DENTISTRY. In the first half of the 19th century, dentistry in Cleveland was just emerging as a profession. Its professional development was hampered by a preoccupation with technical proficiency and a corresponding lack of concern for the need to understand dental pathology in order to diagnose and treat patients' disorders. A further barrier to professionalization was the absence of accepted criteria or qualifications required to practice dentistry in Cleveland or Ohio until 1868. As a result, dentistry in early Cleveland was dominated by itinerant tooth-drawers and uneducated practitioners who had been trained in the traditional way, by a form of apprenticeship. A notable exception to this pattern was BENJAMIN STRICKLAND, the first resident dentist in Cleveland. Strickland, who settled here in 1835, had apparently earned the M.D. degree (although from which school or college we do not know) and received an honorary D.D.S. in 1843 from the Baltimore College of Dental Surgery (the first school of dentistry in the U.S.). But Strickland's academic background was exceptional for the time; before 1860, more than two-thirds of all dental practitioners held no degree, either dental or medical. Leading dentists in Cleveland shared the feeling that the standards of the profession needed to be raised. The first evidence came in 1857, when 36 dentists met in Cleveland and formed the Dental Convention of Northern Ohio (later known as the Northern Ohio Dental Assn.). This group held meetings twice yearly to hear papers addressing topics of common interest, and their first resolution in 1857 endorsed an increase in the standards of dental education. In 1862 the city hosted the second annual meeting of the American Dental Assn. (formed in 1859). This organization had as its first president DR. WILLIAM B. ATKINSON of Cleveland, one of the city's leading dentists. Cleveland dentists, led by Dr. W. P. Horton, helped form the Ohio State Dental Assn. (1867), which secured legislation creating a board of dental examiners for Ohio in 1868.

Despite these early efforts, concerns over education and credentials remained subordinate to local dentists' involvement in the technical advances in their field and with ways to gain greater financial security, delaying dentistry's break with its tradelike heritage. Part of the problem lay in dentists' near-obsession with mechanical improvements and new materials that they could patent and from which they could derive profits. While this technical bent brought American dentistry to the forefront of world acclaim, it hampered an increase in disinterested professional conduct. For example, when William T. G. Morton, a Boston dentist, introduced ether for dental and surgical anesthesia (1844-46), he patented it under the name "Letheon" and offered it for use by his colleagues only after payment of licensing fees. Cleveland dentists, led by Drs. M. L. Wright and Strickland, began using Morton's Letheon as early as Jan. 1847, only 3 months after its first public demonstration in Boston. The licensing and patent system was an accepted part of dentistry. Another example of the influence of the patent system and its potential abuse can be found in the introduction of Vulcanite, a hard rubber used for artificial denture bases. The process of making hard rubber was introduced in 1851 by Nelson Goodyear, brother of rubber-industry pioneer Charles Goodyear. Goodyear did not patent the process or product at that time, however, and dentists were free to use the material for making dentures. In Cleveland, William H. Atkinson used Vulcanite as early as 1859-60 but was compelled to abandon the practice (or at least pay a fee) in 1864, when Dr. John A. Cummings patented the process and sold his rights to the Goodyear Dental Vulcanite Co. From 1864-81 Goodyear required licensing and prosecuted those who did not comply. Consequently, business interest hampered the flow of new techniques in dentistry.

In the early part of the 1900s, some Cleveland dentists began to set aside their concern for immediate financial reward, which had limited the free exchange of innovation. The best example of the new openness is found in the introduction of x-ray in Cleveland. Roentgen's discovery of x-ray in 1895 promised to revolutionize diagnostic procedures in both medicine and dentistry, and its rapid presentation in the scientific press mitigated efforts to constrict its use by either secrecy or licensing encumbrances. Nevertheless, managing early x-ray equipment was not simple, and opportunities to derive personal profit by withholding new knowledge and expertise did exist. In Cleveland's dental community that did not happen, thanks chiefly to Dr. Weston A. Price, a founding member of the American Roentgen Ray Society. He demonstrated the practical application of x-ray before the CLEVELAND DENTAL SOCIETY, the Northern Ohio Dental Assn., and the Ohio State Dental Society between 1897-99. He also designed and patented lead-lined gloves for protection against x-ray burns, but placed his innovation in the public domain instead of commanding fees from users.

