【翻譯練習】醫牙為何分家
Why Dentistry Is Separate From Medicine
作者：JULIE BECK
來源：https://www.theatlantic.com/health/archive/2017/03/why-dentistry-is-separated-from-medicine/518979/
醫牙分家，後果有時可能不堪設想。
醫師歸醫師，牙醫師歸牙醫師，從來不會混為一談。有健保是一回事，有牙科保險又是另一回事。醫師不會問你有沒有用牙線潔牙，牙醫師也不會問你有沒有規律運動。在美國，口腔的診治是和身體其他部位分開的，醫療記者瑪莉．奧圖 (Mary Otto) 在新書《牙齒：在美國，關於美觀、不平等和搶救口腔健康的故事》(Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America) 就探討了這種怪異現象。
怪異之處並不在於牙醫師專門醫治身體的某一處部位，不然皮膚科或心臟科醫師也都屬於專科醫師。怪就怪在，口腔護理跟一般醫學在教育體系、醫師網絡、病歷和支付系統上，都另當別論，所以牙醫師不只是一種專科醫師，竟完全成了另一門職業。
但人體並沒有默認這種醫牙分家的安排，而且牙齒也不會懂得要把口腔的問題留在口腔，不准擴散出去。這種醫牙分家帶來了真實上演的後果：牙科保險往往比健保還難保到 (健保已經很難保了)，沒能治療的牙齒問題持續惡化，有時甚至要了小命。瑪莉．奧圖的書中以德萊弗 (Deamonte Driver) 的故事為主軸，12 歲的馬里蘭男孩德萊弗，因牙齒感染未及時治療，導致波及腦部而喪命。德萊弗的家人沒有牙科保險，最後德萊弗被送到醫院緊急進行腦部開刀，依然回天乏術。
本文作者茱莉．貝克 (Julie Beck) 訪談瑪莉．奧圖，討論醫牙如何走到分家這一步，為何持續陷在此種僵局，以及已造成何種後果。以下是略經編輯與精簡後的對話逐字稿。
茱莉．貝克 (以下簡稱茱)：我們先回頭看看最初醫牙分家的起源。現在大家對醫牙分家已經習以為常，是吧？但這種現象其實真的很不對勁。從前牙科是否曾經併在一般醫科裡呢？
瑪莉．奧圖 (以下簡稱瑪)：普遍來看，醫牙一直都是分家的。看牙齒變成一種買賣交易。在理髮師兼外科醫師 (barber-surgeon) 的年代，理髮師兼外科醫師提供多種個人服務，例如放血、拔罐、拔牙，牙科技術是其中一種。理髮師兼外科醫師把牙科技術當成機械式技術來學，執行補牙拔牙的工作。美國很久以前也有理髮師兼外科醫師這種行業，保羅．李維 (Paul Revere) 就當過假牙技師 ── 他是一位珠寶匠，也有在做假牙。
不過牙科真正成為一種職業，發生在 1840 年的巴爾的摩。我查到的資料顯示，這年世界上第一所牙科學院開幕，而且得歸功於兩名算是自學的牙醫師 Chapin Harris 和 Horace Hayden 為此的付出。他們找上了巴爾的摩馬里蘭大學醫學院的醫師，提議把牙科教學加進醫學院的課程，因為他們真的認為牙科不僅是機械式技術，還應該享有專門職業的地位，也值得作為學科課程、發放執照，以及在科學研究上獲得同儕關注。但接下來的故事是，醫學院醫師拒絕了兩人的提議，還說牙科一點也不重要。
這場事件名為「歷史性的駁回」(historic rebuff)，有時仍會為人所提及，但並不常，不過這件事被認為具有象徵性的意義，而且仍然詭異地定義著醫科/牙科教育、醫科/牙科醫療體系的關係。牙醫師照常鑽牙補牙，至於扁桃腺以下的身體部位，也照常歸醫師管。美國各地幾乎還是醫牙教育分開辦理，而醫牙兩種醫療體系也逐漸分流了。
茱：看起來，自從這場「歷史性的駁回」後，牙醫師就真的想要分家了。妳覺得為什麼呢？
瑪：多年來人們不斷質疑醫牙分家，偶爾也會出現呼籲改革的聲音。大約一百年前，在 1920 年代，美國這位生物化學家威廉．吉斯 (William Gies) 可說是一位先知。
作者：JULIE BECK
來源：https://www.theatlantic.com/health/archive/2017/03/why-dentistry-is-separated-from-medicine/518979/
醫牙分家，後果有時可能不堪設想。
醫師歸醫師，牙醫師歸牙醫師，從來不會混為一談。有健保是一回事，有牙科保險又是另一回事。醫師不會問你有沒有用牙線潔牙，牙醫師也不會問你有沒有規律運動。在美國，口腔的診治是和身體其他部位分開的，醫療記者瑪莉．奧圖 (Mary Otto) 在新書《牙齒：在美國，關於美觀、不平等和搶救口腔健康的故事》(Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America) 就探討了這種怪異現象。
怪異之處並不在於牙醫師專門醫治身體的某一處部位，不然皮膚科或心臟科醫師也都屬於專科醫師。怪就怪在，口腔護理跟一般醫學在教育體系、醫師網絡、病歷和支付系統上，都另當別論，所以牙醫師不只是一種專科醫師，竟完全成了另一門職業。
但人體並沒有默認這種醫牙分家的安排，而且牙齒也不會懂得要把口腔的問題留在口腔，不准擴散出去。這種醫牙分家帶來了真實上演的後果：牙科保險往往比健保還難保到 (健保已經很難保了)，沒能治療的牙齒問題持續惡化，有時甚至要了小命。瑪莉．奧圖的書中以德萊弗 (Deamonte Driver) 的故事為主軸，12 歲的馬里蘭男孩德萊弗，因牙齒感染未及時治療，導致波及腦部而喪命。德萊弗的家人沒有牙科保險，最後德萊弗被送到醫院緊急進行腦部開刀，依然回天乏術。
本文作者茱莉．貝克 (Julie Beck) 訪談瑪莉．奧圖，討論醫牙如何走到分家這一步，為何持續陷在此種僵局，以及已造成何種後果。以下是略經編輯與精簡後的對話逐字稿。
茱莉．貝克 (以下簡稱茱)：我們先回頭看看最初醫牙分家的起源。現在大家對醫牙分家已經習以為常，是吧？但這種現象其實真的很不對勁。從前牙科是否曾經併在一般醫科裡呢？
瑪莉．奧圖 (以下簡稱瑪)：普遍來看，醫牙一直都是分家的。看牙齒變成一種買賣交易。在理髮師兼外科醫師 (barber-surgeon) 的年代，理髮師兼外科醫師提供多種個人服務，例如放血、拔罐、拔牙，牙科技術是其中一種。理髮師兼外科醫師把牙科技術當成機械式技術來學，執行補牙拔牙的工作。美國很久以前也有理髮師兼外科醫師這種行業，保羅．李維 (Paul Revere) 就當過假牙技師 ── 他是一位珠寶匠，也有在做假牙。
