Dentistry's forced return to its roots Gordon J.

Christensen JADA 2011;142;1393-1395

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PERSPECTIVES

OBSERVATIONS

Dentistrys forced return to its roots

entistry has seen significant developments and changes across the past two centuriesnot all of them, I would argue, for the best. I propose that the current recession has slowed and modified those changes and has influenced the dental practice of today in such a way as to make dentistrys past a greater part of its present. Dentistry originally was a profession aimed primarily at eliminating oral pain. Slowly, it evolved into one in which practitioners accomplished some prevention and conservative restoration of teeth with little regard for esthetics. In more recent times, dentistry has become a profession that many would conclude is too esthetically oriented, with practitioners often accomplishing radical procedures for the sole purpose of improvement in esthetics. Now the Great Recession has influenced the profession to go back to its roots, an orientation toward alleviation of pain and conservative preservation of the natural dentition. Dental pain can be one of the most uncomfortable conditions a person can experience. The importance of this debilitating pain in the oral area caused concern among early medical practitioners, and dentistry always has been recognized as being an important area of medicine. Modern dentistry in the United States broke away from the other parts of medicine in 1840 with the founding of the Baltimore College of Dental Surgery, now the University of Maryland

School of Dentistry. This fragmentation has been a matter of educational and political controversy ever since, with easily recognizable advantages and significant disadvantages. In the 1800s and throughout the frontier expansion of the population into the western United States, dentistrys approach to pain management primarily involved extracting carious or periodontally diseased teeth and sometimes replacing them with artificial dentures. Practitioners used amalgam as a restorative material. To this day, amalgam continues to be surrounded by controversy, which historically some have referred to as the amalgam war. Later, stimulated by Dr. G.V. Black and other dental pioneers, the profession initiated a concerted effort to retain natural teeth, and operative/conservative dentistry had its modern start. Restoration of teeth with amalgam, pure gold, gold alloy and the long-used silicate cement dominated dental treatment for the first one-half of the 20th century. Extraction of teeth, and often premature replacement of them with dentures, still were a major part of dental practice. Function of the masticatory system was the mantra, and esthetic considerations definitely were secondary. Metal display in the mouth was commonplace and became relatively well accepted by many patients. Orthodontic therapy was practiced minimally, and preventive dentistry was only beginning to be suggested by private practitioners. Further

Gordon J. Christensen, DDS, MSD, PhD

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development of preventive dentistry was stimulated primarily by the military services during World Wars I and II and by the initiation of the dental hygiene profession. The mid-20th century has been described by many as the golden age of dentistry, for a number of reasons. Dental research blossomed, the American Dental Association became a dominant leader in the profession, dental schools and dental education were standardized and upgraded, preventive measures such as fluoride use and periodontal preventive therapy were instituted, many young people received orthodontic treatment, and overall oral treatment became relatively adequate for the estimated one-half of the overall U.S. population who sought dental care on a frequent basis. The maturation of restorative dentistry continued, periodontal treatment became more commonplace, and in patients who visited dentists frequently, it became possible to retain teeth that in previous eras would have been extracted. Esthetic considerations remained secondary until about 1960, when porcelain-fused-to-metal crowns came into wide use and resinbased composite replaced silicate cement as the material used most often in anterior directly placed restorations. More concern about oral esthetics arose among dentists, and patients rapidly came to embrace the concept. In the 1970s, 1980s and 1990s, root-form dental implants came into use, significantly influencing the treatment plans that dentists could accomplish.
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OBSERVATIONS

Additionally, many in the profession began to promote esthetic or cosmetic dentistry heavily. The American Academy of Esthetic Dentistry (Chicago) and the American Academy of Cosmetic Dentistry (Madison, Wis.) were established in 1975 and 1984, respectively. These organizations initiated a movement that dominated general dentistry and some of the dental specialties until the recent Great Recession. The designations cosmetic dentist or esthetic dentist became visible in telephone books and advertisements and even on dentists business stationery, although such designations are not officially recognized by the American Dental Association (Chicago). It became apparent that some dentists had turned away from dentistrys original objectives to prevent or treat oral disease and had changed their orientation significantly to making patients look better. In my opinion and, I believe, in the opinions of many others who have lived through this transformation, significant overtreatment became obvious. Ceramic veneers were used in young people, crowns were placed where simple direct restorations could have served, bleaching was carried out when the teeth were of normal color, expensive and often questionably needed surgery and orthodontic care to correct minimally observable esthetic impairments were performed, amalgam providing adequate service was replaced with toothcolored materialsmostly for the sake of the esthetic cause. These procedures have had some negative repercussions among conservative dentists and patients. In my opinion and observation, with a few exceptions, dentists always have been trusted by the public throughout my long careerbut in recent
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years, the public has started to question the treatment suggested by dentists. Patients have asked me to provide many more second and third opinions than they have in the past because they did not trust the treatment suggestions of previous dentists. Treatment plans emphasizing esthetics often confused elective treatment with a patients actual need. In my opinion, we can attribute this drop in public trust directly to the heavy emphasis on esthetic dentistry and the absence of presentation of all of the alternatives available for specific treatment situations. Informed consent has been lacking, in my opinion.
THE GREAT RECESSIONS EFFECT ON DENTISTRY

