The school, the practitioner, and the denturist

THE

FUTURE

THE SCHOOL, THE PRACTITIONER,

AND THE DENTURIST

S. HOWARD PAYNE, D.D.S.” University of Buffalo, School of Dentistry,

Bufalo,

N. Y

from the charlatan and barber era, through D apprentice training,hastoprogressed a formal program in establisheddental schools. In the ENTAL

EDUCATION

past three decades,more and more emphasishas been placed on study of the basic sciences,and research in dentistry has expanded from small kernels to immense efforts which are ever increasing. Graduate and postgraduate courses have become numerous, and dental specialties have been delineated. Dental education has acquired a new stature and well-deserved prestige. This increasing emphasis on the biologic scienceshas made it difficult for the dental student to keep pace with the new and complex curriculum. In some schools, the time to teach new and expanded subjects has been taken from the preclinical and clinical courses in restorative dentistry, and there is cause for alarm about the possibility of graduating a dentist who knows less and less about more and more. Added to this educational problem is the need to produce greater numbers of dentists to meet the population explosion. Socialization also wags the warning finger of demand. THE PERIODONTIC-PROSTHODONTIC

PROBLEM

While high speed operative procedures, fluoridation of drinking water, and heavier patient load will buffer some of the need for dental service in the younger age group, the main problems will concern the dental needs of the older age group. Periodontal diseaseis on the increase as a problem related to nutrition, metabolism, and stress and is not likely to be alleviated by a simple discovery or panacea. The prosthetic management of periodontally diseasedmouths, during and after the loss of teeth, constitutes one of dentistry’s most serious problems. Very frequently, The article ls being published simultaneously in THE JOURNAL OF PROSTHETIC DENTISTRY and Journal of Dental EducatZon through arrangement between the editors and the author. This article is one of several presented on the theme “Complete Denture Prosthodontics as a Health Service” at the Conference Session on Complete Denture Prosthodontics, Thirty-ninth Annual Session of the American Association of Dental Schools, in St. Louis, MO., and was read before the Academy of Denture Prosthetics in Colorado Springs, Colo. *Professor of Prosthodontics and Assistant Dean. the

812

pm&;

y

TIIE

SCHOOL,

THE

PRACTITIONER,

AND

THE

DENTURIST

813

there are the conditions of a continued loss of bone, chronic soreness of oral tissue, and inflammatory and hyperplastic lesions that constitute a hazard of potential malignancy. Few physicians are aware of these problems because they have almost no dental orientation in their medical educational program. Further, there are no clinical findings in blood or urine tests that are specifically diagnostic. Yet, the number of people requiring the best type of prosthodontic care increases. LONGER

LIFE

PROBLEM

The aged constitute another group who need good prosthodontic service, and the problems related to geriatric patients are multiple and touch all people in the health professions. It is recognized that good nutrition and a state of happiness are vital in the treatment of elderly people ; but how can a person who must wear inadequate or unscientific dentures be happy or enjoy food when his mouth hurts and he cannot chew food properly ? SOME

SOLUTIONS

It is obvious that there will be an increased need for prosthodontic care in the same groups which require the best prosthodontic service. Three solutions have been suggested : (1) graduate more dentists, (2) build more schools, or (3) make extensive use of auxiliary personnel. No one will seriously dispute the first recommendation, but it involves a program of recruitment sufficiently impressive and effective to fill the present dental schools with qualified candidates. It is somewhat unrealistic to spend funds to build more schools, to be staffed with nonexistent or stolen faculties, and to refuse to give the attention and financial support necessary to bring each of the present dental schools to its greatest capacity. This truth is almost too simple and obvious to be mentioned; yet, individual ambitions and political pressures often institute new construction before full use is made of existing facilities. EDUCATIONAL

QUANDARY

Before discussing the third suggestion, it is pertinent to discuss the practitioner. He must continue to receive a well-balanced dental education which includes adequate preclinical and prosthodontic laboratory procedures. There are some who feel that because a majority of dentists delegate certain laboratory procedures to technicians, there is very little need to teach them to the dental student. This pattern of thinking is comparable to assuming that since the business executive personally does not do all of the jobs he manages, he needs to know nothing about them. A dentist must know how and why in order to supervise intelligently any procedure done for him by others, because he alone is responsible to the patient. One of the rather frequent errors found when complete dentures are inserted is that the anterior teeth do not occlude properly because of heavy posterior tooth contact. The dental student or dentist who carries out his own laboratory procedures knows and can correct the most common errors of construction that

814

PAYNE

J. Pros. Sept..Oct.,

Den. 1962

can cause this condition : (1) ill-fitting recording bases, (2) too much pressure in recording centric jaw relation, and (3) overpacking of the resin during processing procedures. He can avoid these mistakes because he can maintain continuity in every step. However, the student with “prosthetic insufficiency” or the dentist who has not learned enough either in or out of school about correct prosthodontic procedures is willing to allow the commercial laboratory to assume his responsibility. Not only is he unable to trace the errors, but usually he finds it convenient to blame the laboratory. The technician, tired of taking the blame, loses respect for those who try to shift the responsibility. Thus, the person who has not learned proper technical procedures in school contributes to the technician’s loss of respect for the dentist. This condition is one of the main reasons why the disgruntled laboratory technician has developed the desire to deal directly with patients. PROPER