不過牙科真正成為一種職業，發生在 1840 年的巴爾的摩。我查到的資料顯示，這年世界上第一所牙科學院開幕，而且得歸功於兩名算是自學的牙醫師 Chapin Harris 和 Horace Hayden 為此的付出。他們找上了巴爾的摩馬里蘭大學醫學院的醫師，提議把牙科教學加進醫學院的課程，因為他們真的認為牙科不僅是機械式技術，還應該享有專門職業的地位，也值得作為學科課程、發放執照，以及在科學研究上獲得同儕關注。但接下來的故事是，醫學院醫師拒絕了兩人的提議，還說牙科一點也不重要。
這場事件名為「歷史性的駁回」(historic rebuff)，有時仍會為人所提及，但並不常，不過這件事被認為具有象徵性的意義，而且仍然詭異地定義著醫科/牙科教育、醫科/牙科醫療體系的關係。牙醫師照常鑽牙補牙，至於扁桃腺以下的身體部位，也照常歸醫師管。美國各地幾乎還是醫牙教育分開辦理，而醫牙兩種醫療體系也逐漸分流了。
茱：看起來，自從這場「歷史性的駁回」後，牙醫師就真的想要分家了。妳覺得為什麼呢？
瑪：多年來人們不斷質疑醫牙分家，偶爾也會出現呼籲改革的聲音。大約一百年前，在 1920 年代，美國這位生物化學家威廉．吉斯 (William Gies) 可說是一位先知。
為了卡內基基金會一份工程浩大的報告， 威廉．吉斯拜訪了美國和加拿大每一間牙科學校，呼籲應將牙科視為醫療體系的重要一份子。威廉．吉斯說：「不能再把牙科當成單純的牙齒技術了。」他希望口腔醫療和整體醫療合併成同一個體系，但是牙醫師工會拚命維護牙科分家的現狀。牙醫師挺身而出，捍衛他們在私人開業醫師體系上的專業自主和專業獨立，也就是我們目前的樣貌。美國前衛生局長大衛．薩契 (David Satcher) 2000 年發表〈美國的口腔衛生〉(Oral Health in America) 報告時，也有點提過類似醫牙整合的話語，他說，我們必須承認口腔醫學和一般醫學是不可分開的。這也確實構成了挑戰。目前看來，事態有在變化，只是變得很慢。
茱：所以你覺得，牙醫師想要維持分家的原因，真的單純只是專業獨立的問題嗎？
瑪：對，這是個市場問題。專業自主是很龐大的問題。
茱：原來醫牙分家可以追溯到這樣的歷史時刻，聽起來很有意思，因為醫牙分家影響到很多層面 ── 保險，就醫，所有相關的事情。可以簡單描述一下醫牙分家的影響嗎？
瑪：最顯著的例子之一，就是每年有超過一百萬人為了牙齒問題掛急診。他們不像是出車禍受傷，而比較像是牙痛或某種可以去看牙醫師治療的問題。這種不看牙醫師而掛急診的情形，一年就要花掉美國醫療體系超過十億美元。然後病人真正的牙齒問題幾乎無法獲得所需的牙科治療，因為急診室通常不會有牙醫師。病人可能拿到抗生素和止痛藥，醫院也提醒病人該去看牙醫師，但這種病人很多找不到牙醫師。所以這很明白呈現出，口腔醫學包含在一般醫學裡，牙齒問題逼得你掛急診，但你卻遇到醫牙分家的窘境，得不到適當治療。
茱：所以你覺得，牙醫師想要維持分家的原因，真的單純只是專業獨立的問題嗎？
瑪：對，這是個市場問題。專業自主是很龐大的問題。
茱：原來醫牙分家可以追溯到這樣的歷史時刻，聽起來很有意思，因為醫牙分家影響到很多層面 ── 保險，就醫，所有相關的事情。可以簡單描述一下醫牙分家的影響嗎？
瑪：最顯著的例子之一，就是每年有超過一百萬人為了牙齒問題掛急診。他們不像是出車禍受傷，而比較像是牙痛或某種可以去看牙醫師治療的問題。這種不看牙醫師而掛急診的情形，一年就要花掉美國醫療體系超過十億美元。然後病人真正的牙齒問題幾乎無法獲得所需的牙科治療，因為急診室通常不會有牙醫師。病人可能拿到抗生素和止痛藥，醫院也提醒病人該去看牙醫師，但這種病人很多找不到牙醫師。所以這很明白呈現出，口腔醫學包含在一般醫學裡，牙齒問題逼得你掛急診，但你卻遇到醫牙分家的窘境，得不到適當治療。
還有一件，美國的一般病歷和牙科病歷是分開的。牙科有他們自己的治療代碼，但牙科並沒有公認的診斷代碼用語，使得一般病歷和牙科病歷難以整合，而且也不容易研究口腔衛生和整體健康之間的共通點。
一位牙科研究者在我參加的一場會議中說道：「在黑死病猖獗的年代，醫學解釋了人們的死因，但是並沒有解釋牙齒壞死的原因。」人們是怎麼瞭解口腔疾病的，以及是怎麼生成蛀牙的，正是存在著這種落差。當時人們仍然把蛀牙當成必須修正的外科問題，而不是必須預防和治療的疾病。而且，人們幾乎用一種道德的眼光來看待蛀牙，沒有體會患者飽受口腔疾病折磨，反而認定這些人有道德缺陷。
茱：健保和牙科保險也是完全各走各的，而且大多數時候由民眾自行決定要不要加保牙科保險。從政治上來看，牙科是怎麼被定為選擇性的加保項目呢？
瑪：整個二十世紀裡，時不時就會出現有關這個題目的討論。牙醫師工會就跟醫師工會一樣，在很多方面對抗全國化的醫療模式，並且證明了將保險擴展到國家每一位民眾身上的作法並不合時宜。而國家提供的所有健保方案，某種程度上其實把牙科排除在外，不然就是把牙科當成附加的保險項目，讓牙科變成了從屬性質。至於私人保險也同樣採取這一套辦法。
茱：很有趣的是，一方面，牙科保險是「選擇性」的保險項目，但另一方面，就像妳在書中提到的，社會上存在著必須擁有一口美齒的情結，在美國尤其如此，對有錢人而言更是如此。結果牙齒美容產業發了大財。妳認為，這樣的美齒情結是否多多少少加重了醫牙不平等的現象呢？
瑪：我想在一些層面來看，的確如此。人們實在太過強調完美的微笑要露幾顆牙齒的公式，於是這項產業變得有暴利可圖。我研究這項議題的時候，一位和我談話過的牙醫師說「沒人想選最基本最便宜的美齒療程」。當然，做超級高檔的美齒療程，確實可以賺到很多錢。但另一方面來看，基本型的口腔護理也有很龐大的需求。美國有三分之一的人口，連得到有助維持健康的、最基本款的保健和修補療程都有困難。
一位牙科研究者在我參加的一場會議中說道：「在黑死病猖獗的年代，醫學解釋了人們的死因，但是並沒有解釋牙齒壞死的原因。」人們是怎麼瞭解口腔疾病的，以及是怎麼生成蛀牙的，正是存在著這種落差。當時人們仍然把蛀牙當成必須修正的外科問題，而不是必須預防和治療的疾病。而且，人們幾乎用一種道德的眼光來看待蛀牙，沒有體會患者飽受口腔疾病折磨，反而認定這些人有道德缺陷。
茱：健保和牙科保險也是完全各走各的，而且大多數時候由民眾自行決定要不要加保牙科保險。從政治上來看，牙科是怎麼被定為選擇性的加保項目呢？
瑪：整個二十世紀裡，時不時就會出現有關這個題目的討論。牙醫師工會就跟醫師工會一樣，在很多方面對抗全國化的醫療模式，並且證明了將保險擴展到國家每一位民眾身上的作法並不合時宜。而國家提供的所有健保方案，某種程度上其實把牙科排除在外，不然就是把牙科當成附加的保險項目，讓牙科變成了從屬性質。至於私人保險也同樣採取這一套辦法。