About three years ago, the Great Recession started. It is well known what has happened to dentists and the dental profession during the last three years. As I observe dentists across the country in my many continuing education courses and meet with dental materials and equipment distributors to determine their activity and needs, I see a general trend of conservatism, one that differs slightly depending on geographic location. Some areas are not feeling the recession to a significant degree, whereas other areas are genuinely depressed, with numerous bankruptcies among dentists. The following information represents what I see as changes in both dentists and the publics attitudes related to the forced return to our roots caused by the financial limitations and the psychological frustrations imposed on the public by the recession, the decrease in discretionary income, fear of the recessions returning and loss of retirement savings. Growth of minimally invasive dentistry. There are several identifiable movements
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encouraging prevention and conservative therapy, as evidenced by the establishment of a model called caries management by risk assessment (known widely as CAMBRA); the development of organizations such as the World Congress of Minimally Invasive Dentistry (Imperial Beach, Calif.); and the inclusion in most large regional and national dental meetings of numerous continuing education courses regarding minimally invasive and preventive procedures. These movements and dentists continuing and expanding acceptance of them have reduced the incidence of more extensive procedures in all areas of dentistry. The minimally invasive concept supports use of preventive chemicals and materials, use of tooth sealants, conservatism in tooth preparation, remineralization of tooth structure when indicated, conservative periodontal therapy instead of periodontal surgery, endodontic care instead of tooth extraction, placement of less invasive small-diameter implants, orthodontic treatment instead of placement of veneers and crowns, placement of fewer crowns and more conservative small restorations, and an overall emphasis on maintaining the natural dentition in its original state for as long as possible. I applaud these developments. Fewer crowns. Crowns and fixed prostheses compose a major part of the activity of general dentists. As reported by Bennett Napier, executive director of the National Association of Dental Laboratories (Tallahassee, Fla.) (oral communication, Sept. 11, 2011), the numbers of crowns placed in the last three years have decreased. Mr. Napier reported a reduction of about 3.5 percent in the total number of indirect restorative units made since the beginning of the recession.

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Additionally, he reported that about 2,000 U.S. dental laboratories have closed since the fall of 2008. At first observation, this information appears to be negative. However, the data can be interpreted as meaning that more teeth either were not restored unnecessarily or were restored with more conservative techniques. In my opinion, the trend to restore teeth in a more conservative manner is a positive one. Patients are living longer than ever. As all dental restorations have a finite life expectancy, the fewer times teeth are restored across a lifetime, the more likely it is that restorations and teeth will serve for that lifetime. However, waiting to restore teeth with overt dental caries will result in significant negative challenges when patients finally are forced to seek treatment. Fewer veneers. During the height of the esthetic movement in dentistry, many veneers were placed. In my opinion, some of the minor esthetic needs experienced by the patients who received these veneers could have been solved easily and inexpensively by, instead of veneers, minor orthodontic treatment; simple, conservative resin-based composite restorations; or even bleaching. One of the largest dental laboratories in the nation confirmed that veneer placement has decreased by about 12.5 percent during the recession (James Shuck, vice president of sales and marketing, and Darryl Withrow, vice president of operations, Glidewell Laboratories, Newport Beach, Calif., written communication, Sept. 12, 2011). Fewer requests to replace amalgam with resin-based composite. It is my observa-

tion that the elective treatment to replace trouble-free amalgam restorations with resinbased composite restorations has been discussed and accomplished less often in the past few years, as patients have had less discretionary income to spend on such procedures.
THE STATE OF DENTISTRY AND ITS PATIENTS IN LATE 2011

It is my observation that the dental profession has been forced by the recession to return to a more conservative orientation. In place of comprehensive and expensive treatment that dentists might have suggested just a few years ago, we are seeing more conventional preventive therapies, less aggressive treatment and less treatment oriented primarily toward esthetic enhancement. In addition, many patients refuse even conservative therapy because they do not feel they can afford it. Whether the undeniable and observed decline in patients acceptance of oral preventive care and treatment represents a measurable reduction in patient income or a mediaproduced reluctance to spend is a moot point. However, the result of this challenge is both good and bad. For the many dentists who previously promoted primarily esthetic procedures, the current situation in which the profession finds itself has changed their practices significantly. For the many dentists who were practicing more conventional dentistry, the recession has not been such a major impediment in their practices. For the patients who are among the approximately 9.1 percent of U.S. workers who are unemployed1 and who have

been putting off needed oral therapy, there will be a significant financial outlay in their future to accomplish the needed therapy. Patients who have put elective therapy on hold always can accept that treatment in the future as the economy stabilizes. It seems logical that there will be an eventual return to more esthetic and other elective procedures. But whether the profession will return to the same prerecession state I have described is unknown. The return to a more conservative profession is welcomed by some and upsets many others. However, it appears that we have no choice for a while.
SUMMARY

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As a result of the recession, the orientation of the profession definitely has shifted from many relatively expensive and comprehensive treatment procedures, some solely esthetic in nature, to more preventive and less aggressive restorative and periodontal procedures. Although some would consider this change to be a negative one, others are pleased to see us return to our roots as a profession dedicated primarily to prevention of oral disease, early disease intervention and conservative therapy. I
Dr. Christensen is the director, Practical Clinical Courses, and a cofounder and the chief executive officer, CR Foundation, Provo, Utah. He also is an adjunct professor, Brigham Young University, Provo; and an adjunct professor, University of Utah, Salt Lake City. He is a diplomate of the American Board of Prosthodontics. Address reprint requests to Dr. Christensen at CR Foundation, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Economic and financial indicators. The Economist Sept. 3, 2011;400(8749):93-94.

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