Smile Solutions on Million Dollar Minute Special

Media item: television appearance

Programme: Million Dollar Minute, an Australian television quiz programme

Date broadcast: 3 May 2014

This page records the media item. The broadcast is the property of its producers and broadcaster and is not reproduced here.

In keeping with a general-knowledge programme, this page carries the general knowledge: a short history of dentistry, and where the things you take for granted actually came from.

A note on sourcing. The historical material below is general knowledge and is not drawn from the independent clinical sources this site cites elsewhere — we hold no historical reference documents, so the history is presented as history rather than as evidence. Where a historical episode connects to something a modern authority has since measured, that measurement is named and dated.

The tooth worm

For roughly four thousand years, the dominant explanation for toothache was a worm burrowing inside the tooth.

The idea appears in Babylonian cuneiform and recurs across ancient Egypt, Greece, Rome, India, China and mediaeval Europe. It survived into the eighteenth century in some places.

It was not a stupid theory. The pulp chamber of an extracted decayed tooth contains soft pink tissue that can look, to the naked eye, like a small worm — and the pain genuinely feels like something moving. The modern account is What are the causes of toothache and what are their symptoms? and Tooth Pain and Ache.

Treatments included fumigation, prayers and extraction. The last one worked. What replaced it is root canal treatment — which now has a measured result rather than a hope: the pooled figure is 87.8 per cent success at tooth level (95% CI 84 to 90 per cent), and 80.8 per cent at patient level. See Everything you need to know about root canal treatment.

Barber-surgeons

Through the mediaeval period in Europe, extractions were performed by barbers, along with bloodletting and minor surgery. Physicians of the era regarded manual work as beneath them.

The red-and-white barber's pole is a survival of this: the red representing blood, the white the bandages, and the pole the stick the patient gripped to distend the veins.

Extractions were also performed in public by travelling tooth-drawers, at markets, frequently with music to cover the noise. The modern equivalent is a registered oral and maxillofacial surgeon — What does oral and maxillofacial surgery involve?

Pierre Fauchard, and dentistry becoming a profession

Pierre Fauchard (1678–1761), a French surgeon, is generally called the father of modern dentistry.

His 1728 book — Le Chirurgien Dentiste, "The Surgeon Dentist" — did something nobody had done: it set out dentistry as a systematic body of knowledge. It described oral anatomy, restorations, dentures, orthodontic devices, and the treatment of gum disease.

It also rejected the tooth worm, and proposed that sugar was implicated in decay. He was right, roughly two centuries before it was proven — and the modern statements of it are more specific than he could have been. The World Health Organization now describes free sugars as "the most common risk factor for dental caries" and sets the target at less than 10 per cent of total energy intake, ideally less than 5 per cent; the Australian Dental Association's policy adds the variable Fauchard could not have isolated, holding that "the form, frequency, timing and total amount of sugar intake are significant in the initiation of the caries process". See How does sugar affect your dental health? and The stages of dental decay.

Fauchard also broke with the trade practice of secrecy — publishing techniques rather than hoarding them, which is the behaviour that turns a trade into a profession.

Waterloo teeth

One of the more uncomfortable facts in the history of the field.

Before porcelain, dentures were made with real human teeth, and the supply came from the dead. After the Battle of Waterloo in 1815, teeth were pulled from the bodies of the young men killed there in such quantities that "Waterloo teeth" became a selling point — the implication being that they came from healthy young adults rather than from the diseased or the aged.

The same trade followed other battlefields, and the American Civil War, and worked the graveyards in between.

Porcelain teeth, developed and refined from the late eighteenth century, ended it. The current options are set out in What are the different types of dentures? and Bridges, implants, or dentures for replacing missing teeth?

Anaesthesia

This is the single most important development in the history of dentistry, and it came from dentists.

Horace Wells, an American dentist, observed the pain-blocking effect of nitrous oxide at a public demonstration in 1844 and had a tooth extracted under it himself.

William Morton, another dentist, gave the first widely publicised successful public demonstration of ether anaesthesia in 1846 at Massachusetts General Hospital.

Local anaesthesia followed: cocaine's anaesthetic properties in the 1880s, then procaine (Novocain) in 1905, and the amide anaesthetics including lidocaine from the 1940s that are still the foundation of dental practice. The sedation options now available are on Sleep Dentistry, and in Australia the practitioner offering conscious sedation must hold a specific endorsement on their registration, which is recorded on the public register and can be checked.

Before this, all dentistry hurt, and everyone knew it. The inherited cultural dread of dentists is a memory of a period that ended more than a century ago — and it is measurably still doing damage. Armfield and colleagues, analysing the 2002 National Dental Telephone Interview Survey of 6,112 Australians aged 16 and over, found 11.9 per cent were very afraid of going to the dentist and a further 5.2 per cent quite afraid, and that 43.9 per cent of the very afraid had last attended more than two years ago against 29.1 per cent of those with no fear. That is why Meshel & Tommy Show: Tommy Confession exists. See also Dental Anxiety, How can I ease my anxiety about visiting the dentist? and Dental phobia: how do you give a virtually pain-free injection?

