This article, which was written in 2000 was a reflection of my time working for The Indian Public Health Service 37 years ago. In light of the controversy and resistance that surrounds the long-overdue effort of the federal government to revamp the health system that is currently in place across the United States, this article is relevant even now. While there have been positive changes to the state and federal programs to help these and other populations who have limited access to care I am of the opinion that there is still a gap regarding the supply of adequate dental treatment is still present.
I’m going to confess to confess. When I was a student at dentist school back in late 1970’s, my mind was filled with ambitious goals. In the 1970’s, the Vietnam War was winding down and it was an era of peace and love for the other man. As an older person, I looked into numerous possibilities that would let me earn a living as dentist and serve humanity. I was convinced that I could achieve these goals by working in a dental practice or operating an mobile dental van in the inner cities with low incomes or rural areas where quality dentistry was scarce. After that, I was introduced to an opportunity that could be the solution to my problems.
After I completed my studies at Georgetown Dental School in 1973 I decided to join the Indian Public Health Service. I believed that it was a great opportunity that would allow me to further my education and start a long-term career of giving back to my community. I was transferred for placement on The Fort Berthhold Indian Reservation five miles away of Newtown, North Dakota. We were provided with the house with three bedrooms. It was situated on a compound which included another ten homes as well as an office. A physician, along with other health professionals, including me, social workers and nurses lived in the different homes. It was an amazing experience. It was just a few minutes walk and we had an unobstructed perspective of the Missouri River from our window and wild horses running through the fields, surrounded by the gorgeous Dakota buttes. I was extremely excited to be living in such a gorgeous and spiritual area with my family , and thrilled about the possibility of helping people who otherwise wouldn’t get dental treatment. The most important thing was knowing that I was not required to depend in charging to pay for my skills or setting up a huge volume practice to make it through. My bubble burst and the inefficiency and inequity of the system came to light.
The fundamentals of dental care such as cleanings, examinations, extractions and fillings, were available. Additional more expensive services that could have been needed to preserve teeth, such as dental endodontics (root canal treatment) or bridges, crowns and as well as full or partial dentures as well as the periodontal (gum as well as bone) treatment require pre-approval similar to pre-authorizations that are required for insurance firms. The majority of children were approved for basic procedures, however treatments for adults, especially those who required the combination of root canal treatment and bridges and crowns were not always considered to be approved.
Due to the low size of the population (4000) as well as the small budget of the program certain dentists and physicians such as myself were hired right out of dental school. They were put in a difficult position in which they were as the only providers in their area of health care within the facility. Dental professionals who were not experienced had the benefit of additional instruction in the field, working with other professionals in their field who had more experience, to consult or performing more complex procedures. Evidently, my knowledge was inadequate as were my clients, who became the unlucky victims of my education. The first time I realized what the real meaning was of the word, ” to practice dentistry.”
In accordance with the financial system Indian Public Health often recommended extraction (removal) of teeth, as well as full or partial dentures. Similar situations can be found in similar situations where patients who receive government-sponsored Medicaid benefits, or those with private or dental insurance offered by employees might be denied necessary tooth-saving treatment due to the fact that it’s not economically beneficial to save teeth. While some patients are assisted by these programs and might not be able to pay for even the simplest dental care and recommendations based on cost-effectiveness and profit margins is not the best. They often resulted in elimination of teeth that were damaged in a marginal way. This, as well as the unforgivable, but inevitable mistakes made by the untrained dentist, created the impression of distrust between the dental professional and the patients he treated.
The building of trust and affection among the dentist as well as patient is among the most crucial aspects of a successful relationship in the dental setting. I laugh whenever I consider how foolish I was. I attempted to circumvent the system by requesting tooth-saving benefits for adult patients. They were denied. I wrote articles about nutritional health for dental clinic’s bulletin. It was not received well. I tried to instruct my patients in how to care for themselves at home and give them advice on nutrition. There was not much interest. I set up a children’s Dental Health Week poster competition. I offered prizes from solicited giveaways like floss and toothbrushes for the top winners. Only a handful of children participated. I appeared on a local show known as “Bowling to earn money” and a few radio shows to get the message out. It did not make a difference. It became increasingly frustrating for me as time passed by. I realized that the years of neglect and abuse by the system could not be wiped out by the actions of a Jewish white man coming from New York. This absence of “love and trust” was often evident in the form of scared patients, or the excessive amount of missed appointments or the difficulty of filling out the appointment book. However, the most important thing resulted in the fact that the missing component is “love as well as trust.” They did not trust me. They didn’t trust me.