茱：很有趣的是，一方面，牙科保險是「選擇性」的保險項目，但另一方面，就像妳在書中提到的，社會上存在著必須擁有一口美齒的情結，在美國尤其如此，對有錢人而言更是如此。結果牙齒美容產業發了大財。妳認為，這樣的美齒情結是否多多少少加重了醫牙不平等的現象呢？
瑪：我想在一些層面來看，的確如此。人們實在太過強調完美的微笑要露幾顆牙齒的公式，於是這項產業變得有暴利可圖。我研究這項議題的時候，一位和我談話過的牙醫師說「沒人想選最基本最便宜的美齒療程」。當然，做超級高檔的美齒療程，確實可以賺到很多錢。但另一方面來看，基本型的口腔護理也有很龐大的需求。美國有三分之一的人口，連得到有助維持健康的、最基本款的保健和修補療程都有困難。
茱：我很納悶，人們如此欣羨好萊塢明星式的完美微笑，會不會有一部分是因為，太多人沒有能力去看牙醫，所以完美的牙齒成了一種可以清楚彰顯自身財富的標誌。就算每個人都可以看牙醫顧好牙齒，但亮麗的牙齒還是更為顯著的炫富手段。
瑪：有可能。有趣的是，這整個「美式完美微笑」其實源於經濟大蕭條時期的好萊塢。當時電影還是很新的玩意，有位年輕牙醫師查理斯．平可斯 (Charles Pincus) 在好萊塢與藤街 (on Hollywood and Vine) 開了間牙科診所，他也會去看電影。他在大銀幕上看到有些電影演員的牙齒並不美觀，譬如詹姆斯狄恩 (James Dean)，狄恩在農場長大，有戴假牙，另外還有茱蒂嘉蘭 (Judy Garland)、秀蘭鄧波爾 (Shirley Temple)。查理斯．平可斯開始和片場合作，他幫秀蘭鄧波爾製作這種可拆卸的小型牙套，觀眾就不會看到她的乳牙掉了。秀蘭鄧波爾一整年都戴著這副完美的亮白牙套。
但妳說得對，就是有這種追求美齒不顧一切的極端路線。上排的六顆牙齒被稱作「社交六齒」(The Social Six)，而上排六齒的美觀牙套，不只在美國是地位的象徵 ── 在全世界都是人人趨之若鶩的成功印記。
茱：我猜這種牙齒美容的市場，是牙科診所之所以較常出現在有錢人地帶的原因之一，而鄉下或貧困地方往往鬧牙醫師荒。但是另一方面，妳寫到很多例子描述牙醫師實在不願意讓別人來執行口腔保健的工作，像是訓練口腔衛生師 (dental hygienist) 去學校教導潔牙。這點到底哪裡起爭議？
瑪：此事說來話長，我也因而徹底瞭解了耳聞的幾則故事，像是南卡羅萊納州的一位口腔衛生師譚米．拜爾德 (Tammi Byrd)。這個州約有 25 萬名孩童住在鄉下，得不到牙科照護，譚米．拜爾德和其他幾位口腔衛生師極力爭取修法，好讓他們不必先接受牙醫師的檢核就能下鄉服務孩童。牙醫師工會也做出反擊，促成通過一項緊急法規，阻止譚米．拜爾德下鄉之舉。最後聯邦貿易委員會 (Federal Trade Commission) 介入，站在這些缺乏牙科保健省錢管道的孩童立場，為譚米．拜爾德打贏了這場仗。
但是，市場版圖問題的依然存在。私人牙醫師工會緊守他們的牙科市場，也緊握著私人開業牙醫提供牙科服務的權力，如此一來卻將許多人排除在外。不論是南卡羅萊納州這位口腔衛生師的戰役，還是有關牙科治療師 (dental therapist) 這種中階的服務提供者在好幾個州上演的戰役，諸如此類的事情，在在證明牙科市場被嚴密防守的程度。
牙醫師工會一直宣稱目前牙醫師的供給可以滿足需求，還說如果醫療體系肯多花點錢在牙科護理上，就有更多醫療人員願意在這些窮困地區定點服務。工會總說美國人必須更重視顧好牙齒這件事，也必須更積極地去看牙醫做檢查。工會把大部分的錯推到社會頭上。
茱：牙醫師反對口腔衛生師站出來充當這個角色，這跟口腔衛生師大多由女性擔當的情形是否有關係？妳在書裡寫說，有些古板的牙醫師會這麼想：「是啊，女性最適合當牙助了，因為女性的野心不會很強，而且她們會照顧病人。」而且感覺牙科界或多或少還瀰漫著這種心態。
瑪：可以說現在大概還是存在著這樣的觀念。牙醫師工會的權威們，確實深深以為只有牙醫師有資格執行絕大部分的牙科事務。
但是，市場版圖問題的依然存在。私人牙醫師工會緊守他們的牙科市場，也緊握著私人開業牙醫提供牙科服務的權力，如此一來卻將許多人排除在外。不論是南卡羅萊納州這位口腔衛生師的戰役，還是有關牙科治療師 (dental therapist) 這種中階的服務提供者在好幾個州上演的戰役，諸如此類的事情，在在證明牙科市場被嚴密防守的程度。
牙醫師工會一直宣稱目前牙醫師的供給可以滿足需求，還說如果醫療體系肯多花點錢在牙科護理上，就有更多醫療人員願意在這些窮困地區定點服務。工會總說美國人必須更重視顧好牙齒這件事，也必須更積極地去看牙醫做檢查。工會把大部分的錯推到社會頭上。
茱：牙醫師反對口腔衛生師站出來充當這個角色，這跟口腔衛生師大多由女性擔當的情形是否有關係？妳在書裡寫說，有些古板的牙醫師會這麼想：「是啊，女性最適合當牙助了，因為女性的野心不會很強，而且她們會照顧病人。」而且感覺牙科界或多或少還瀰漫著這種心態。
瑪：可以說現在大概還是存在著這樣的觀念。牙醫師工會的權威們，確實深深以為只有牙醫師有資格執行絕大部分的牙科事務。
茱：如果不讓口腔衛生師或牙科治療師補足牙科服務的人力缺口，那麼有在規劃其他辦法嗎？還有什麼辦法比較順牙醫師的意呢？
瑪：他們自己有一套替代模式，有點像是健康領航員，幫民眾配對現有的牙醫師，這屬於社區健康工作者一類的模式。健康領航員幫忙把急診室的民眾轉到既有的牙科診所，幫民眾掛號，教民眾如何維持口腔健康，也為民眾照顧小孩的口腔健康。但這套模式是把人引導去找既有的牙醫師，而不是擴編牙科的人力。
茱：而且如果民眾沒有保險，也沒有很大的幫助吧？
瑪：幫助不大。除非有慈善機構或類似團體募款來支應口腔護理的經費。
茱：從這點看來，醫牙分家的情形實在很難撼動。妳認為這種情形可以推翻嗎？應該推翻嗎？醫牙可以更相融一點嗎？醫牙整合可能是怎樣的景象，妳覺得會有幫助嗎？
瑪：在推動《病患保護與平價醫療法案》(Patient Protection and Affordable Care Act) 的時候，醫界有談到「三重目標」(Triple Aims)：把成本曲線轉到保健導向、更廣泛且更平價地擴大醫療照護、以及打造更良好的照護品質。牙科界也有必要討論一下這幾點，我想現在有比較常在討論了。
茱：妳認為是可能在牙科界發生平行的改革，還是可能有點回到醫牙整合的方向呢？
