Dentistry began to emerge as a recognized specialty within medical surgery in seventeenth-century Europe, although scattered examples of basic dental practice (especially extractions) and attention to oral hygiene can be traced to earlier centuries. The French surgeon Pierre Fauchard, author of Le Chirurgien Dentiste (1728), is generally recognized as the "father" of modern dentistry. Among his select clientele was an occasional child, usually a daughter of one of his (mainly female) patients, who would present with a badly carious, visible tooth that she was reluctant to extract because an empty space or replacement tooth might threaten her physical appearance and social position. Fauchard's creative solution, which apparently met with some success, was to withdraw the diseased tooth and then replace it immediately in its socket. Beyond providing pain relief, Fauchard and his contemporaries also experimented with new procedures to straighten misaligned teeth; children ages twelve to fourteen were the principal clientele.
These early examples notwithstanding, it was rare for a child of any social class to visit a dentist in the eighteenth and nineteenth centuries. Even among leading professional spokesmen, the traditional view still held that children's primary (deciduous) teeth were expendable, unworthy of financial investment, and unrelated to future oral health. The reparative treatment of carious teeth improved in quality and gained in popularity during the late nineteenth century, but its primary reliance on expensive gold fillings militated against its general extension to children. Extraction remained the primary response to children's dental diseases. Trained dentists–few in number, located mainly in cities, and expensive–were largely peripheral to the extraction trade, which was dominated by barbers, nostrum salesmen, and itinerant "tooth-pullers" who promised instant, pain-free relief. Not surprisingly, business boomed for replacement teeth and prosthetic devices in the nineteenth century, not just for the elderly but also for young adults who emerged from childhood with few usable teeth and constant mouth pain. Dentists and craftsmen worked singly and collaboratively to meet public demand and to improve the quality and fit of prosthetic devices (famous portraits of George Washington's clenched mouth exemplified why technical improvements were considered necessary). Dentists in the United States established clear superiority in "mechanical dentistry" and in the production, quality, variety, and economy of prosthetic devices.
Children's dentistry emerged as a distinct subspecialty in Canada, Great Britain, and the United States in the first half of the twentieth century. Oddly, the field took shape mainly outside rather than inside dentists' offices, and under public rather than private sponsorship. Most dentists remained ambivalent, if not hostile, to integrating children into their private practices. The challenges and rewards of technically sophisticated, adult-oriented mechanical dentistry, not child-oriented, poorly compensated, preventive dentistry, drove the bulk of the profession. Nonetheless, a major shift in scientific direction, professional orientation, and public discourse about dental disease was evident by the early 1900s. For the first time, dentists seriously questioned the panacea of extraction and the presumed inevitability of toothlessness. A new gospel of "prevention" became a clarion call for dentistry to transform its customary assumptions about children's dental needs, and to make "mouth hygiene" a vital concern in medicine, public health, and education.
Several scientific advances in the 1880s and 1890s underlay the new viewpoint. Most important were Dr. William Miller's "chemico-parasitic" theory, which described the bacteriological process by which caries emerged under gelatinous plaques, and his "focal infection" theory, in which an unclean oral cavity was seen as the prime avenue of penetration for infectious disease in children. Also important in building professional confidence were Dr. Edward Angle's creative inventions for straightening teeth, which raised hopes for addressing the entire range of difficult problems surrounding malocclusion. New techniques and equipment for saving carious teeth with better, longer lasting, and cheaper filling materials also promised a bright future for reparative dentistry.
Children's dentistry was integral to the Progressive Era's (1890–1920) wide-ranging child welfare and Americanization campaigns, and, in particular, to the school health movement. Educational programs made prevention the central theme of children's dentistry. While educators emphasized the importance of nutrition and regular prophylaxis, they urged above all that children maintain lengthy, stringent, technically perfect standards of brushing their teeth: three, four, and ideally five times per day. Mothers as much as children were the audience for the new conventional wisdom. As with other elements of the Progressive child welfare agenda, mothers were assigned major responsibility for sparing their children needless pain and suffering, and thereby ensuring their success in school and assimilation into American life.
The provision of operative treatment via schools and clinics was the boldest innovation of early-twentieth-century children's dentistry. In the 1910s, several dozen dental clinics were established exclusively or primarily to serve children in public schools and in local health departments; a few clinics with private support, most notably in Boston and Rochester, were also founded. These clinics brought prevention-and-treatment oriented dentistry to the masses for the first time. In many clinics, dentists not only inspected children's teeth but also performed reparative treatments and extractions. Equally innovative was the introduction of regular prophylaxis, usually performed by members of the new, entirely female, school-centered specialty of dental hygienists. Despite its acknowledged importance in caries prevention, prophylaxis was time-consuming, laborious, and generated low fees. Dentists rarely performed prophylaxes in their private offices until hygienists or comparably trained assistants became more widely available. Although male dentists provided most school- and clinic-based operative service, it was lower-level women professionals–teachers, nurses, and hygienists–who mainly carried the banner of children's dentistry, much as in other areas of Progressive child-welfare reform.
