CANADA'S A NATION OF DENTAL CRIPPLES
Already four out of five Canadian schoolchildren lack treatment for open cavities, and their general health is suffering. But to treat them we need three dentists for every one we have now — and fewer dentists than ever are in training. Here’s a report on an unrealized crisis in Canadian public health
IN AN AGE when diseases are being checked and prevented, the problem of tooth decay is a conspicuous exception. We are rapidly becoming a nation of dental cripples.
More than 80 percent of our schoolchildren have open cavities needing treatment; 70 percent have crooked teeth; 40 percent have lost some of their teeth; 20 percent already have gingivitis — a forerunner of pyorrhea, a serious gum condition that leads to the early loss of all teeth. With children living on a diet of soft foods, and nibbling away at sweets, the rate
of destruction is bound to increase.
The condition of adults’ teeth is just as bad. Despite the $100 million we’re spending on dentistry each year, a backlog of $500 million worth of work remains. A few months ago an Ontario government committee enquiring into the need for fluoridating communal water supplies observed that “the total national physical handicap due to dental disease and poor oral hygiene makes it a major health problem.”
The committee was only repeating what every other dental, medical and
public health organization had already said. The prospects are gloomy. Canada’s 5,800 dentists are tired and overworked. One dentist can adequately care for a thousand patients. But in Canada, the dentist-population ratio is one to 3,018. In Newfoundland, it’s a staggering one to 10,441. Because dentists are attracted to cities, scores of communities are without regular service. Ten years ago, the WeyburnFstevan Health Region in Saskatchewan organized a service to treat the 12.000 children in the district. It started with five dentists. This year the clinics were forced to close shop because all the dentists had left, retired or died. “The situation is desperate.” says Dr. C. R. Lenk, the medical health officer.
Canada’s six dental schools come nowhere near meeting the current need for dentists. Last year, they graduated 193; this year the figure will drop to 179, a reflection of the unwillingness of young people to become dentists.
“Our first-year class in dentistry is half empty,” says Dr. Jean - Paul Lussier of the University of Montreal. A recent national survey could see no improvement in the dentist-population ratio during the next twenty years.
Why are we apparently so lax about dental services? One explanation is that the public grossly underestimates the hazards of bad teeth. You don’t die if a tooth becomes decayed and has to be extracted; but continued neglect of the mouth can lead to pain, discomfort, general illness and, in some cases, death. The famous clinician Charles H. Mayo has observed that "Life might well be prolonged ten years through dentistry alone.”
Recently, a 19-year-old soldier at the Kingston Military Hospital developed acute rheumatic fever following the extraction of several badly decayed teeth. Bacterial endocarditis — inflammation of the lining membrane of the heart — has been attributed to unhealthy teeth. Doctors believe that
there’s a significant relationship between bad teeth and many chronic illnesses — rheumatism, arthritis, diabetes. nephritis. TB and certain kinds of anemia.
As a way out of the present dilemma, dental and public health leaders emphasize prevention. “We can prevent 85 percent of tooth decay by making use of everything we know,” says Dr. Gordon Nikiforuk, a University of Toronto dental research scientist. Preventive measures include the fluoridating of water; educating parents and children to eat the right foods and avoid the wrong ones; stressing the importance of brushing the teeth correctly and visiting a dentist regularly if there’s one available.
The most potent weapon now available against tooth decay is the fluoridation of water. Adding sodium fluoride to water (one part per million parts of water) would do more for oral health than ten thousand additional dentists. Fluoridation is fea-
sible. economical, effective and safe — a conclusion reached by virtually every medical and scientific body in North America and Europe. Yet, at this writing, only a million Canadians are using fluoridated water. A vocal and hysterical minority has scared the rest of us off. There are signs that its influence is on the wane. After a thorough investigation, the Ontario government recently granted municipalities the right to fluoridate — a step that will undoubtedly spur the fluoridation movement in Canada.
EDUCATION REALLY DOES HELP
Even without fluoridation, a lot can be done by oral-hygiene education. A surprisingly large number of children still don’t brush their teeth regularly or properly. The last report on Toronto’s 112,000 schoolchildren revealed that about 25 percent had poor oral hygiene, indicating that many were strangers to even the most elementary tooth care. One of these was a small
girl with every one of her twenty teeth decayed, abscessed or in need of extraction. “This child’s plight is shared by thousands of others,” says the report.