瑪：我覺得似乎會走醫牙整合的路線。這方面已經有動作了，有在試著讓口腔護理師進入聯邦合格保健中心 (federally qualified health center)，這種保健中心是美國公衛安全網的一部分，專門服務貧窮鄉村社區。醫牙整合的議題，好像愈來愈引起各州一些議員、州長、和公衛官員注意，他們有意降低各種醫療照護的成本，並相信有機會成功推展降低成本的措施。他們說，美國人把太多錢浪費在急診上，以及浪費在為了可事先預防的疾病卻大費周章的住院上，所以醫牙整合有著成本上的誘因，讓民眾能夠得到更屬於保健性質、更及時的常規牙科修補照護。
茱：試著消除「歷史性的駁回」帶來的傷害。
瑪：是的，很有趣吧？
Doctors are doctors, and dentists are dentists, and never the twain shall meet. Whether you have health insurance is one thing, whether you have dental insurance is another. Your doctor doesn’t ask you if you’re flossing, and your dentist doesn’t ask you if you’re exercising. In America, we treat the mouth separately from the rest of the body, a bizarre situation that Mary Otto explores in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America.
Specializing in one part of the body isn’t what’s weird—it would be one thing if dentists were like dermatologists or cardiologists. The weird thing is that oral care is divorced from medicine’s education system, physician networks, medical records, and payment systems, so that a dentist is not just a special kind of doctor, but another profession entirely.
But the body didn’t sign on for this arrangement, and teeth don’t know that they’re supposed to keep their problems confined to the mouth. This separation leads to real consequences: Dental insurance is often even harder to get than health insurance (which is not known for being a cakewalk), and dental problems left untreated worsen, and sometimes kill. Anchoring Otto’s book is the story of Deamonte Driver, a 12-year-old boy from Maryland who died from an untreated tooth infection that spread to his brain. His family did not have dental benefits, and he ended up being rushed to the hospital for emergency brain surgery, which wasn’t enough to save him.
I spoke with Otto about how the dentistry/medicine divide came to be, why it’s stuck around, and what its consequences have been. A lightly edited and condensed transcript of our conversation is below.
Julie Beck: Let’s go back to the origin of how dentistry and medicine became separate in the first place. It’s something we take for granted now, right? But it’s actually really weird. Was there ever a time when dental care was integrated with medical care?
Mary Otto: It stayed generally separate. Taking care of the teeth became kind of a trade. In the barber-surgeon days, dentist skills were among one of the many personal services that barber surgeons provided, like leeching and cupping and tooth extractions. They approached it as a mechanical challenge, to repair and extract teeth. Barber surgery was practiced in the very early part of our country's history. And Paul Revere was a denturist—he was a jeweler and he made dentures too.