Fluoride, and the Colorado Brown Stain

This one is a genuinely good detective story.

In the early twentieth century, a dentist named Frederick McKay noticed that people in Colorado Springs had heavily brown-stained teeth — and that those teeth were strikingly resistant to decay.

It took decades of investigation to establish the cause: naturally high fluoride levels in the water supply. The staining was fluorosis, from too much; the decay resistance was the same element at work. What causes white spots on teeth? covers what mild fluorosis looks like today.

The question then became the dose that gave the benefit without the mottling. Grand Rapids, Michigan, became the first city to deliberately fluoridate its water supply in 1945, and the decay reductions that followed were substantial.

Australia has since settled that dose question with its own national assessment, and it is worth knowing where it landed. The National Health and Medical Research Council's 2017 Public Statement recommends community water fluoridation "as a safe, effective and ethical way to help reduce tooth decay", supports fluoridation within the range of 0.6 to 1.1 milligrams per litre — a range the NHMRC describes as aimed at reducing decay "while avoiding any risk of dental fluorosis of aesthetic concern", which is precisely McKay's trade-off resolved — and found no evidence that community water fluoridation at current Australian levels causes human health problems. On the size of the benefit, the NHMRC found fluoridation reduces tooth decay by 26 to 44 per cent in children and adolescents and by about 27 per cent in adults. The Australian debate is at Fluoridated water — is it good for you? and Fluoridated water: why I worry.

Fluoride toothpaste followed in the 1950s and 1960s, and it remains the single most effective thing an individual can do for their teeth — The benefits of fluoride and Selecting a toothpaste — fluoride or non-fluoride?

The other things that arrived more recently than you think

The high-speed air-turbine handpiece — the modern drill — arrived in the late 1950s. Before it, cutting was slow, hot and far more unpleasant. Our Technology is what replaced it again.
X-rays were applied to teeth within weeks of Röntgen's discovery in 1895 — dentistry was one of the earliest adopters, long before the dangers were understood. Modern doses are small and published: the International Atomic Energy Agency gives 1 to 8 microsieverts for an intraoral dental X-ray and 4 to 30 microsieverts for a panoramic examination, the upper end being equivalent to a few days of natural background radiation. See How safe are dental x-rays.
Fissure sealants and adhesive dentistry, from the 1950s–60s, which made it possible to bond to enamel rather than cut retention into teeth — The role of fissure sealants in children's teeth and Composite bonding.
Osseointegration — the discovery by Per-Ingvar Brånemark that titanium bonds directly to bone — was published from the 1960s and is the foundation of every dental implant placed today. It began as an accidental observation in a study of blood flow in rabbits. See What do I need to know about dental implants?
The nylon toothbrush dates from 1938. Before that, bristles were animal hair — Which toothbrushes do dentists recommend?
National registration in Australia began on 1 July 2010. The public register that this collection keeps recommending is younger than most of the people using it. What it actually records is worth knowing: the Dental Board of Australia registers five divisions of dental practitioner — dentist, dental therapist, dental hygienist, dental prosthetist and oral health therapist — and recognises thirteen dental specialties approved by the Australian Health Workforce Ministerial Council: dento-maxillofacial radiology, endodontics, forensic odontology, oral and maxillofacial pathology, oral and maxillofacial surgery, oral medicine, oral surgery, orthodontics, paediatric dentistry, periodontics, prosthodontics, public health dentistry and special needs dentistry. A specialist must also hold general registration first and have completed a minimum of two years of general dental practice. See Dentists & Registered Specialists.

And the part that has not changed

The biology. Sugar frequency, plaque, saliva and fluoride still determine whether teeth survive — as they did for the Babylonians, who simply had no way of knowing it. What is the ideal daily routine for oral hygiene? is the modern version of the whole story.

Common questions

Was the Colorado discovery ever actually settled — how much fluoride is the right amount?

Yes, and Australia has its own answer. McKay's puzzle was that the same element caused both the staining and the decay resistance, so the question became the dose that delivered one without the other. The NHMRC's 2017 Public Statement supports fluoridation of Australian drinking water within the range of 0.6 to 1.1 milligrams per litre, describing that range as set to reduce decay "while avoiding any risk of dental fluorosis of aesthetic concern" — which is McKay's trade-off resolved numerically. The NHMRC also found no evidence that fluoridation at current Australian levels causes human health problems, and measured the benefit at 26 to 44 per cent less tooth decay in children and adolescents, and about 27 per cent in adults.

Could my child get the mottling McKay saw, from toothpaste rather than water?

