June 2010, Volume 31, Issue 5
Published by AEGIS Communications
The Dawn of the Industrial Age and the Cottage Industry of Dentistry
Edward F. Rossomando, DDS, PhD, MS
Series Synopsis: This four-part series examines the forces affecting the acceptance of innovative equipment and products in dentistry. In particular, the dynamics produced by scientific, political, and social changes are evaluated in regard to their relative importance to dentists. The first article had discussed the scientific, political, and social changes from the years 1850 to 1900. The second article, which is below, explores how dentists in the years between 1900 and 1910 reacted to these innovations. Part 3 will review the period 1950 to 2000 and will discuss the country’s scientific, political, and social changes. Part 4 will examine how these factors influenced dentists’ acceptance of equipment and products in the decade 2000 to 2010, comparing this period to 1900 through 1910. To read the first article, which appeared in the March 2010 issue of Compendium, please go to http://www.compendiumlive.com.
The interval from 1900 to 1910 was a glorious decade for science, technology, politics, and social changes. In 1901 Orville and Wilber Wright successfully completed the first powered flight in Kitty Hawk, North Carolina. In 1905 Model Ts were rolling off Henry Ford’s assembly line at the world’s largest manufacturing facility, the Rouge River plant in Michigan. The year 1904 marked the beginning of the largest public works project since the pyramids—the digging of the Panama Canal. In 1905 Albert Einstein published five papers, one of which was about special relativity. Also, the decade ushered in two vast social changes: the Industrial Revolution and the Organizational Revolution.
Partly in response to these changes, a new political movement emerged that would eventually become the Progressive Party. In the early 1900s the Progressive Party was led by Theodore Roosevelt, who became president after the 1901 assassination of William McKinley.
Rate of Acceptance of Scientific Innovations
How did the dental office of 1910 differ from that of 1850? Did the the scientific, political, and social turbulence of this decade encourage these changes? For example, in 1910 the dental office had a drill, which was introduced by James Beall Morrison in 1871 and was powered by a foot treadle (Figure 1). In 1893, the drill was modified to include an electric motor (Figure 2). The dentist also had an x-ray machine (the first dental x-ray was taken in 1895) (Figure 3) and the hydraulically adjustable chair introduced by Basil Wilkerson in 1877. In addition, a dentist at this time might have offered the use of nitrous oxide and/or ether, introduced in 1844 and 1846, respectively, for general anesthesia and painless extraction. Because of Charles Goodyear’s discovery of vulcanization in 1839 and Charles J. Essig’s chapter of “Vulcanized Rubber as Base for Artificial Dentures” in 1896, dentists in 1910 could advertise the fabrication of dentures using rubber bases and porcelain teeth (launched in the US circa 1817) and the use of Alfred Einhorn’s newly “invented” Novocain introduced in 1905. As most of these innovations were based on scientific discoveries from the latter half of the 19th century, it would appear that the commercialization proceeded relatively rapidly and dentists accepted these innovations into their practices shortly after the products entered the market. Clearly, without the scientific discoveries in the years 1850 to 1900, the dental office could not have changed.
But was this change rapid? It took 57 years from the 1839 discovery of vulcanization to Essig’s 1896 chapter describing the use of rubber for denture bases. This provides a benchmark; in the 19th century, nearly 60 years were required for scientific discoveries to move the dental office forward.
Role for Social and Political Forces
By 1900 the Yankee ingenuity that had unleashed the steamboat (as captured in the writings of Mark Twain in Tom Sawyer in 1876 and Huckleberry Finn in 1884), Alexander Graham Bell’s telephone in 1876, and Thomas Edison’s electric light in 1880 was already part of American folklore. This resourcefulness was combined with the entrepreneurial spirit prevalent in the post-Civil War United States, making the period of 1880 to 1910 unique. In dentistry, when these forces were combined and translated into back-room experimentation, a flood of dental products emerged—items of immediate use and therefore immediately accepted by the dentist. This type of innovation and entrepreneurship would be seen again in the 1960s, 1970s, and 1980s when computer “geeks” worked in garages and basements to perfect microprocessors, chip technology, and codes that would fuel the 21st century communication industry.
By 1900 dentists had better methods to drill teeth, make denture bases, and eliminate pain. Treatment changed, but the delivery of dental services did not. The organization in the office and management of patients’ problems had not varied between 1850 and 1910. Dentistry remained a cottage industry.