But the dental profession really became a profession in 1840 in Baltimore. That was when the first dental college in the world was opened, I found out, and that was thanks to the efforts of a couple of dentists who were kind of self-trained. Their names were Chapin Harris and Horace Hayden. They approached the physicians at the college of medicine at the University of Maryland in Baltimore with the idea of adding dental instruction to the medical course there, because they really believed that dentistry was more than a mechanical challenge, that it deserved status as a profession, and a course of study, and licensing, and peer-reviewed scientific consideration. But the physicians, the story goes, rejected their proposal and said the subject of dentistry was of little consequence.
That event is remembered as the “historic rebuff.” It's still talked about sometimes, not a lot, but it’s seen as a symbolic event and it’s continued to define the relationships between medical and dental education and medical and dental healthcare systems in funny ways. Dentists still drill and fill teeth and physicians still look at the body from the tonsils south. Medical and dental education is still provided separately almost everywhere in this country and our two systems have grown up to provide care separately, too.
Beck: It seems like since the historic rebuff, dentists have really wanted to stay separate. Why is that, do you think?
Otto: People have raised questions about the system over the years, and they’ve called for reforms periodically. Nearly a century ago, in the 1920s, this biological chemist named William Gies was a kind of prophet. He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the healthcare system. He said: “Dentistry can no longer be accepted as mere tooth technology.” He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate. [Dentists] emerged as defenders of the professional autonomy and professional independence of the private practice system that we have here. David Satcher, the [former] surgeon general, he kind of said the same thing when he issued this “Oral Health in America” report in 2000. He said we must recognize that oral health and general health are inseparable. And that too, was a kind of challenge. And it seems like things are changing, but very slowly.
Beck: So you think the reason they wanted to stay separate was really just a matter of professional independence?
Otto: Yeah. It’s a marketplace issue. It’s a formidable thing, professional autonomy.
Beck: It’s interesting to hear this separation traced back to one moment because it has shaped so many things—insurance, access to care, all these things. Can you give an overview of what the effects have been of carving dentistry out of medicine?
