Dental Autonomy

Dentistry Must be a Health Service
Oral Sepsis and Bodily IIIs are Linked; Successful Diagnosis and Treatment
Therefore Should Recognize the Relation.
So writes Dr. E. Melville Quinby in
“DENTAL AUTONOMY”

Since it must be admitted by even the most charitable observer that dentistry is in the throes of some malady which cries out for immediate relief, and with a deep[ and sincere appreciation of the pressing nature of this malaise, the following suggestions are advanced, with all deference, by way of diagnosis and treatment.
The first cause, I believe, is a lack of appreciation of the scope of dentistry in the field of health service.
When dentistry was first established as a separate profession nearly 100 years ago, it was quite natural that the most obvious needs of the public from a dental point of view should be studied.
Odontoclasia and its consequences seemed to demand the most attention; and to that end the relief of pain, the filling of teeth, the removal of hopelessly diseased teeth, and the making of artificial substitutes, became the most absorbing task of the dentist. On that basis the acquisition of more and more mechanical skill has characterized the work of the American dentist, and elicited oft-expressed admiration of operators in foreign countries.
One of the objects of this article, however, is to point out gently but firmly, that what was undoubtedly good training for the infant of (1839) is too restricted in scope of the adolescence or maturity of the dental profession.
If dentistry as a name is to survive, it must, like medicine, be understood to embrace all the various scientific studies—the ologies which advance of knowledge in the various fields of research may dictate. This means, of course, far more attention to etiology, diagnosis, prognosis, and outlines of treatment which shall be really scientific and devoid of any suspicion of empiricism.
For proof of the foregoing statement every dentist in the country is invited to examine every dental machine of all patients over twenty years of age, from the point of view of an efficient organ, as to function of the dental units and health of the supporting tissues of the teeth.
A lecture given twenty years ago by one of the best known dentists of our time on the subject of the “Mutilated and Neglected Mouth,” formed the inspiration for a habit of obtaining models of the dental machine in most cases which have come under the writer’s notice. This plan has brought to light the fact that out of the hundreds of models so obtained, only a scant half dozen can be said to meet the test of a dental machine with all the teeth present in physiological occlusion.
In common with all branches of human endeavor at the present crises we as dentists will be compelled to readjust our point of view and our method of attack on the dental problem in the interests not only of public health but also for the economic benefit of the dental practitioner.
Having arrived at the position of discovering one central truth—you have found something which governs numberless facts. For as Tagore says: “This discovery of a truth is pure joy to a man—it is a liberation of his mind. For a mere fact is like a blind lane, it leads only to itself—it has no beyond. But a truth opens up a whole horizon—it leads us to the infinite.”
In order to carry out this (suggested) mental orientation to a profitable conclusion, without any paralyzing restrictions we must enter the field of readjustment, as we are reminded by Confucius, entirely free from “Foregone conclusions, arbitrary predetermination, obstinacy, and edoism.”
A dental curriculum which has stressed, too much, the acquisition of mechanical skills and the need for a medical point of view in dealing with oral lesions rather than a purely dental one, are the next two in the causes of the present ill health of dentistry. They will be discussed together, one being a corollary of the other.
In venturing upon a discussion in such a controversial field as the “status of dentistry,” one writer at least is quite aware of his temerity in doing so; but having devoted many years to the study and practice of dentistry, with a background of a medical education, it is perhaps not strange that such a person might have accumulated a few ideas, and possibly facts, on the subject at issue. Moreover, any statements made will follow the rules, so far as is humanly possible, as laid down by the Chinese philosopher aforesaid.
Should Medicine Absorb Dentistry
The present study then is “on the Question whether Dental practice should be included in Medical practice.” (Journal of Research, Vol. XII, No. 6, Dec. 1932.)
“Dentistry, a separately organized profession since 1839-40, has merited and won a distinguished place in public service and in public respect.”
Opponents of dental autonomy then are in the delicate position of all those who attempt to readjust standardized opinion on any subject, the extreme difficulties of which attempt have been the despair of the philosophers through the ages.
One obstacle in the path of the would-be reformer is well expressed in the statement that “the capacity of the human mind for withstanding useful information cannot be overestimated” and also that: “what people call their principles are often their pretexts for acting in the obviously convenient way; and the convenient way leads around obstacles rather than through them.” (Swift.)
In the further consideration of this vexed question as to whether dentistry is a logical branch of medicine, or is entitled to pursue and independent course, all readers are implored to give the pros and cons equal consideration; and not to allow the undoubted obstacles, in the readjustment of medical and dental education, to misdirect the trend of logical and progressive ideas and tend to that sense of false security in which policies are so apt to be dictated by expediency, and the principle of letting well enough be.
In that respect a quotation from the North Carolina Dental Bulletin is very inspiring:
“Blessed are they who were not satisfied
To let well enough alone;
All the progress the world has made
We owe to them.”