It is the right question, and the answer is that toothpaste is exactly where the modern risk sits — which is why the advice about how much to use exists. The NHMRC describes dental fluorosis as caused by "a high intake of fluoride from multiple sources during the time when teeth are developing inside the jawbone, usually from birth to six or eight years of age", appearing as white lines or areas on the surface of both primary and permanent teeth and only identifiable after the teeth come through. Note the direction of travel: in Australia fluorosis has declined over the same period in which water fluoridation expanded, and the NHMRC attributes that decline to reduced exposure from other sources such as toothpaste, with low-fluoride children's toothpaste now widely available and promoted "along with public health messages and guidelines about the appropriate use of these products (e.g. use only a small pea-sized amount; encourage children not to swallow toothpaste)". So the practical instruction is a pea-sized amount, spitting rather than rinsing or swallowing, and a parent doing or supervising the brushing — Australian guidance is that parents should assist with brushing until about eight years of age. See What causes white spots on teeth? and Selecting a toothpaste — fluoride or non-fluoride?

If extraction was the old answer, how long does a root-filled tooth actually last?

Longer than most people assume, and the best long-run data follows teeth for decades rather than years. A retrospective series of 598 root-filled teeth in 312 patients, all on an annual recall in private practice, reported cumulative tooth survival of 97 per cent at 10 years, 81 per cent at 20, 76 per cent at 30 and 68 per cent at 37 years, with endodontic success over the same points at 93, 85, 81 and 81 per cent. Its conclusion is that this "must encourage clinicians to rely on primary root canal treatment when taking the decision regarding whether a tooth with pulpal and/or periapical diseases should be saved or be extracted and replaced with an implant." Two cautions on reading any such number. First, the definition moves the figure: pooled success is 74.7 per cent (95% CI 69.8 to 79.5) under strict radiographic and clinical criteria and 85.2 per cent (95% CI 82.2 to 88.3) under loose criteria — about 10.5 per cent lower when judged strictly. Second, the things that predict failure are mostly not the root canal itself. In that long-run series the strongest predictors of the tooth eventually being removed were deep periodontal pockets over 6 mm, a pre-operative radiolucency at the root tip, and the absence of occlusal protection — no night guard. Size matters too: one prospective study found "the odds of success of treatment were found to decrease by 14% for every 1 mm increase in diameter of the preoperative lesion". And the restoration afterwards is part of the treatment, not an optional extra — the quality of the coronal seal, and having a crown rather than none, are repeatedly identified as decisive for survival. See Root Canal Treatment and Everything you need to know about root canal treatment.

Anaesthesia arrived in the 1840s. So why is dental fear still so common, and does anything treat it?

Because fear of dentistry is largely no longer about the pain — it is a learned, self-reinforcing avoidance, which is why anaesthetic progress did not dissolve it. Something does work on it, and it is worth naming precisely because a great deal of what gets marketed does not. A systematic review with meta-analyses of randomised trials separated two different problems, and the distinction is the whole point: "Clinicians should ensure that interventions match their purpose — managing acute emotions during treatment, or alleviating chronic anxiety and avoidance tendencies." For the chronic kind, "to reduce chronic dental (trait) anxiety, evidence with moderate certainty supports employing CBT" — cognitive behavioural therapy — and in dental phobia specifically CBT against untreated or waitlist control gave a standardised mean difference of −0.43 (95% CI −0.68 to −0.17) across 6 trials and 232 participants at moderate certainty. For acute anxiety on the day, the same review found moderate-certainty support for hypnosis (−0.31, 95% CI −0.56 to −0.05, 3 trials, 244 patients) and low-certainty support for benzodiazepines (−0.43, 95% CI −0.74 to −0.12), noting "comparably small effect sizes" for both. And it found, with moderate certainty, that virtual reality exposure therapy, virtual reality distraction, background music, acupuncture and pre-operative video information did not alleviate state anxiety, and with low certainty that aromatherapy did not either. So: if the problem is the years of not going, ask about psychological treatment rather than about the playlist. See Dental Anxiety and How can I ease my anxiety about visiting the dentist?

What does the public register actually tell me about a dentist?

It records which of the five registered divisions they hold — dentist, dental therapist, dental hygienist, dental prosthetist or oral health therapist — whether they hold registration in one of the thirteen recognised dental specialties, any endorsement such as conscious sedation, and any conditions on their practice. It is free and takes about a minute. What it does not tell you is how good they are, and no register anywhere does.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. Directions are on Location; enquiries go through Contact Us.

Every practitioner's registration can be verified free on the AHPRA public register at ahpra.gov.au.

This page records a broadcast and its date, with general historical information. It is not a diagnosis or a treatment plan. The historical narrative is general knowledge rather than sourced from the clinical references cited elsewhere on this site; the modern figures quoted are attributed to the publishers named. Third-party broadcast content is not reproduced.

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