Otto: One of the most dramatic examples is that more than a million people a year go to emergency rooms with dental problems. Not like they’ve had a car accident, but like a toothache or some kind of problem you could treat in a dental office. It costs the system more than a billion dollars a year for these visits. And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care.
There’s also the fact that our medical records and our dental records are kept separately. Dentistry has treatment codes, but it doesn’t really have a commonly accepted diagnostic code language which makes it hard to integrate medical and dental records and harder to do research on the commonalities between oral health and overall health.
One dental researcher said at a meeting I was at, “Back in the days of the bubonic plague, medicine captured why people die. We don’t capture why teeth die.” There’s this gap in the way we understand oral diseases and the way we approach tooth decay. We still approach it like it’s a surgical problem that needs to be fixed, rather than a disease that needs to be prevented and treated. And we see tooth decay through a moral lens, almost. We judge people who have oral disease as moral failures, rather than people who are suffering from a disease.
Beck: Insurance is all separated out as well, and a lot of times it’s optional. How, politically, did dental care come to be seen as optional?
Otto: There were discussions all through the 20th century, periodically, about this subject. Organized dentistry, like organized medicine, fought nationalized health care on a lot of fronts and testified against the practicality of extending benefits to everyone in the country. And all the healthcare programs that we’ve come up with as a nation have on some level or another left oral health out, or given it sort of an auxiliary status as a fringe benefit. Private insurance has also treated it that way.
Beck: It’s interesting, on one hand, dental care is treated as “optional,” but on the other hand, as you note in the book, there’s this social pressure to have perfect teeth, especially in America, especially among the rich. And so there’s a lot of money to be made in cosmetic dentistry. Do you think that social pressure to have perfect teeth is kind of exacerbating the inequality?
Otto: I think on some level it must. We do put so much emphasis on perfect smiles and there is a lot of money to be made in that field. One dentist I talked to as I was working on this project said “Nobody wants to do the low-end stuff anymore.” Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic basic care. A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy.
Beck: I wonder if the value put on that perfect Hollywood smile is in part because so many people don’t have access to dental care, so perfect teeth are a very clear way of signaling your wealth. More clear than if everyone had access to good care and had decent teeth.
Otto: It could be. It’s very interesting. This whole “perfect American smile” did have its origins in Depression-era Hollywood. Filmed movies were still pretty new at that point. There was this young dentist named Charles Pincus who had this dental office that opened on Hollywood and Vine and he went to the movies too. And he saw these movie actors who didn’t have perfect teeth up on the silver screen, like James Dean, who actually grew up on a farm and had dentures, and Judy Garland, and Shirley Temple. He started working with the studios. He created these little snap-on veneers for Shirley Temple so we never saw her lose her baby teeth. Over all the years she had a perfect little set of pearly whites.
But you’re right, there’s this kind of feast and famine aspect to this that’s striking. They call the [top] front six teeth “The Social Six,” and the perfect set of veneers for these front six teeth are not just a status symbol here in this country—they’re sought around the world as a marker of success.
Beck: I guess partially because of this market for cosmetic dentistry, dentists tend to cluster in rich areas, and there are often shortages in rural areas or poorer areas. But at the same time, you write about a lot of instances where dentists were really resistant to allowing anyone else to provide that preventive care, like training hygienists to do cleanings in schools. Why is that so controversial?
Otto: There’s been a long history of that and it really came home to me with some of the stories I heard, like the story of Tammi Byrd, this dental hygienist in South Carolina. There’s about a quarter million children living in the rural areas of the state who weren’t getting care, and she and some other dental hygienists fought to get the law changed so they could go out and see children without being first examined by a dentist. The dental association just fought back, they got an emergency regulation passed to stop her from doing her work and finally the Federal Trade Commission came in and took her case and won it for her, in the interest of getting economical preventive care to all these children who lacked it.
But, yeah, there’s this marketplace issue. Private organized dentistry protects the marketplace for care and the power of private practitioners to provide it but that leaves a lot of people out. Stories like the battle of this dental hygienist in South Carolina, or the battle that’s going on over these midlevel providers called dental therapists in a number of states, really illustrate how fiercely that terrain is protected.
Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas. That we Americans need to value our care more and go out and find care more aggressively. They see the fault as being with society at large.
Beck: This opposition to hygienists stepping up and filling that role, does that have anything to do with the fact that hygienists are mostly women? You quoted some old-timey dentists who were like, “Ah yes, the best assistant for a dentist is a woman because she won’t be ambitious and take over our patients." And it kind of sounds like that attitude is still around in some ways.
Otto: You could say that there might be a sense of that still. There’s certainly a deep sense among the powers of organized dentistry that only dentists are qualified to do the lion’s share of dentistry.
Beck: Are there other plans proposed to fill the gap in dental care, if not letting the hygienists or the dental therapists do it? Is there another plan that would be more pleasing to dentists?
Otto: They have their own alternative model. It's kind of a health navigator who connects people with existing dentists, a community-health-worker type of model. [The navigator] helps divert people from ERs into existing dental offices, helps people make dental appointments, educates them about maintaining oral health, and taking care of their children. But it’s guiding people to existing dentists, rather than expanding the dental workforce.
Beck: And if they don’t have insurance then it’s not going to help very much?
Otto: It’s not as helpful. Unless there’s a philanthropy or some kind of group that’s raising money to pay for the care.
Beck: The separation between dental and medical care is pretty entrenched at this point. Do you think it can be overcome, that it should be overcome, that the two could be integrated a little more? What might that look like, do you think it would help?
