Dan Fischer, DDS
Paradigm shifts rarely occur. Historically, most generations came and went without witnessing a new paradigm. However, more paradigm shifts have occurred in the last 100 years than in the previous 2,000. Yet, for the majority of dentists and dental schools, their operative dentistry treatments changed little in the 20th century. This is in sharp contrast to other health-care sciences. This could be a tribute to dentistry`s pioneers. It might also remind us of the need to reappraise our operative dentistry technologies. Yes, in a relative sense, amalgam and other metals have served dentistry quite well for years; however, it would be tragic if that relative success kept us complacent. We can`t let status quo or complacency dictate our science, our treatments, and our ethics.
Without forgetting the great contributions of the past, we must maximize the benefits of the present. We must provide dental care befitting the "quality-of-life" needs of the 21st-century patients we serve. We should not prejudice ourselves against infant technologies that are experiencing growth pains. Yes, we must carefully study and learn the new materials and techniques, sorting out the best of logics, then continue perfecting techniques as the new meaningful technologies advance and improve. Where would we be with heart transplants, cancer therapy, air travel, computers, and the like if the pioneers had given up? Where would we be if the pioneers of new technology automatically adhered to a 10-to 15-year "evidence-based research" requirement for every development in their progression? We all care for our patients and wish to protect them, but the greatest of risks is to take no risk at all. Learning means making mistakes. Progression does not occur by reverting back to the old; it comes by learning how to overcome the obstacles of the valued new.
With the preceding in mind, and for the purpose of stimulating thought, the following satire is humbly presented to allow dentists to look at today`s new technologies from a different field of view. To accomplish this, a hypothetical chronology is used to present a subject which is vital to dentistry for the 21st century.
Envision that 120 years ago there existed a famous dentist who discovered a most promising polymer-based tooth restorative material. After years of mistakes followed by hard-earned breakthroughs, this famous dentist improved the new material to a remarkable level. Compressive and tensile strength were great; elasticity was superb. Wear was very acceptable, and thermal expansion and conductivity came close to that of the tooth.
Because this dentist realized the value of restorations being an integral part of the tooth in both a structural and sealing sense, an adhesive system was developed which bonded and sealed the new material to enamel. It was later discovered that dentin also could be bonded, and at strengths virtually twice that of enamel! A marvelous new paradigm was realized. Not only were restorations strengthened from the tooth, but the new bonded restoration facilitated a reinforcement to the tooth in reciprocal appreciation. The possibilities were endless!
Over time, this famous dentist was able to achieve an almost miraculous esthetic quality. Using additives from Mother Earth, the new filling material was endowed with optical properties very close to that of both enamel and dentin. Color, opacity, translucency, value, and brilliance were exquisite. Fabulous esthetic results were achieved by simply matching restorative dentin shades to adjacent dentin, and enamel shades to adjacent enamel. In an ironic and fun way, this famous dentist`s name was quite befitting the contribution. Her name was Dr. C.D. White. Dr. White`s materials and procedures became affectionately known as "White`s Bonded Composite."
Because Dr. White`s bonding adhesives provided strengths close to that of both dentin and enamel, she was able to design and teach fabulous conservative filling preparations. She found the principle ingredient for preparation design was to simply remove the soft lesion. Fractures could be principally addressed by freshening the broken surfaces. Amputating significant quantities of tooth structure to accommodate the needs of earlier materials was eliminated. The need for expensive laboratory procedures was dramatically reduced. Multi-cusps and marginal ridges were directly bonded into place. Blinders and habits of earlier years began to be shed.
A few years later, Dr. White improved the bonding adhesive so it could form a strong bond to prior-placed composite as well. Historically, when problems occurred, total replacement was the norm. Now "repair-ability" took on a rich, new ethical meaning. With conservative care, old was repaired and hence renewed! The respect of dentists for humans, including their dental tissues, reached a new pinnacle. Exposure of dentinal tubules came to an all-time low. Vitality of teeth rose to an all-time high. Conservative restorative perfection caused periodontists to applaud.