The basic equipment making possible the modern era of "painless dentistry" was introduced between 1900-20. Cleveland dentists adopted the dental unit or equipment stand (combining high-speed electric drill, electric light, fountain spittoon, and built-in power supply), the hydraulic lift chair, and the x-ray machine. An important addition to dental anesthetics in this period was Novocain, a local anesthetic discovered by Alfred Einhorn in 1905. The technology of dental practice did not change substantially between 1920 and the 1960s, when dental chairs, turbine drills, and other equipment assumed their present (1994) form, and new synthetic materials found greater use in dentistry. Associated with technical change was the emergence of dental specialties in Cleveland. Nationally, societies and academies for specialties came into being between 1900-30, and included orthodontia (1901), periodontia (1914), oral surgery (1918), and pedodontia (1927). In dental directories ca. 1900, a few Cleveland dentists began to announce that they had restricted practice to a variety of these fledgling specialties. In 1914, for example, Drs. Charles and William Teter claimed that they had a "practice limited to minor oral operations, extracting teeth and administering nitrous oxide and oxygen for surgical purposes." By the early 1920s, around 10 dentists chose to limit their practices to a single distinct specialty, usually either oral surgery or periodontia. The number of dental specialists increased gradually to around 45 in the period 1945-60, when statistics from the American Dental Assn. show that Cleveland supported 12 oral surgeons, 24 orthodontists, and fewer than 5 each in the fields of periodontia, pedodontia, prosthodontia, and endodontia. The incidence of specialization increased substantially in the 1960s and then leveled off in the 1970s, reaching an average of 1 specialist for every 20 general practitioners. The role of these specialists remains, in general, ancillary and supportive, in contrast to medicine, where several specialties (particularly internal medicine and gynecology) have assumed roles formerly filled by general practitioners or family doctors.

A new emphasis on preventive dentistry in Cleveland at the turn of the century was as important as specialization. Preventive dentistry, based on periodic examination, cleaning, and treatment of teeth, was intended to prevent minor dental problems from becoming serious ones. Convincing the general public of the effectiveness of such preventive measures was not easy, however. The advent of preventive dentistry was locally a direct outgrowth of efforts by the Cleveland Dental Society (formed 1886) to offer "free dental service for needy children." The society, under the leadership of HENRY LOVEJOY AMBLER and William George Ebersole, formed a Committee on Dental Instruction in 1897 to promote dental hygiene in the public schools. To plan an effective program that would help all children in the city, members of the society met with HARRIS R. COOLEY, director of charities for Cleveland, in 1906. With his support, the Cleveland Board of Education established dental clinics, which in 1909 were staffed by the Cleveland Dental Society and furnished by loans from dental-equipment manufacturers. As part of this program, Dr. Ebersole conducted the "Marion School Experiment" in 1910. He selected for study and observation a group of 40 children in grades 4 through 7 at Marion School. For 6 months the children underwent dental examinations and received training in proper methods of chewing their food and brushing their teeth. Necessary dental care, from fillings to oral surgery, was provided without charge. The experiment results confirmed dentists' claims that proper mouth hygiene contributed substantially to better overall health and academic performance among school-age children. Buoyed by these findings, the Cleveland Dental Society inaugurated the Mouth Hygiene Assn., which came under the sponsorship of the Cleveland Federation for Charity & Philanthropy in 1916. Thereafter, the dental-hygiene movement gradually outgrew its relief orientation and increasingly came to emphasize the virtues of preventive dentistry, through window displays, health fairs, and parades. Such efforts ultimately culminated in the creation of Children's Health Day in 1941 by the Cleveland Dental Society and dental-hygiene exhibits organized in cooperation with the HEALTH MUSEUM.

In Cleveland, the key to achieving a professional standing for dentistry was education. In a general sense, education at a university dental college was favored, to give prospective dentists a firmer grounding in the health sciences, enabling them to master new knowledge in the fields of oral and dental pathology and physiology. Moreover, in the absence of a large institutional base (such as the hospital constitutes for medical doctors and surgeons), the university-affiliated dental college constituted the chief place where students could acquire clinical experience under close supervision, and also where professors and students could carry out research programs. Perhaps most importantly, education at a state-certified school of dentistry could become the essential qualification for professional status among dentists.

