d e to w ard his profession. F o r the m an w ho is forever seeking th e “big cases,” the one w ho constantly talk s of “big con tra c ts” an d thousand dollar reconstruc tions, the economic aspects of the practice of preventive den tistry may have no ap peal. T h e “ thousand d o llar cases,” most of us w ill agree, are w indfalls th a t come once in a lifetim e, if at all. M o st of us m,ust depend fo r o u r livelihood o n the frequent re tu rn of patients, th e o rdinary and nonspectacular fees and routine d en t istry. A nd, fu rth erm o re, few of our patients are prepared o r w illin g to be the other party to these spectacular “ th o u sand d o lla r” transactions. W e have gone a long w ay to w ard economic im prove m ent w hen w e succeed in im pressing en ou r patients th e saving to them in tim e and money th a t comes from freq u en t vis its to the d en tal office for exam ination, prophylaxis and the trea tm e n t o r correc tion of simple carious defects or gingival inflam m ation. T h e steady flow of re tu rn ing patients, each paying a fair fee for dental treatm en t, in the long ru n shows a m ore favorable business office rep o rt th an th e trea tm e n t of th e occasional and spectacular case and th e atten d in g in ter vals of idleness. C h ild ren ’s dentistry, prophylaxis, simple operative procedures w hich are of the greatest value to the patient can likewise be m ade profitable to the dentist. T h e shunning of the sim ple things w hich are producible in great volume, in the fruitless search for the
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w ill-o ’-the-w isp of a spectacular and high fee case, is a common d ental economic fallacy. A m erica is an insurance-m inded nation. W e insure our lives, ou r incomes against the inroads of ill-health and accident, our homes and our goods against fire and rob bery; w e insure against the liability of an autom obile accident, a misplaced golf shot and a suit for m alpractice. B u t in surance for dental health rem ains u n know n. M en w ho spend freely of their money for every conceivable form of in surance still too com monly begrudge m oney spent to “ insure” their dental mechanism. L e t us present the case of preventive service to our patients as a form of insurance. T h e analogy is strik ing. T h e money spent each year for d en tistry represents the “ prem ium ” neces sary for the hazards, risks and responsi
bility of a p articu la r case. A nd like all other form s of insurance, the rate is higher in relation to th e h azard s of the p articu lar case: th e person w ith a great susceptibility to caries, for instance, m ust pay a higher “ prem ium ” rate, represented in a g reater yearly outlay fo r dentistry, th an the person w ith g reater im m unity. In common w ith life insurance alone, dental h ealth insurance pays a “ divi dend.” T o recover the money spent for accident, health, fire, burglary, or lia bility insurance, it is necessary th a t w e suffer a loss of some kind. N o t so w ith dental h ealth insurance. T h e “ divi dends,” w hich are large and generous, begin the day th a t the patien t subscribes for preventive d ental service, and they are payable, n o t in script, n o r in stock nor in cash, b u t in the greatest of all m un dane rew ards— health.
CAST GOLD ALLOYS: THEIR PHYSICAL PROPERTIES A N D DENTAL APPLICATION* By JO H N S. SHELL, B.S., San Francisco, Calif. H E investigation of the physical properties of gold alloys as related to their use in dentistry has opened a new era in the field of restorative den tistry. T h e em piric m ethods so long practiced by the dentist in selecting m a terials, and the dorm ant attitu d e of many dental m anufacturers, led to so m any failures in com plicated restorations th a t operators w ere forced to m odify their ideas in design to comply w ith the lim ita
T
*R ead before the Section on P a rtia l D e n tu re s ; C row n and B rid g e a t the M id w in ter Clinic o f the C hicago D ental Society, Feb. 3, 1931. Jour. A . D . A . , M a y , 1931
tions of the m aterials. T h e past decade has seen a m arked im provem ent in the physical properties of gold casting alloys fo r dental purposes, and as decided a change in the attitu d e of the progressive dental p ractitioner to w ard th e reception of the accum ulating d ata in the field of physical m etallu rg y as applied to den tistry. T h e science dealing w ith the investiga tion of the in tern al stru ctu re of m etals is of such recent developm ent, w hen com pared w ith m ost other fields, th a t it is not surprising to find its practical applica tion to d entistry slow er th an th a t of the