Otto: Something that was talked about in the medical world during the work going into the Patient Protection and Affordable Care Act was the “Triple Aim”: bending the cost curve toward prevention, expanding care more broadly and more cheaply, and [creating] a better quality of care. It’s something that needs to be discussed in the oral health world too, and I think it’s being discussed more.
Beck: Do you think it would be like a parallel reform in dentistry or would it be more integrating them back together somewhat?
Otto: It seems like it’s going to have to involve both. There’s been work being done in this area, there’ve been efforts to put dental hygienists into these federally qualified health centers that are part of our public-health safety net, which serve poor rural communities. It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise. They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people.
Beck: Trying to undo some of the damage of the historic rebuff.
Otto: Yeah, isn’t it funny?
Doctors are doctors, and dentists are dentists, and never the twain shall meet. Whether you have health insurance is one thing, whether you have dental insurance is another. Your doctor doesn’t ask you if you’re flossing, and your dentist doesn’t ask you if you’re exercising. In America, we treat the mouth separately from the rest of the body, a bizarre situation that Mary Otto explores in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America.
Specializing in one part of the body isn’t what’s weird—it would be one thing if dentists were like dermatologists or cardiologists. The weird thing is that oral care is divorced from medicine’s education system, physician networks, medical records, and payment systems, so that a dentist is not just a special kind of doctor, but another profession entirely.
But the body didn’t sign on for this arrangement, and teeth don’t know that they’re supposed to keep their problems confined to the mouth. This separation leads to real consequences: Dental insurance is often even harder to get than health insurance (which is not known for being a cakewalk), and dental problems left untreated worsen, and sometimes kill. Anchoring Otto’s book is the story of Deamonte Driver, a 12-year-old boy from Maryland who died from an untreated tooth infection that spread to his brain. His family did not have dental benefits, and he ended up being rushed to the hospital for emergency brain surgery, which wasn’t enough to save him.
I spoke with Otto about how the dentistry/medicine divide came to be, why it’s stuck around, and what its consequences have been. A lightly edited and condensed transcript of our conversation is below.
Julie Beck: Let’s go back to the origin of how dentistry and medicine became separate in the first place. It’s something we take for granted now, right? But it’s actually really weird. Was there ever a time when dental care was integrated with medical care?
Mary Otto: It stayed generally separate. Taking care of the teeth became kind of a trade. In the barber-surgeon days, dentist skills were among one of the many personal services that barber surgeons provided, like leeching and cupping and tooth extractions. They approached it as a mechanical challenge, to repair and extract teeth. Barber surgery was practiced in the very early part of our country's history. And Paul Revere was a denturist—he was a jeweler and he made dentures too.
But the dental profession really became a profession in 1840 in Baltimore. That was when the first dental college in the world was opened, I found out, and that was thanks to the efforts of a couple of dentists who were kind of self-trained. Their names were Chapin Harris and Horace Hayden. They approached the physicians at the college of medicine at the University of Maryland in Baltimore with the idea of adding dental instruction to the medical course there, because they really believed that dentistry was more than a mechanical challenge, that it deserved status as a profession, and a course of study, and licensing, and peer-reviewed scientific consideration. But the physicians, the story goes, rejected their proposal and said the subject of dentistry was of little consequence.
That event is remembered as the “historic rebuff.” It's still talked about sometimes, not a lot, but it’s seen as a symbolic event and it’s continued to define the relationships between medical and dental education and medical and dental healthcare systems in funny ways. Dentists still drill and fill teeth and physicians still look at the body from the tonsils south. Medical and dental education is still provided separately almost everywhere in this country and our two systems have grown up to provide care separately, too.
Beck: It seems like since the historic rebuff, dentists have really wanted to stay separate. Why is that, do you think?
Otto: People have raised questions about the system over the years, and they’ve called for reforms periodically. Nearly a century ago, in the 1920s, this biological chemist named William Gies was a kind of prophet. He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the healthcare system. He said: “Dentistry can no longer be accepted as mere tooth technology.” He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate. [Dentists] emerged as defenders of the professional autonomy and professional independence of the private practice system that we have here. David Satcher, the [former] surgeon general, he kind of said the same thing when he issued this “Oral Health in America” report in 2000. He said we must recognize that oral health and general health are inseparable. And that too, was a kind of challenge. And it seems like things are changing, but very slowly.
Beck: So you think the reason they wanted to stay separate was really just a matter of professional independence?
Otto: Yeah. It’s a marketplace issue. It’s a formidable thing, professional autonomy.
Beck: It’s interesting to hear this separation traced back to one moment because it has shaped so many things—insurance, access to care, all these things. Can you give an overview of what the effects have been of carving dentistry out of medicine?
Otto: One of the most dramatic examples is that more than a million people a year go to emergency rooms with dental problems. Not like they’ve had a car accident, but like a toothache or some kind of problem you could treat in a dental office. It costs the system more than a billion dollars a year for these visits. And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care.
There’s also the fact that our medical records and our dental records are kept separately. Dentistry has treatment codes, but it doesn’t really have a commonly accepted diagnostic code language which makes it hard to integrate medical and dental records and harder to do research on the commonalities between oral health and overall health.
One dental researcher said at a meeting I was at, “Back in the days of the bubonic plague, medicine captured why people die. We don’t capture why teeth die.” There’s this gap in the way we understand oral diseases and the way we approach tooth decay. We still approach it like it’s a surgical problem that needs to be fixed, rather than a disease that needs to be prevented and treated. And we see tooth decay through a moral lens, almost. We judge people who have oral disease as moral failures, rather than people who are suffering from a disease.