Vigorous education in oral hygiene can produce spectacular results. One study reported that the children of dentists had 85 percent fewer cavities than other children — undoubtedly the result of parental influence. At the Elgin-St. Thomas Health Unit in southern Ontario, four years of counseling doubled the proportion of children with caries-free teeth.
Diet is the first target of this kind of education. Sweet foods are dangerous: sixty minutes after being eaten the sugar turns to acid and attacks the tooth enamel. Sugary foods should be taken at mealtime, when other food and drink will dilute the strength of the acid in the mouth and help wash it away. And meals should include something that gives the gums and teeth a workCONTINUED ON PAGE 56
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Canada’s a nation
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out. Dr. Gerard Bastien, a Haitian dentist, suggests raw carrots, celery, apples, pears, dried apricots, stale rye-bread toast, and chicken bones.
Many dentists in private practice may be neglecting preventive dentistry. “Most dentists,” says Dr. Peter Currie of London, “are either unenthusiastic or cynical about the potentialities of their offices for education.” The present scale of fees may be to blame. It takes only a few minutes to pull a tooth compared to thirty minutes to prepare and fill a cavity, but the dentist gets the same fee for both jobs. The most lucrative work is prosthetic dentistry — making plates and other mechanical appliances. A respected University of Toronto clinician and teacher, Dr. Stewart MacGregor, says, “1 can see little hope of people retaining their teeth to a ripe old age . . . when the fee for prosthetic dentistry exceeds the fee for preventive measures.”
At the Canadian Dental Association convention in Ottawa last September Dr. A. M. Blair of Alliston, Ontario, complained that “too many dentists are doing slipshod work.” Fillings are hastily inserted before all the decay is drilled away. The result: the decay spreads and the fillings fall out. “It’s worse than putting fresh paint over a coat of old flaky paint,” Blair said. Another speaker, the distinguished American dentist Miles R. Markley, observed that “too many teeth are sacrificed.” A survey of a thousand failures in amalgam fillings showed that 85 percent were caused by improper preparation.
At present, dentists are subject to no supervision whatsoever. Dr. Blair thinks there should be a regular inspection service. “The time has come to clean house,” he says. “We should get rid of the dentists who do poor work. We have inspectors to safeguard fish and game, so why not provide the same service for people?” Dr. W. J. Dunn, registrar of the Royal College of Dental Surgeons, Toronto, finds this a difficult question to answer. “There’s no workable system of policing the private dentist,” he says. “You have to take it for granted that he’s a professional person with integrity. We can only act on complaints of gross neglect and fraudulence.”
But the brightest hope for preventive dentistry lies in research, “The future possibilities of producing a decay-proof tooth are good,” says Dr. Gordon Nikiforuk of the University of Toronto, who, like other investigators, is concentrating his attention on the hard white enamel that coats the tooth. The enamel differs from the rest of the tooth in two important ways: it contains much more fluoride, much less carbonate. If the enamel begins to run low on fluoride or high on carbonate, the enamel breaks down and tooth decay ensues. The object, therefore, is to devise ways of keeping the fluoride and carbonate at their proper levels.
Ways of doing this have already been found. The most familiar is by drinking water to which sodium fluoride has been added — it strengthens the fluoride coating on the tooth. Another substance that will be widely used in the future is a tin compound, stannous fluoride. Painted on the teeth of schoolchildren once a year in Ottawa, Toronto and several communities in the United States, it reduced tooth de-
cay by as much as 60 percent: ‘it’s the best thing we’ve found yet for topical application,” says Dr. H. K. Brown, dental consultant to the Department of National Health and Welfare. Ottawa.
Researchers are also investigating the relationship between geography and decay. New Zealand dentists wondered why the children of the seaport of Napier suffered so little decay. An analysis of locally grown food showed that it was unusually rich in molybdenum. This was the result of an earthquake, a few years earlier, which had drastically altered the composition of the soil. When tested on rats, molybdenum brought sharp reductions in tooth decay. It has not yet been scientifically tested on human beings, but New Zealand dentists believe that it has great possibilities.
It has also been noted that cavities multiply and flourish in the mouths of people living in districts where the soil is rich in selenium, another trace element. A comparison with certain age groups in Toronto showed that Israelis had only a third the amount of tooth decay. Malayans and Pakistanis half the amount. Researchers would like to know why. A Canadian observation made during World
War II was that the teeth of servicemen from coastal areas were inferior to those from other parts of the country. Before being shipped overseas, the 730 officers and men of the West Nova Scotia Regiment needed an abnormally large volume of dental work to meet minimum army requirements: 1,800 fillings, 3.300 extractions and 350 dentures.
