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Early in My Career

Dental health for children was never a priority in England when I was growing up, and tooth extraction was considered a quick and easy solution for most dental problems. Things were actually so bad that dentures were given to some young people as wedding gifts, the idea being that extractions at an early age could ward off a lifetime of pain, problems, and expense.
My training as a dentist began at London University in the mid-1960s. I was fortunate to have been there then, as my teachers of dentistry at Guy’s Hospital presented exciting new ways to protect and strengthen teeth. For the first time, the inevitability of tooth decay and tooth loss was being challenged. We were shown how, with correct care, patients could completely avoid the cavities and extractions previously believed to be a part of life.
We learned about the chemistry of the mouth and the biology of cavities and how dental problems could be prevented and even reversed. It was amazing to realize how easily patients could use a natural process to strengthen, protect, and even repair teeth on their own. The idea of a world where everyone could enjoy dental health without cavities or gum disease was very exciting.
My first job after dental school was working as a dentist in Lausanne, Switzerland. The Swiss dental insurance system appeared to favor healthy teeth and the prevention of dental problems. As the size of cavities and fillings increased, so did patient co-payments, providing a financial incentive for people to visit their dentists regularly, to learn to care for their teeth, and to keep cavities as small as possible. Patients used rinses and foods to strengthen their teeth and keep them healthy, thus avoiding fillings, crowns, and root canals. Extractions were rare, and dentures appeared to be regarded as a last resort when all other options failed.
I chose to start my career in Switzerland because I was concerned about the British National Dental Care System. Later I was excited to take the new techniques that I had experienced and use them to help improve treatment for patients in England. Dental health care in England at that time was driven by factors that did not seem to be in the patient’s best interest. Under the government-operated system, dentists were paid on a sliding scale keyed to the size of a filling. The bigger the filling, the larger the fee. Money and ethics often clashed. Exaggerating the size of a filling could increase the dentist’s income, and no one would be the wiser. “Extension for prevention” was a professional joke about making a filling bigger than it needed to be, leaving so little tooth, there was nothing left to decay. Dentists were well reimbursed for extractions, so they became the commonplace solution to dental problems. Some dentists had daily quotas to meet, and because the patients had no financial stake in the process, they quietly accepted the treatment. Extractions were common, as were overfilled, crowded, crooked, damaged, and stained teeth. The unfortunate system of dental care provided generations of comedy routines and jokes about ugly, unhealthy British teeth.
My first job in England was as a community dentist in a school clinic in the early 1970s. The clinic was a large room with one dental chair in the center. After greeting the office staff on my first day, I opened the door to welcome my first patient. A thirty-foot bench extended from the doorway to the end of the hall, and it was filled with at least twenty small children waiting to have their teeth extracted. Strained little faces looked at me with round, moist eyes. Mothers resigned to the inevitable sat beside their children with an air of compassionate authority.
That was the era when adults believed that children should be seen and not heard. Children were expected to sit quietly and handle whatever came their way. They were expected to undergo drillings or tooth extraction without complaining or crying—and, often, without an anesthetic. When the treatment was over, they were required to politely shake hands and thank the doctor and the office staff.
One by one the children silently came over to me. I was expected to extract their teeth according to the treatment plan I had been given. My head was spinning. I didn’t know whether to carry out the dreadful treatment or to send them away. I did what I was expected to do, but I vowed from that day forward that by whatever means I could, I would help children everywhere enjoy healthy teeth and avoid cavities, fillings, and unnecessary extractions.
I began the next part of my career taking a closer look at the dental health of the children in my local community. I found an epidemic of tooth decay: babies with cavities and preschoolers with abscesses, lost teeth, and pain. I started a preventive dental program to teach pregnant women and young mothers how to look after their teeth and the teeth of their infants and toddlers. Because I was alone in the project, I divided the children into groups, sending older children with large cavities to family dentists who were happy to fill them with big and lucrative fillings. I used temporary fillings for baby teeth that were soon going to fall out, and I worked hard on behalf of the younger children, teaching their parents ways to prevent cavities.
I used permanent fillings in newer baby teeth instead of extracting them. Baby teeth are important because they hold a space for the permanent successor that grows between the roots, underneath in the jaw. Without baby teeth as placeholders, adult teeth can move around in the jaw, finally erupting out of line. Without a baby tooth, six-year molars can move forward and crowd out teeth that erupt in front of them a little later, during early teen years. Overcrowded teeth are difficult to clean and create traps for bacteria and plaque.
Baby teeth are also important as indicators and potential carriers of dental infection to newly erupting adult teeth. Children with cavities in their baby teeth are found to be at much greater risk for cavities in their permanent adult teeth. My experiences in Switzerland had taught me that ending meals with a tooth-protective food could make a huge difference to dental health and also how important nighttime oral care is for children and adults.
My new patients were happy to take the steps I suggested, and we quickly saw dramatic improvements. It was an exciting time for me as I realized how eager people were to avoid dental treatments and how interested they were in a new kind of treatment I called preventive dentistry.
Before long I was visited by a government representative who was upset about the reduced number of extractions at the clinic. Someone had noticed that temporary fillings were being put in teeth, and a staff member had complained that I was just talking with people. I had arrived at a career crossroads, and it was obviously time to leave the school clinic.
The next part of my dental career began when I opened my own practice just a few doors away from the government clinic. Parents arrived in large numbers, and although normal treatments allowed under the government system were without charge, my patients were willing to pay a small fee to bring their children for this preventive program. I was different from most dentists in town; dental visits were no longer a cause of fear or terror for the children. I was a teacher and a coach. Furthermore, at that time a female dentist in a pantsuit was something of a British novelty.
As the years passed, the volume of patients I treated outgrew my office space to the point where I could not fit another patient in the door. Every day we were busy from early until late. On Saturday mornings we helped nervous children become familiar with the dental office by having them watch movies in the waiting room and play with the dental chair. Parents came to learn about taking care of their children’s teeth, and the positive results soon became obvious to them.
The children were not developing cavities because they were following the simple procedures and preventive routines I prescribed. Mothers came in to take advantage of the new dentistry for themselves, followed by their sisters, mothers, husbands, fathers, aunts, cousins, and more. Whole families were learning and using my routines and techniques to prevent cavities and enjoy healthy teeth.
My office grew, and I saw more and more people with special needs who required sophisticated dentistry to save their damaged teeth. London was home to the Eastman Academy of Dentistry, and I took classes there to learn about treatments to care for the developmentally disabled.

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