Dental education in Cleveland actually began in the Medical Department of WESTERN RESERVE UNIVERSITY (WRU), where Lewis Buffet lectured on oral and dental pathology and oral surgery from 1874-81. This professorship fell victim to a merger of the medical faculties of WRU and the Univ. of Wooster. There was no other university-level instruction in dental subjects until 1892, when WRU established a dental school. At first the dental and medical schools of WRU were intimately associated, sharing entrance requirements and classes and occupying the same building. Liberal endowments received by the medical school from businessman John L. Woods led to a general upgrading of the curriculum and entrance requirements that elevated the medical school to a position of nationally recognized excellence, but the school of dentistry could not keep pace, owing to meager resources. In consequence, the two schools separated in 1896, much to the detriment of local dental education. The fledgling school of dentistry found new quarters in the Bangor Bldg. on Prospect Ave., but its fortunes deteriorated over the next decade. The financial situation was so bleak that WRU welcomed an offer to purchase the school. Dental-supply entrepreneur Henry Milton Brown bought the school in 1906 and ran it as a profit-making proprietary institution, while retaining the name and degree-granting privileges of WRU. Although Western Reserve was relieved to be free of the school's rising debts, it later regretted the arrangement. The quality of education plummeted: at one point, as many as 35% of the graduates taking the state licensing exams failed. In 1917 WRU, which occupied a new site in UNIV. CIRCLE, bought back the school.

WRU found in FRANK MONROE CASTO a capable and energetic dean for the school of dentistry. Casto's impeccable academic credentials included a specialization in orthodontia, and he possessed a solid sense of how to create an outstanding institution of dental education. During his 2 decades as dean (1917-37), Casto raised entrance standards, increased the number of full-time faculty from 2 to 8, developed a respected library, and transformed the school's clinic from a profit-making venture to a true center of learning for students, where dental care was available to anyone regardless of their ability to pay. Casto's tenure also initiated the tradition of research projects that won national recognition, including a landmark study of the development of children's jaws and teeth conducted by THOMAS WINGATE TODD, M.D., and BIRDSALL HOLLY BROADBENT, D.D.S., a study funded in part by the local BRUSH FOUNDATION. Casto and his successors brought WRU into the front ranks of American dental schools; in its first 80 years of existence, WRU graduated one-third of all dentists in Ohio and two-thirds of the dentists in northeast Ohio.

In the postwar period, 2 issues have attracted attention to dentistry and the dental profession in Cleveland. The first, in the domain of PUBLIC HEALTH, is the question of fluoridation of drinking water. The second is a matter of dental economics; namely, the emergence of retail-store dentistry. In 1950 the Cleveland Dental Society inaugurated a campaign to gain public support and acceptance of fluoridated water, which promised to reduce dental caries by 60%. CLEVELAND CITY COUNCIL authorized fluoridation in 1951, but it was not achieved until 1956, owing to delays incurred by controversy and legal action. Subsequent studies of Cleveland schoolchildren demonstrated that between 1956-63 the incidence of tooth decay dropped by 66%. Cleveland's example stimulated statewide action, mandated by the Ohio legislature in 1969. A resolution passed by the city council in 1976 officially recognized the leadership role played by the Cleveland Dental Society in achieving these results.

Perhaps the most profound of recent changes in dentistry falls in the domain of economics, particularly as manifested in the problems that confront dentists establishing themselves in practice and in the selection and payment choices made by patients. While medical and hospital expenses are increasingly met by third-party payers, dentistry has not fared as well. As of 1980, dental services constituted only 2% of total federal expenditures for health care, and less than 25% of dental expenses were covered by prepaid insurance plans. In 1995 the financial burdens of graduates of a dental school, particularly of a private institution such as the School of Dentistry of CASE WESTERN RESERVE UNIV., compel them to seek immediate remunerative employment. The high initial capital investment in equipment and instruments for private practice adds to this indebtedness. A solution for many is franchise dentistry in large retail stores. Consumers seem to prefer the conveniences of credit-card payment and proximity to other commercial establishments. The result is a marked increase in retail-store dentistry in Greater Cleveland, a trend likely to be on the rise elsewhere throughout the U.S.

James Edmondson

Dittrick Museum of Medical History

See also MEDICINE.

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