New diets may provide at least part of the answer to the riddle of decay. Swedish schoolchildren are now being fed bread made with flour containing dibasic calcium phosphate. This experiment was embarked on after the compound had cut down tooth decay by 81 percent. At the University of Toronto, Dr. K. J. P. Paynter and Dr. R. M. Grainger are using diet to produce a specially shaped "decay-proof” tooth. They have noticed that the teeth most vulnerable to decay are large and contain deep pits and fissures. When pregnant animals are fed diets rich in certain fluorides and phosphates, the offspring have small teeth with shallow pits and fissures. It may be possible to do the same thing with human beings.
The relationship between bad teeth and the emotions is being examined. During World War II and the Korean conflict, army medical men noted a marked increase in tooth decay and gum diseases
Summer breaks out all across the country about this time of year when the boats reappear in the sportinggoods sections of all the department stores. We wonder if business will be as good and the service as friendly in the Vancouver Eaton’s as it was one day last summer, when a customer was seen trying to haul a light canoe out the side door to his waiting car. and an assistant manager rushed up to help him. For two men it was a breeze, and the co-operative assistant manager returned briskly to the sports department to find none of the clerks huíl sold a canoe that day.
Parade pays $5 to 510 for true, humorous anecdotes reflecting the current Canadian scene. No contributions can be returned. Address Parade, c/o Maclean's Magazine, 4SI University Ave., Toronto 2. Ontario.
of all kinds during periods of combat stress. Again. U. S. Navy dentists have been puzzled by the fact that submariners have tw'ice as much tooth decay as sailors serving above water. What happens in the chemistry of the mouth as the result of tension? This is the question service scientists have posed and are attempting to answer. They have already found that tension makes the saliva more acid and more viscous.
Significant bits of information about decay continue to come from our research laboratories. Dr. P. H. Keyes, a
U. S. Public Health Service scientist, has shown that decay is an infectious, transmissible disease. When rats or hamsters with good teeth shared a cage with animals with bad teeth, they "caught” decay. At Indiana University, Drs. H. E. Brewer and J. C. Muhler, after surgically cutting down the blood supply to normal teeth, found a 43 percent increase in cavities.
Some day, a scientific breakthrough will be made in dental health. But until that time, we must take active measures to increase the present number of dentists.
We have six dental schools; we need
double that number. A more immediate goal is to fill the schools we already have. At least part of the failure to recruit more students must rest on the dental profession. “By and large,” says Dr. James D. McLean, Dalhousie’s dean of dentistry, "the profession has made no attempt to recruit students.” Recently in Halifax, when high schools conducted lectures on vocational guidance, dentistry was one of the few professions not represented by a speaker. For another thing, the dental profession has failed abjectly in creating what the motivational re-
searcher would call “a favorable image” of the dentist. In the opinion of Dr. Stewart A. MacGregor, a prominent Toronto dental teacher and clinician, “Something is wrong when dentists are always portrayed on film, radio and TV as nincompoops.”
Dr. D. W. Gullett, secretary of the Canadian Dental Association, and Dr. W. J. Dunn, registrar of the Royal College of Dental Surgeons, offer various explanations why young people are not attracted to dentistry. Dentistry, they say, lacks the glamorous appeal of other pursuits. The cost of the five-year dental course is high — about $8,000; furthermore, the young graduate has to spend up to $9,000 to equip his office.
In practice, the dentist finds his daily work physically and psychologically grinding. He faces a constant procession of nervous, frightened people. The last place in the world they want to be is in his chair. He’s afraid of hurting them, both for humanitarian and practical reasons: the rough dentist loses patients. He’s always racing against time, trying to complete an appointment every thirty minutes. Confined to a cubicle-like office, he has no physical outlet for his psychic tension. His eyesight becomes strained. His spine is thrown out of alignment because he continually shifts his weight to his right foot while operating the drill control with his left. A three-year mortality study of dentists shows that, starting at the age of fifty, dentists have an above-average death rate due to diseases of the heart and blood vessels. It also reveals that more dentists commit suicide and are murdered than people in other occupational groups.
For all his hard work, say Gullett and Dunn, the earning of the dentist doesn’t measure up to that of the other highly paid professions. He’s led by doctors, engineers and architects, and lawyers. By the time the dentist is thirty, he’s averaging $8,000 a year. Five years later he’s reached the $11,000 - $12,000 bracket and there he
stays until he’s 49. Then his income begins to fall: at 60, he’s back at $8,000. This compares unfavorably with doctors, whose income often continues to rise after fifty and even sixty.