Dr. White was able to quickly and easily teach dental students modern conservative preparation designs. For many practicing and teaching dentists who were entrenched with earlier materials and systems, the transformation took more time. Yes, the placement of Dr. White`s bonding adhesive and composite required attention to detail and, subsequently, more skill and time. Dentists developed and honed their skills to a new high. They became empowered, enriched, and fulfilled as no other dentists had been. They were doctors at the most respected of levels. They carried themselves, as such, with dignity and pride. Textbooks and dental schools came to endorse and teach the high standards of Dr. White throughout the 20th century. A fabulously high standard had been set. Dentists were happy!
Patients richly benefitted from their dentists` tremendous technical skills. Equally important, patients came to appreciate their deep human caring. They were able to laugh and speak with new-found confidence. Masses of patients maintained dentate into their twilight years.
Humans were benefitting richly and personally in this era of elegance and grandeur of the new 20th century. The modern industrial revolution was directly improving their quality of life. Patients were happy!
To replace was to revert
It was seldom done
Hence enamel, vital pulps
And tubules won.
Repair/renew
With esthetics the norm
For rich, for poor
Modern dentistry was born!
Patients did want
And patients did need
Chewing function with comfort
But smiling did lead.
They knew what they got
They liked what they had seen
Patients loved dentists
They knew they weren`t mean.
About 100 years later, an opportunist with a different motive came upon the scene. Having observed miners use mercury to recover silver from sludge and seeing it slowly amalgamate, he thought, "Wow! This is so simple. It`s so easy! No more `wasted` time refining hard composite, and no more need for esthetic development." This dentist`s name was quite befitting his "contribution." His name was Dr. G.B. Silver.
Silver ran his studies
And results what would you bet?
"Heavy metals aren`t a problem
Well, at least not as of yet."
Silver knew his metal
Was nothing like the teeth
It creeps, corrodes, and swells
Until teeth fracture for relief.
Preparation, high-speed cutting
From the tooth cut grooves and planes
To the filling goes the winning
To the tooth, disgrace and shame.
Place my fillings three times quicker
Carve anatomy with ease
But do not build to contact
As my fillings break, you`ll see.
Speed brought dentist into excess
Twice the dentists for demand
As they slaved to make the quotas
As they packed to beat the band.
But Silver blew his bugle
Blasting, "No one need dismay
My fillings leak, as you shall see,
And teeth they will decay.
"Repair is gone, renewal is nil
And so is White`s hermetic seal
Hence cut them, wrap them, and with seal
Full crown back up - what a deal!
Insurance companies rake it in
"Well, making money`s not a sin!"
Pack `em, carve `em, looks like tin
Increased number means you win!
Insurance sectors happy
Multi-socialist bureaucrats too
As they jumped to dental poker
In a game they couldn`t lose.
Repeat treatments do not fret
Just like premiums, no regrets
The clients come, the clients go
Hi Ho! Hi Ho! To work we go.
G.B. did blow his bugle
And it rang around the world
The "old" and caring ways of White`s
Were not again unfurled.
Silver trashed White`s great adhesion
Flushed away the fabulous seal
He rationalized, "Mine`s forgiving
When it leaks, well mine will swell.
"When voids are at the margins,
And yes, they shall occur,
The Ds will rust to Cs in time,
And shift the false bell curve."
Flexing, sealing, and esthetics
Bonding/strengthening to demise
"But tell me, what is progress
Without human compromise?
"Remember `Doctor` is for function
Masticatory, gum, canal,
Loftier forms for human value
Not in dental are to dwell.
The patients cried, "Who brought this blight?
Years back our smiles were such delight"
But G.B. scoffed, "We`ll stay on track
Just pay your bill and come on back."
And through it all the patients paid,
Creeping, cracking and recurrent decay
And to the end continued debate
"Again replace? No, extract, it`s too late!"
The satire now is over,
But the question`s to us all,
Saga then or saga now,
Will we as a group stand tall?
Quality of life, it is our banner
Human care, our constant goal
Will we stand for human value ...
Or with complacence sell our soul?
© Dan Fischer, DDS, 1999. All rights reserved
For more information about this article, contact the author at (801) 553-4198.