Returning for moment to the birth of dentistry in 1839-40 it should be remembered that the godfathers of the infant hoped, nay even expected, that the said infant would be adopted by its logical parent, medicine. And it was only after the abandonment of the newcomer to its own resources, that any of those responsible for its welfare ever dreamed that dentistry would be compelled to nurture itself and pursue and independent course.
In other words dental autonomy at the outset was an entirely unforeseen and fortuitous happening; and furthermore it was the only possible way of perpetuating the existence, and stimulating the growth of the newborn dental infant.
But infants, if healthy, have a way of growing, more especially if the environment is favorable for growth. So also with worth-while ideas: they are not static, no live thing is. Consequently, as might be expected, the scope of the dentist and dentistry has extended from the original tooth filling, teeth making plan to a dental health service, which should be the equivalent of a medical health service.
That being the case, it is only fair, if embarrassing perhaps, to ask the heads of the dental profession if , in their opinion, the average dental practitioner is educated to the degree necessary to elevate his daily work to the dignity of a health service.
It is were possible to obtain a real answer to this question, one free from all suspicion of diplomacy or expediency, the path would be cleared for an authoritative discussion of ways and means to dissolve for all time this fog of self-delusion, and laissez-faire.
As human beings we seem to be prone to delude ourselves into a state of mental obfuscation in many stages of living. For instance in order to get up in the morning at six o’clock we must put our watches and clocks one hour ahead, otherwise we could not divorce ourselves from the blankets at the right time! Whereas all that one has to do is to leave the watch alone, and rise at six. As to the necessity for adopting the medical point of view in the consideration of dental lesions, it seems to the writer that once seeing the light as it were, would be sufficient to make a person realize the fact that herein is something worth further thought. It is in line also with Tagore’s philosophy, this discovery of a truth “which is a liberation of his mind.”
If one seriously asks himself questions as to the adequacy of dental service to carry out any duty except that of patch-work of questionable durability and of more than doubtful value as a health service, such a person promptly changes a state of mind, which may be termed a negation of curiosity into one of awakened interest. For as Galsworthy points out nothing is static; and yet for a hundred years dentistry has been decidedly in that condition.
Future of Professions Cannot be Ignored
Various spasmodic efforts to awaken the dental profession from its dream of fanciful security have been made from time to time by pioneers in the field of dental renaissance; and it is with much appreciation that the following excerpt from a paper read by Dr. Alfred Owre before the Central Dental Association of Northern New Jersey at Newark, Nov. 5, 1930, at a combined medical and dental meeting is included:
“It is a pleasure to discuss this question before a group of thinking men of both professions. The problem is of considerable interest nowadays, not only in our country but abroad. It has two chief phases—one the immediate, practical question of what we can do as to the future of medicine and dentistry. Neither aspect can be ignored in an intelligent consideration of the issue. One thing seems fairly certain—the old systems of dental and medical education and practice are bound to see radical changes in the next decade or so. Economic considerations are arousing both public and practitioner to protest against waste and inefficiency. There is genuine interest in revamping both education and practice with an eye to economy in educational outlay as well as in expenditure for adequate and scientific health care. The blissful ignorance of the systemic effects of oral practice largely enjoyed by doctors and dentists prior to 1910 is no longer tolerated. You will recall that in that year Dr. William Hunter, a distinguished London pathologist, fired a death-dealing broadside against current dental practice as well as medical indifference to mouth conditions in the diagnosis and treatment of disease.
Oral Sepsis Stressed by Hunter
“What I desire to impress upon you (medical) students,” stated Dr. Hunter in a Montreal address,* “and all students entering the profession, and all those already engaged in the practice of the profession, is , it is not a matter of teeth and dentistry.’ It is an all-important matter of sepsis and antisepsis that concerns every branch of the medical profession, and concerns very closely the public health of the community. It is not a simple matter of ‘neglect of the teeth’ by the patient, as is so commonly stated, but one of neglect of great infection by the profession—a great infective disease for which the patient is not primarily responsible any more than he is responsible for the contraction of typhoid fever or tuberculosis. The condition referred to is that to which I have given the name of ‘oral sepsis.’
“The subject of ‘oral sepsis,’ as I designated and defined it—namely, the septic lesions of streptococcal infection found in the mouth—belongs to no one department of medicine or surgery. It is common ground on which the general doctor, physician, or surgeon, the throat, nose and ear, and eye specialist, in ‘rheumatic’ diseases, in fevers, in skin diseases, in nervous and mental disease, and, lastly, the dental surgeon, all meet on terms of equal responsibility. In its earliest manifestations no special knowledge is required to deal with it; a sound grasp of the principles underlying antisepsis alone is required. Unfortunately for the patient, it is precisely this grasp which I grieve to say is wanting.”
“My clinical experience satisfies me that if oral sepsis (and nasopharyngeal) could be successfully excluded, the other channels by which ‘medical sepsis’ gains entrance into the body might almost be ignored.”