The Unmovable Delivery of Dental Services
In the decade 1900 to 1910, Model T automobiles were rolling off Ford’s newly introduced assembly lines, railroad companies were restructuring operations to increase efficiency, Andrew Carnegie was reorganizing the steel industry to cut labor and reduce costs, small farms were being bought by what would soon be called agribusiness, and cotton goods and clothing were mass produced using methods not seen before. However, dentistry was largely unaffected and a dentist continued to function as a craftsman.
As in 1850, the dentist in 1910 remained the only person to deliver oral healthcare. Patients were seen individually, and the dentist performed all diagnostic and therapeutic procedures. A diagnosis was based on a visual examination, some poking and probing with an explorer, and perhaps an x-ray. The physicist Wilhelm Conrad Röntgen discovered x-rays in December 1895, which was followed by the first dental radiograph made by the German dentist F. Otto Walkoff in January 1896. Once a diagnosis was made—usually the identification of the offending tooth—a plan was devised, which consisted of one of two options: to extract or treat. Regardless of the choice, the dentist performed the therapy. For all its “modern equipment,” the dental office of 1910 had not changed much since 1850.
One can only imagine how different the delivery of dental services would be in 2010 if the dental profession had opted to adopt a factory approach and introduced mass production techniques. For example, suppose the American Dental Association hired Ford as a consultant to introduce an assembly line method to the delivery of dental care. He might have designed the dental office as follows: After admission, the patient would be taken to the first station to be given x-rays and moved to the next station to be seen by the dentist, who would make a diagnosis based on an oral examination and study of the x-rays. For example, such a determination might be decay on the lower left first molar. The prescription would be written as the following: remove decay and place an amalgam restoration. The dentist would inject Novocain, and then the patient would be moved to the next station—the operatory—where a specially trained technician would remove the decay with an electric drill. The patient would then be transferred to the next station where another technician would place the amalgam restoration. This technician might have specialized in occlusion and mixing amalgam—carving the oral anatomy. This same person would adjust the bite. Then, the patient would be sent to the cashier before going home. Of course, the dentist of 2010 performs all these functions, except the payment process and x-ray taking. In Ford’s assembly line office, there would be one dentist and at least three to five additional specialists, each completing a single task and moving the patient to the next station. Or taking the assembly line analogy one step further, Ford would move the chair and patient from station to station.
Given that the virtues of factory manufacturing were probably described in daily newspapers and the benefits of mass production were visibly resulting in lower prices, it is unclear why dentists did not adopt this model but instead elected to function as craftsmen as their predecessors did a century earlier. Had this approach been adopted, the dental curriculum would have eliminated the mechanical component of education and focused more on diagnosis, as well as office organization and operation. In addition, many more “vocational-style” schools would have opened to train the numerous technicians needed to perform dentistry’s mechanical components.
Another reason that the model should have been adopted was the introduction of new equipment and products that made the dentist’s mechanical work easier to teach. Usually, a new automation allows a process to be delegated. Examples in manufacturing and medicine are plentiful. In dentistry, the simplification of the prophylaxis and taking of x-rays allowed for these tasks to be delegated. The addition of dental assistants and four-handed dentistry were attempts at automation. The introduction of the laboratory technician as part of the dental office team was an attempt to delegate some of the fabrication process. But as long as the dentist performed most of the tasks—especially with the fabrication process—incorporating the major advance of the industrial revolution was not possible.
Given the historical content, it is puzzling that the delivery of dental services based on the assembly line model was not adopted. Could this decision be a reflection of the interests of those who entered the profession in the 1850s?
Could this group, usually self-selected from medicine, have enjoyed the mechanical aspects of dentistry, particularly the fabrication component? Many inventors and entrepreneurs were among this group during these time spans.
While scientific discovery is the primary force behind any innovation, other aspects often have a role in the acceptance of that innovation into dental practice. Other factors might include those generated by social and political changes. Part 2 of the series has examined the period 1900 to 1910, a decade noted for significant political and social changes. During this time, the United States entered the Industrial Age, which was characterized by increases in manufacturing output—a result of introducing the assembly line and newly emerging concepts in organization.
While dentists in this decade rapidly adopted new technologies and products, they failed to accept the mass production techniques introduced into manufacturing. Dentistry remained a cottage industry. It is unclear why dentistry chose to remain with this business model, but one explanation would be related to the interests of those directing the profession. This will be examined in the Part 3 of this four-part series.
The author wishes to express his gratitude to Dr. Scott Swank, Curator, The Dr. Samuel D. Harris National Museum of Dentistry, for his review of the article and assistance with providing historical images.
About the Author
Edward F. Rossomando, DDS, PhD, MS
University of Connecticut School of Dental Medicine
Center for Research and Education in Technology Evaluation