TEAM

WORK

The relation between a well-educated dentist and the ethical technician is one of mutual respect and appreciation for common problems. A well-educated dentist knows the importance of good casts and good recording bases, the problems of assaying vertical dimension, and the requirements of prosthodontic occlusion. In addition, he must be capable of applying his knowledge of the basic sciences to the patient in order to know his systemic and nutritional state and his anatomic, physiologic, and pathologic status. He must also envision and replace the lost masticating mechanism so that the patient will understand the problems, be willing to learn the proper use of the new appliances, and appreciate fully the possible changes and need for future treatment. The dentist must know details about all of these conditions. He cannot be overeducated in the basic sciences and satisfactorily permit a laboratory technician to do the restorations ; nor can he diagnose properly and assay a patient psychologically and systemically if he has not had adequate basic science education. The practice of dentistry requires the dentist to possess the knowledge to diagnose and the skill and dexterity to treat. Clinical judgment can be based only upon a proper balance of knowledge of the didactic and the clinical sciences. THE

CHALLENGE

In dentistry today, there are the newest materials, the finest equipment, and the best educated professional people in the world. There are also ethical technicians and commercial laboratories dedicated to serving these dentists. Yet, there are too many stereotyped, piano key, false-looking artificial dentures. What is their source? They come from the dental offices of the men who do not reset or change the false tooth look at the try-in of the waxed dentures. They come from the men in the illegal laboratory and from laboratories which select teeth and establish occlusal relations without proper prescription from the dentist. A technician who does not see the patient cannot be expected to select and arrange the anterior teeth properly. Dentistry must assume these prosthodontic responsibilities. The selection and

Volume Number

12 5

THE

SCHOOL,

THE

PRACTITIONER,

AND

THE

DENTURIST

81.5

arrangement of teeth in order that they appear harmonious and natural, thus giving proper support to the lips and musculature, can be done only by educated and responsible dentists. The dentist who shirks these responsibilities and allows substandard dentures to shriek to the world that they are false injures the profession and invites the less skilled to take over prosthodontic service. The educators who do not allow sufficient technical and clinical teaching time in school, whether they realize it or not, are unwittingly contributing to the deterioration of prosthodontics and of the appearance of the American public. AI-XILTARY

PERSONNEL

The third suggestion for meeting the increased need for dental care is to tnake greater use of auxiliary personnel. This solution is good so long as the extended duties are under the direct and continuous supervision of the dentist ; but many feel that prosthodontic measures can be carried out by technicians or denturists who would deal directly with the patients, a circumstance that cannot and mnustnot prevail. Since prosthodontics constitutes a health service and concerns the physiology, nutrition, and happiness of the aging patient, its problems cannot be solved by making a greater number of restorations of inferior quality. A cheap chair may be sat in, a cheap rug can be walked on, but unscientifically made dentures can rarely function satisfactorily. The additional time, expense, and service in remaking these would result in a greater number of disgruntled patients. The patients who account for the increased need of prosthodontic service are those in the periodontal diseaseand geriatric categories. The treatment of these patients requires greater clinical judgment and ability, not less. The nondentist group members, consisting mostly of self-trained or apprenticetrained people, would create a situation of caveat emptor if they were allowed to deal directly with the public. Further, since they are not bound by ethics of a profession or by service motivation, one could expect an increase in multiadjective advertising by radio, television, and the press. Even the greatest stretch of ima
FOR

ACTION

What can be done? First, dentists must become cognizant of the problem and its seriousness. Second, they must be reawakened to their responsibilities now! Third, the profession must develop an effective means to handle the few who do not assume their responsibilities. The public must be made more aware that prosthodontics is a health service-not a hardware counter. This educational service should be approved by the American Dental Association and sponsored ly ethical sources. The curriculum must be examined and streamlined. If the need were to become great enough, it might be advisable to have some of the basic sciences given in the preprofessional course rather than to sacrifice the balance of technical education which is necessary to develop a good practicing dentist. It is also

PAYNE

816

J. Pros. Sept..Oct..

Den. 1962

possible with sufficient financial help and additional faculty to graduate more dentists by using the accelerated plan of World War II. However, an effective recruitment program is a necessaryelement of any plan that is adopted. In the past few years, it has become increasingly difficult to find dental school applicants who possessboth intellectual ability and manual dexterity. Some educators believe that all dental students should not be expected to become clinicians and that those who do not show manual aptitude should be allowed to concentrate on the more didactic areas. It is my opinion that those in the latter group should receive the Master’s degree, not the D.D.S. degree. A minimal dental educational program, followed by a mandated year of concentration in the special area of interest, has been suggested as a plan for dental education. A program of this type might improve the quality of service in the individual clinical areas, but it will not fulfill the need for quantity. Then, too, the cost of dental service under this system will increase and make it unavailable to the masses.The greatest future need is for more general practitioners, and every method must be explored to produce a greater number of well-educated, ethical dentists. Further, an expanded use must be made of all auxiliaries for nonoral procedures and for oral prophylaxis. But let us not by innocence or design endanger the health of the public by advocating that there be two level dentistry, that laboratory men turn denturists, or that illegal laboratory technicians make worse dentures for more people. UNIVERSITY OF BUFFALO Scmo~ OF DENTISTRY 3435 MAIN ST. BUFFALO 14, N. Y.