__________
*An address on the Role of Sepsis and of Antisepsis in Medicine. Delivered at the opening of the session of the faculty of medicine of McGill University, Montreal, Oct. 3, 1910, by Wm. Hunter, M.D., Edin.; F.R.C.P. London; Physician and lecturer on Pathology to the Charing Cross hospital, London; Physician to the London Fever hospital. Published in the Lancet, vol. CLXXX, No. 4559, Jan. 14, 1911.
__________
“One of the worst cases of sepsis I have ever seen was brought me by a doctor who told me that the moth had been carefully seen to and was in good order.’ The patient was a tall, handsome man in the prime of life—a case of severest Addisonian, so-called ‘pernicious,’ Idiopathic Anemia. His mouth was, indeed, clean to all outside appearance, for it was one mass of gold caps, bridges, crowns, fillings, false teeth, so ingeniously built up that one could hardly tell what was false and what was real. To free that the man from his sepsis in his state of health involved what was really equivalent to a major operation in surgery. The conditions of sepsis, necrosis, etc., revealed on removal of this golden architecture was perfectly appalling.
“No one has probably had more reason than I have had to admire the sheer ingenuity and mechanical skill constantly displayed by the dental surgeon. And no one has had more reason to appreciate the ghastly tragedies of oral sepsis which his misplaced ingenuity so often carries in its train. Gold filings, gold caps, gold bridges, gold crowns, fixed dentures, built in, on, and around diseased teeth, form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine or surgery. The whole constitutes a perfect gold trap of sepsis of which the patient is proud and which no persuasion will induce him to part with. For has it not cost him much money, and has he not been proud to have his black roots elegantly covered in beaten gold, although no ingenuity in the world can incorporate the gold edge of the cap or crown with the underlying surfaces of the root beneath the edges of the gums? There is no rank of society free from the fatal effects on health of this surgical malpractice.”
“I speak from experience. The worst cases of anaemia, gastritis, colitis of all kinds and degrees, of obscure fever of unknown origin, or purpura, or nervous disturbances of all kinds ranging from mental depression up to actual lesions of the cord, of chronic rheumatic affections, of kidney disease are those which owe their origin to, or are gravely complicated by, the oral sepsis produced in private patients by these gold traps of sepsis. Time and again I have traced the very first onset of the whole trouble of which they complained to a period within a month or two of their insertion. The sepsis hereby produced is particularly severe and hurtful in its effects. For it is damned up in the bone and in the periosteum, and cannot be got rid of by any antiseptic measures which the patient or the doctor can carry out. Moreover, it is painless, and its septic effects therefore go on steadily accumulating in intensity without drawing attention to their seat of origin.
“Such are the fruits of this baneful so-called one of the teeth were a series of ivory pegs planted in stone sockets. But the teeth being what they are—namely, highly developed pieces of bone tissue, possessing, I would point out, a richer blood-and-nerve-supply than any piece of tissue of the same size in the whole body—and planted in sockets of bone with the closest vascular relations to the bone and the soft tissues of the periosteum and the gums, the title that would best describe the dentistry here referred to would be that of ‘septic dentistry.’ Conservative it is, but only in one sense. It conserves the sepsis, which it produces by the gold work it places over and around the teeth, by the satisfaction which it gives the patient, by the pride which the dentist responsible for it feels in his ‘high-class American’ work, and by his inability or unwillingness to recognize the septic effects which it produces.”
The gravity of these assertions has been substantiated by other celebrated authorities. Dr. Charles Mayo stated, some years ago:
“The dentist’s patients must be warned of the mouth as being by far the greatest portal of entrance of germ life into the body, the most infected part of the alimentary canal. The people will gradually demand of their medical advisers. The next great step in medical progress in the line of preventive medicine should be made by the dentists. The question is will they do it?”
And again:
“Modern dentistry is relieving the world of much of its misery by watchful care of foci connected with the teeth, and the trend of modern medicine and dentistry is bringing their fields again closely together. Dentistry should be a department of medicine, as it is as closely associated with medicine as are the specialties of the eye, ear, nose and throat, and others.”
Only last September Dr. Mayo was quoted as stating that 61 per cent of the cases in the Mayo Clinic come as a result of oral infection.*
Dr. John B. Murphy, the famous Chicago surgeon, wrote in 1916:
“Why should the dentist be educated in a different room from the surgeon in the essential elements, in his bacteriology, histology, biology, physiology and anatomy? He should not. The first two years should be the same with the aorist, the oculist, the surgeon, the neurologist, the internal medicine man, and the dentist, and until his educational error is corrected there will be no correlation and no co-operation and between dentistry and internal medicine.”
__________
*Cited in “Why Dental Health Education?” by Forrest K. Staples, D.D.S., Dental Survey, September, 1930.
Boston, Mass.
E. Melville Quinby,