Beck: Insurance is all separated out as well, and a lot of times it’s optional. How, politically, did dental care come to be seen as optional?
Otto: There were discussions all through the 20th century, periodically, about this subject. Organized dentistry, like organized medicine, fought nationalized health care on a lot of fronts and testified against the practicality of extending benefits to everyone in the country. And all the healthcare programs that we’ve come up with as a nation have on some level or another left oral health out, or given it sort of an auxiliary status as a fringe benefit. Private insurance has also treated it that way.
Beck: It’s interesting, on one hand, dental care is treated as “optional,” but on the other hand, as you note in the book, there’s this social pressure to have perfect teeth, especially in America, especially among the rich. And so there’s a lot of money to be made in cosmetic dentistry. Do you think that social pressure to have perfect teeth is kind of exacerbating the inequality?
Otto: I think on some level it must. We do put so much emphasis on perfect smiles and there is a lot of money to be made in that field. One dentist I talked to as I was working on this project said “Nobody wants to do the low-end stuff anymore.” Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic basic care. A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy.
Beck: I wonder if the value put on that perfect Hollywood smile is in part because so many people don’t have access to dental care, so perfect teeth are a very clear way of signaling your wealth. More clear than if everyone had access to good care and had decent teeth.
Otto: It could be. It’s very interesting. This whole “perfect American smile” did have its origins in Depression-era Hollywood. Filmed movies were still pretty new at that point. There was this young dentist named Charles Pincus who had this dental office that opened on Hollywood and Vine and he went to the movies too. And he saw these movie actors who didn’t have perfect teeth up on the silver screen, like James Dean, who actually grew up on a farm and had dentures, and Judy Garland, and Shirley Temple. He started working with the studios. He created these little snap-on veneers for Shirley Temple so we never saw her lose her baby teeth. Over all the years she had a perfect little set of pearly whites.
But you’re right, there’s this kind of feast and famine aspect to this that’s striking. They call the [top] front six teeth “The Social Six,” and the perfect set of veneers for these front six teeth are not just a status symbol here in this country—they’re sought around the world as a marker of success.
Beck: I guess partially because of this market for cosmetic dentistry, dentists tend to cluster in rich areas, and there are often shortages in rural areas or poorer areas. But at the same time, you write about a lot of instances where dentists were really resistant to allowing anyone else to provide that preventive care, like training hygienists to do cleanings in schools. Why is that so controversial?
Otto: There’s been a long history of that and it really came home to me with some of the stories I heard, like the story of Tammi Byrd, this dental hygienist in South Carolina. There’s about a quarter million children living in the rural areas of the state who weren’t getting care, and she and some other dental hygienists fought to get the law changed so they could go out and see children without being first examined by a dentist. The dental association just fought back, they got an emergency regulation passed to stop her from doing her work and finally the Federal Trade Commission came in and took her case and won it for her, in the interest of getting economical preventive care to all these children who lacked it.
But, yeah, there’s this marketplace issue. Private organized dentistry protects the marketplace for care and the power of private practitioners to provide it but that leaves a lot of people out. Stories like the battle of this dental hygienist in South Carolina, or the battle that’s going on over these midlevel providers called dental therapists in a number of states, really illustrate how fiercely that terrain is protected.
Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas. That we Americans need to value our care more and go out and find care more aggressively. They see the fault as being with society at large.
Beck: This opposition to hygienists stepping up and filling that role, does that have anything to do with the fact that hygienists are mostly women? You quoted some old-timey dentists who were like, “Ah yes, the best assistant for a dentist is a woman because she won’t be ambitious and take over our patients." And it kind of sounds like that attitude is still around in some ways.
Otto: You could say that there might be a sense of that still. There’s certainly a deep sense among the powers of organized dentistry that only dentists are qualified to do the lion’s share of dentistry.
Beck: Are there other plans proposed to fill the gap in dental care, if not letting the hygienists or the dental therapists do it? Is there another plan that would be more pleasing to dentists?
Otto: They have their own alternative model. It's kind of a health navigator who connects people with existing dentists, a community-health-worker type of model. [The navigator] helps divert people from ERs into existing dental offices, helps people make dental appointments, educates them about maintaining oral health, and taking care of their children. But it’s guiding people to existing dentists, rather than expanding the dental workforce.
Beck: And if they don’t have insurance then it’s not going to help very much?
Otto: It’s not as helpful. Unless there’s a philanthropy or some kind of group that’s raising money to pay for the care.
Beck: The separation between dental and medical care is pretty entrenched at this point. Do you think it can be overcome, that it should be overcome, that the two could be integrated a little more? What might that look like, do you think it would help?
Otto: Something that was talked about in the medical world during the work going into the Patient Protection and Affordable Care Act was the “Triple Aim”: bending the cost curve toward prevention, expanding care more broadly and more cheaply, and [creating] a better quality of care. It’s something that needs to be discussed in the oral health world too, and I think it’s being discussed more.
Beck: Do you think it would be like a parallel reform in dentistry or would it be more integrating them back together somewhat?
Otto: It seems like it’s going to have to involve both. There’s been work being done in this area, there’ve been efforts to put dental hygienists into these federally qualified health centers that are part of our public-health safety net, which serve poor rural communities. It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise. They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people.
Beck: Trying to undo some of the damage of the historic rebuff.
Otto: Yeah, isn’t it funny?
留言
張貼留言