Our National Smile – It couldn’t happen here?
THE MAKING OF THE AMERICAN MOUTH: DENTISTS AND PUBLIC HEALTH IN THE TWENTIETH CENTURYBy Alyssa Picard Piscataway (NJ): Rutgers University Press; 2008. 312 pp., $45.95
On 17 June 2007, Clark Hoyt, ombudsman for the public at the New York Times, wrote an entire column about a single image that had accompanied a story on immigration reform.1 At issue: An opponent of an immigration bill, William Murphy, who had been photographed sitting and smiling on his front steps, was clearly missing a tooth.
More than 1,200 readers had written to complain. They accused the Times of purposefully selecting the photo to demonize Murphy and, by implication, the entire anti-immigration reform movement. Others had written to say that they agreed with Murphy’s views, although they personally distanced themselves from him because of the photo.
Hoyt described the difficult decision editors faced in featuring that side of Murphy’s face. He was missing an eye on the other side and had asked the paper to photograph his “good side.” Murphy acknowledged that his appearance made people uncomfortable, regretting that readers focused on his appearance rather than the merits of his arguments.
But so it is in America. Good teeth signal social class and intellectual achievement here, as Alyssa Picard knows well. In The Making of the American Mouth, she provides an engaging history of the evolution of American dentistry, including the profession’s influence over our social norms and health policy. It’s a book that anyone keen to understand and improve our current national state of oral health ought to read.
Picard describes how dentists’ major goals—improving oral health and advancing professional status—first aligned in the early part of the twentieth century. But she also convincingly asserts that now dentistry as a profession largely has abandoned public health goals in favor of protecting its economic self-interest.
The book initially describes how dentists’ professional evolution of establishing education standards, adhering to science, and creating licensing closely tracked physicians’ evolution, although the dentists lagged their MD colleagues by more than a decade. Physicians did not consider oral maladies to be infectious diseases. They relegated the human mouth to dentists—a clinical separation that continues to the present day.
In the early 1900s, oral hygiene programs based in public schools established the foundation for modern dentistry with routine preventive tasks, female assistants, and regular visit schedules. Parents who could afford follow-up treatments took their children to private dental practices. Dentists actively promoted the connections between good oral health and American aspirations, particularly with poor immigrant children. From very early on, Americans learned to value dentists’ clinical authority and aesthetic prescriptions.
Publicly funded hygiene programs managed by dentists furthered their civic, professional, and entrepreneurial goals. Providing preventive services to children created a public good and advanced the profession’s stature. At the same time, dentists established a norm that instead of relying on government-funded programs, restorative care took place in private practices and was paid for by patients.
Picard details how dentists struggled with the nascent science of tooth decay. Some theorized that decay was an evolutionary process similar to humans’ losing our sagittal crest, the elevated bony ridge on the skull whose necessity withered as jaws reduced in size. Others hypothesized that decay was due to genetic degeneracy. In hindsight, the theory that processed food deleteriously affected teeth and health—first put forward in the 1910s—proved prescient.
America’s expansionist ambitions in the Philippines and elsewhere in these early years of the twentieth century took U.S. dentists overseas, and adopting American clinical standards and aesthetic norms became an index of successful cultural assimilation. At the same time, some U.S. expatriate dentists noted the excellent oral health of indigenous populations and challenged the need for “American” teeth.
As the book continues, Picard describes how dentists, like physicians, fought against government involvement and public insurance, insisting that private practices, supplemented by charity care, were sufficient. Schemes for “socialized” insurance promoted but never realized during the Depression would, they argued, cripple innovation, curtail liberty, and restrict profits.
Dentists achieved a major goal when they championed the addition of fluoride to drinking water in the 1950s, although battles with opponents, discomfort with government involvement, and the resulting loss of clinical work soured their appetite for other public health interventions. Although fluoridation is heralded as a major public health achievement, dentists ultimately perceived it as a threat to their practices.2
Medicare, Medicaid, the Civil Rights movement, and the women’s rights movement further threatened the profession with government encroachment and demands by black dentists and female hygienists for more respect. Picard maintains that dentists’ promoting individualism and the private marketplace, in lieu of government initiatives, masked a desire to maintain race, sex, and economic prerogatives of the mostly white, mostly male profession.
In response to these perceived threats, in the 1960s and 1970s dentists retreated from public health, redoubling their focus on revenues for and aesthetics in their practices, particularly orthodontia. Picard shines especially in Chapter 7 with her description of the phenomenon among hip-hop devotees of adorning teeth with gold “grills.” The practice serves to demonstrate wealth, while mocking the norm established by whites. Ironically, Picard notes, the only widely accepted practice of garish teeth adornment is orthodontia.
Picard’s book falls short in presenting the consequences of our nation’s aesthetic preoccupations and dentists’ abdication of the community good. In 2000 the U.S. surgeon general declared a “silent epidemic” of oral diseases affecting our most vulnerable citizens.3 The 30 percent of Americans not well served by the private-practice system are the poor, the institutionalized, those living in rural areas, and those burdened with several medical conditions.4 Despite growing evidence of the connection between oral health and overall health, the inventory of untreated diseases and inequities is long.
The sociologist Eliot Freidson challenged professions not to use their practice monopolies for selfish advantage.5 Picard’s book leaves the reader feeling that dentistry has failed this challenge during the past half-century. Picard presents a rather monolithic assessment of the profession, given the numerous subgroups within dentistry that continue to advance policies and initiatives to improve the public’s health.
Dentists wield enormous power to make, or break, the American mouth. In the past few years, however, leadership for improved oral health has come increasingly from outside mainstream dentistry. Pediatricians have enhanced patient education and their clinical practices to address children’s oral health. Philanthropies have dedicated considerable resources to addressing dental access inequities. State legislatures have slowly expanded the scope of practice for midlevel dental professionals. And with federal funding, the Institute of Medicine has initiated two committees to recommend solutions for the silent epidemic of untreated cavities and diseases around teeth and in gums.
William Murphy, whose photograph outraged many New York Times readers, told the newspaper that he couldn’t wear his prosthetic tooth the day of the photo because of swelling from a medical condition. Imagine readers’ responses to him had he beamed an American smile.
Len Finocchio1
1 Len Finocchio (lfinocchio@chcf.org) is a senior program officer at the California HealthCare Foundation in Oakland. He leads the foundation’s program work in oral health.
NOTES
- Hoyt C. The ugly part wasn’t his face. New York Times [serial on the Internet]. 2007 Jun 17. Available from: http://www.nytimes.com/2007/06/17/opinion/17pubed.html?_r=1&scp=1&sq=Ugly%20Part%20Wasn’t%20His%20Face&st=cse
- Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900–1999. MMWR. 1999;48(12):241–3.[Medline]
- U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville (MD): Public Health Service; 2000.
- Brown LJ. Adequacy of current and future dental workforce: theory and analysis. Chicago (IL): American Dental Association; 2005.
- Freidson E. Professionalism: the third logic. On the practice of knowledge. Chicago (IL): University of Chicago Press; 2001.
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