But dentistry also offers many advantages and satisfactions, according to Gullett and Dunn. The dentist is in urgent demand to relieve pain and promote health. It’s not difficult to get into a dental school. With the growth of specialties, the work is becoming more interesting. Despite the fictional view of the dentist, he enjoys high status in his community. And while the average dentist earns about $11,000, there are 856 in Canada who earn more than $15,000.
It’s difficult to understand why the profession has failed to sell dentistry as a career for women. Only two percent of Canada’s dentists are women, against 30 percent in Denmark, 80 percent in Russia, 8 percent in the U. K. Dr. Mollie Jackson, who teaches at the University of Toronto dental school, says, “Women have the right kind of hands — gentle and with a light touch. They’re particularly good in treating young children who are used to women nurses, babysitters and teachers.” A woman dentist’s income approximates that of a man. Marriage and dentistry mix well. The dentistmother can so arrange her appointments that she’ll have time to spend with her children. Or she can easily get a parttime job in a school dental clinic.
Until the number of dental graduates is materially increased, the shortage of dentists can be relieved in part by increasing the productivity of dentists now in practice. It’s possible for • our 5,800 dentists to do the work of almost 10,000. This can primarily be achieved by relegating all but the most skilled dental work to trained helpers. Further time can be saved by efficient office layout and modern equipment. “The whole practice of dentistry can be revolutionized,” says Dr. J. K. Brown of Ottawa.
One dentist I visited is an example.
He is a handsome man who has practised and taught dentistry in Toronto for over twenty years. Patients who come to his office are greeted by a receptionist, who also answers the phone, makes appointments and keeps the books. In one office, a dental hygienist takes X-rays, cleans and scales teeth, and instructs patients in the care of the teeth. The dentist works in another office, helped by a chairside dental assistant, who hands him instruments and prepares fillings. Prescriptions for dentures are sent to an outside dental technician. In British Columbia, some dental technicians have been licensed to deal directly with the public, thus cutting down on the dentist’s work load. However, this development is a highly controversial issue in dental circles.
This dentist uses a drill that reduces cutting time by about 25 percent. A builtin rinsing spray of warm water, with a power evacuator resting in the patient’s mouth, enables him to drill without delays. “In the old days patients used to spit away two Cadillacs’ worth of time a year,” he says jokingly. Two earphones are applied to the patient during treatment. By means of a hand control, the patient can fill his ears with loud music or noises, to overload the central nervous system so that there’s little room left to conduct the sensation of pain. It works for two out of three patients. One patient was so relaxed he actually went to sleep during drilling operations.
This up-to-date dentist wastes little time moving around. Everything comes to him. Instruments are laid out on mobile stands. He’s experimenting with a low stool that enables him to sit comfortably when he works, with his patient’s head tipped back in his lap. “It will lessen fatigue,” he explains.
Dentists who employ a staff of two, three or more have been able to jump their volume of work by as much as two thirds. They’ve also increased their income. But two obstacles are holding up the wider use of auxiliaries in Canada, though neither of them is insuperable.
The first is a lack of trained dental hygienists. At present, the University of Toronto is the only school in Canada providing training. It’s a two-year course. The graduating class this year will total exactly eight. However, the situation is about to improve: the University of Alberta and the University of Manitoba are initiating similar courses this fall.
The second obstacle is the attitude of many dentists toward employing a staff'. Six out of ten Canadian dentists either work alone or with one jack-of-all-trades assistant. “It’s hard to change a man after he’s practised a certain way for many years,” says Dr. Gullett, secretary of the Canadian Dental Association. Dentists argue that they don’t want to bother with employees; that they prefer to give their patients their full personal attention. An unspoken objection is that the dental hygienist is a threat. In places like New Zealand, the hygienists have taken on such duties as drilling and filling cavities.
If the dental auxiliary is to become an accepted part of dental practice, the place to start is in the dental school. Undergraduates should be trained to work with auxiliaries, so that later it won’t occur to them to conduct a practice without them.
When Dr. A. W. Price, a leading American nutritionist, recently warned that tooth infection was leading man “downward to extinction,” he was overstating the case. On the other hand, the weight of evidence from private dentists, dental clinics, schools and health surveys proves beyond doubt that we are faced with a serious and growing national health problem. ★