A small corps of women dentists also emerged in the early twentieth century that began to focus primarily on children. M. Evangeline Jordon was arguably the first specialist in children's dentistry, beginning in 1909. Jordon authored the field's first expert textbook, Operative Dentistry for Children, in 1925. In his preface to Jordon's text, the prominent dental scholar Rodrigues Ottolengui observed that prior to 1915 he "had never heard of a dentist specializing exclusively in dentistry for children," and that "Dr. Jordon, so far as we have been able to learn, was the first dentist to practice exclusively for children, and thus she is the pioneer pedodontist of the United States, and perhaps of the world" (p. vii). In 1927, around the time of her retirement as a practitioner, a small group of dentists formed the American Society for the Promotion of Dentistry for Children, based on a common understanding that "if children are to be served, general dentists would have to provide most of the treatment." In 1933, the Journal of Dentistry for Children was founded.
General dentists did begin to serve children in larger numbers during the Great Depression, but mainly as paid employees in schools and clinics that expanded under government auspices. The Depression brought considerable hardship for dentists, and publicly funded programs in school and clinic settings were essential for their professional survival. Now numbering in the hundreds, these clinics provided around half of the total amount of dental treatment that children received from any source during the 1930s. (As the draft examinations in World War II would reveal, however, the oral health of American children and youth was still abominable, especially in rural communities and in the South, where publicly financed school and dental clinics never took hold.) Thus, out of necessity more than design or desire, children and dentists were no longer strangers to one another. A base of professional experience and client expectation for integrating children into general dentistry had been laid. Signifying the subspecialty's gradual arrival at professional legitimacy, the American Society for the Promotion of Dentistry for Children was renamed the American Society of Dentistry for Children in 1940.
The provision of free reparative and restorative dentistry to several million servicemen during World War II also did much to create a new consumer base for children's dentistry in the postwar era. With the return of prosperity, this potential was soon realized–but now in the private rather than in the public sector. In the decade following the war, the private practice of American dentistry boomed as never before, and the share of children receiving private dental care expanded dramatically. By the late 1950s, nearly half of the school-age population was visiting a dentist about once per year. Organized dentistry–which, unlike organized medicine, had largely supported free school and clinic dental programs for children during the previous half-century–adopted a condescending stance toward such programs in the 1950s, claiming that they provided inferior treatment, used outdated equipment, misled parents about their children's true dental needs, and were no longer necessary. School clinics and other public agencies that had grown accustomed to calling upon unemployed or underemployed dentists on an hourly per capita or fee basis to treat children now found that dentists no longer had the time or financial inclination to participate in such arrangements. The long-sought ideal of the "family dentist" was finally becoming a reality.
An equally major change emerged in the postwar years that would profoundly transform children's oral health by the 1980s. This was the discovery of the preventive possibilities of fluorides for dental caries. Schools returned briefly in the 1970s to a central role in children's dentistry as the National Institute of Dental Research launched a major publicity campaign to convince educators and dentists alike that school-based fluoride rinse programs represented the most cost-effective, school-based means available to prevent tooth decay. By 1980, nearly one-quarter of the nation's school districts were participating in fluoride rinse programs, which may have reached as many as 8 million children. Although bitter fights over water fluoridation occurred in numerous communities, with some opponents casting fluoridation as a Communist plot, the fluoridation of water supplies grew rapidly in the postwar era. By the end of the 1950s, nearly two thousand communities serving over 33 million people had fluoridated their water supplies. By 1980, over eight thousand communities and more than half of the U.S. population was drinking from artificially or naturally fluoridated water supplies.
In addition, the advent of fluoride-based toothpastes beginning in the 1960s and the growing availability of fluoride mouth rinses in the 1970s further increased the likelihood that children, whether their community had fluoridated its water supply or not, had ready access to fluorides' preventive possibilities. The impact of pervasive exposure to fluorides on children's dental health was spectacular. By the late 1970s, a precipitous nationwide decline in the incidence of dental caries was evident, in non-fluoridated as well as in fluoridated communities. Dentists began to report substantial growth in the numbers of cavity free children, who were virtually unknown just two decades earlier. While the precise causes were uncertain, the omnipresence of fluorides in the food chain, as well as their widespread ingestion via community water supplies, tablets, mouth rinses, and toothpastes, contributed substantially to the decline.
By the beginning of the twenty-first century, the perceived crisis in "mouth hygiene" that had given rise to the specialty of children's dentistry was clearly over. To be sure, dental caries still compromise children's health, and some subgroups of children, particularly among the disadvantaged, continue to suffer disproportionately from caries. But leaders in the field have understandably turned their attention to a variety of new issues and unmet needs. These include paying more attention to periodontal diseases in children; intervening earlier to treat malocclusions; grounding dentist–child relations more consistently on scientific principles of child development; extending dental care to disabled children; expanding the dentist's responsibility in recognizing CHILD ABUSE and neglect; managing medically compromised patients, such as those with AIDS; and inventing a caries vaccine. Concerns about aesthetic issues as well as health issues led to growing rates of treatment with braces and other straightening devices from the mid-twentieth century onward.
Perhaps bolder still, some leaders in "preschool dentistry" insist that the relatively recently established ideal age for children to see a dentist for the first time–age three–is in fact far too late to preserve optimal dental health. Instead, they recommend that parents schedule their child's first dental appointment between six months and one year of age. The entire field of preschool dentistry was inconceivable a century ago. But its basic premise remains consistent with that of Jordon and other pioneers in early-twentieth-century children's dentistry: "The prevention of disease can never be started too early" (Pinkham, p. 4).
See also: Hygiene; Pediatrics.
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STEVEN SCHLOSSMAN