A Remarkable Ride

As we move ever closer to the end of the 20th century, it is worthwhile to review the historical development of the dental profession in America -- a relatively young profession.

The founding of the American Dental Association in the 1850s marked the beginning of the profession we know today, although the first dental school program was established in 1839 at Baltimore College. Change in the first 50 years was not rapid when compared with the rate of change we have experienced in recent years, although there were events and influences worth mentioning. The work of G.V. Black may have been the most notable contribution to the advancement of the art and science of dentistry as it has been practiced for much of the 20th century. His texts on dental anatomy and cavity preparation in the 1890s were significant. Certainly, the first dental X-ray in 1896 contributed immensely to a more scientific approach to the diagnostic decisions of dentists in the years that followed. One aspect of growth during this half century was the organization of the profession. In addition to the ADA, the predecessor state organizations to the California Dental Association and some of the first component dental societies were formed.

The first 50 years of the 20th century were characterized by a strengthening of the scientific and technical foundations of the profession. Continuing contributions by Black and the inlay technique developed by William Taggart in 1907 strengthened the restorative emphasis that dominated dental practice for years. Dentistry in the first half of the century was primarily reparative and was provided to those who needed it or sought it and paid for it out of their own resources. Notable during this period was the Carnegie Foundation Report by William J. Gies. The report established a framework for professional education and training that has served the profession well over the years. Dental colleges would become affiliated with universities, eliminating the proprietary or commercial programs. This still stands as one of the most important influences on the development of the dental profession in this century. Also significant in the first half of the century was the acceptance of seven of the eight specialties in dentistry from 1947 to 1949. Endodontics followed in 1963.

While a few dentists may have operated their practices in a businesslike manner in the first 100 years, that focus would not really commence until the final half of the century. The American Academy of Dental Practice Administration (1956) was one of the first groups to promote management systems and efficiency in dental practice. The Dental Assistant Utilization Program, which garnered some federal support because of perceived staffing needs, brought a much-needed emphasis on such topics as organizational efficiency, personnel management, and chairside assistant utilization (four-handed dentistry) to the dental schools in the late 1950s. On the technique side, the late 1950s would see the introduction of high-speed air-driven and belt-driven handpieces. This equipment would facilitate the delivery of restorative treatment, making dentistry more user-friendly.

Access to dental care became a topic of more frequent discussion; and California Dental Service, which was initiated by the profession in 1955, brought increased access to dental care to many via dental benefits. The profession became active in efforts to fluoridate public water and to encourage preventive dentistry through school screenings, health fairs, and similar voluntary activities. Individual dentists and local dental groups have received positive recognition over the years for their community efforts to improve the dental health of the public. These continuing activities have undoubtedly contributed to a strong ranking for dentistry in many of the public image surveys taken in the past two decades.

The age of consumerism arrived in California in the 1970s with the appointment of the first consumer member to the California Board of Dental Examiners, Jennifer Cross. Prior to that time, only dentists served on the board. Advertising by professionals became permissible as a result of the Bates-O’Steen decision in 1977. Up to the time, dental professional codes of ethics had set the standards to which members were judged, and advertising had not been permitted by members of the organized profession. Many in the profession decried the changes forced upon it from the outside.

Increases in the education and graduation of new dentists and greater utilization of auxiliaries contributed to a staffing surplus in the first half of the 1980s. Institutional advertising by CDA and internal and external marketing plans developed either by or for individual practitioners were set in motion in this decade to bring patients into the dental chair to address the "busyness" crisis. Preferred provider organizations also appeared about 1984 and were promoted to dentists as a method of putting new patients in the dental chair. By 1984, AIDS would start to affect the infection control awareness of dentists and the public. Shortages of dental handpieces and their capability to withstand the temperatures required for sterilization were just two of the headaches experienced by many dentists as they endeavored to comply with new regulations and guidelines governing sterilization and infection control. While various forms of implants had been studied and tried without success in prior years, the latter years of the 1980s saw the emergence of osseointegrated dental implants as an important option for restoring function and cosmetics. The 1980s also marked noticeable improvement in the cosmetic and bonding characteristics of tooth-colored restorative materials.

New regulations, including the Bloodborne Pathogens Standard in 1991, would emerge to forever change and upgrade the standards in dental practice, helping to prevent transmission of infectious diseases such as hepatitis B and AIDS in the dental office. By the early 1990s, succeeding generations of the composite resin materials, porcelain veneers, and tooth-bleaching techniques had combined to add the potential for a significant emphasis in cosmetic treatment in general dental practice. The 1990s have been notable for the advancement of technology in dental practice. Significant numbers of practices have adopted computer management software. Electronic claims transmission and imaging systems have brought what was once considered the future into the present day in many practices. Some predict that the patient record will be paperless throughout the profession in just a few years.

At the organizational level, by the mid-90s, the profession had seen rather significant change in its composition, particularly in California. In recent years, efforts have been initiated to help the profession make the most of its increasing diversity in gender and ethnicity. There has long been a realization within organized dentistry that there is value to building one voice and avoiding the fragmentation that can weaken the mission of the profession.

To the dismay of many in organized dentistry in the 1990s, the increased costs of health care have encouraged dental benefits managers to adopt dental contract plans with managed care controls in an effort to contain the costs to employers. Underfunded plans in particular have incurred the wrath of many in the profession who believe they have forced dentists to compromise treatment quality and ethics.

Due to the complexity of the marketplace, significant numbers of dentists are now relying successfully on professional advisers -- such as practice management consultants and accountants -- who are skilled in assessing the needs and deficiencies of their clients. While some practitioners are critical of the business environment the contemporary practice must operate within, it has been our observation that those who have sought and followed the counsel of good advisers have been achieving their goals and are pleased with the progress of their practices.

While we may suffer from myopic vision because of our close contact with only the past 35 years of dentistry in this century, our quick summary should nonetheless show that this most recent period of development appears to feature the fastest and most remarkable change in the approximately 150 years of American dentistry. It is our belief that the strong technical and ethical foundations established in the first 100 years have made the changes due to advances in communication, technology, and new techniques of the past half century possible without chaos, even though some of the change has been unpleasant in the view of many dentists.

It is unlikely that the profession will ever again experience the level of growth and change seen in the last decades of this century. Undoubtedly, there will be changes in the mission of the profession resulting from continuing prevention efforts and the education of the populace to dentistry. This creates unknowns that make it extremely difficult to predict either the nature or rate of change in dentistry in the 21st century. What IS important at this time is to salute the significant achievements of this profession as this century comes to a close. Despite some criticism from within our ranks, in retrospect, it has been a remarkable ride.