Forty years after it happened, Jim Harris still remembers his fear.

As he reluctantly trudged up the dimly lit stairs toward the second floor, two-room office in Washington, Iowa, the pain from the front teeth he’d knocked out on a swing set paled in comparison to his trepidation at going to the dentist.

“This was in the 1960s, and my family dentist still practiced 1950s-style dentistry,” Jim recalls. “His office was dark and cramped, his equipment wasn’t updated—and let’s just say that sterilization wasn’t his foremost concern.”

But, if he hadn’t made that visit when he was 11 years old, he wouldn’t have ended up in the dentist chair for some remedial work when he was a sophomore member of the University of South Dakota swim team. If he hadn’t seen how much dentistry had improved in those intervening years, he probably wouldn’t have gone on to dental school at the University of Iowa. And if that hadn’t happened, Jim Harris, 76BS, 79DDS, wouldn’t be back in his hometown now, working to ensure that new generations of children no longer dread a visit to the dentist.

After off-putting experiences at the dentist when they were young, Jim and Ann Harris make sure that their own practice in Washingon, Iowa, offers a welcoming atmosphere to patients.

Jim’s practice in Washington, which he shares with his wife, Ann, 77BS, 84DDS, 86MS, is a far cry from the dentist’s office that he considered a chamber of horrors as an adolescent. Like most modern offices, theirs projects a professional yet welcoming atmosphere and relies on modern technology to serve their patients. “It’s such a different world compared to the kind of dentistry I grew up with,” Jim says.

It’s also a busier world. Even with a population of just more than 7,000, Washington keeps six dentists in business. The Harrises’ practice serves between 1,700 and 2,000 clients from Washington, nearby towns such as Kalona, and small rural communities. Even though many patients aren’t covered by insurance, they still want services ranging from sealants that ward off cavities to implants that prevent the need for dentures to aesthetic options that can improve their smiles. Better educated about dental care than ever before, a typical patient is willing to put his money where his mouth is.

UI College of Dentistry

In 1882, the UI Department of Dentistry was founded, with an enrollment of 14 students. The College of Dentistry, which now enrolls some 300 students in its D.D.S. program, is the only provider of predoctoral dental education in Iowa. It is one of only a few dental schools in the country to offer advanced education in all dental specialties, as well as residencies in general and hospital dentistry. The College of Dentistry has received continuous training support from the National Institutes of Health for 25 years—longer than any other dental school in the nation. The college’s Simulation Clinic, with its 80 advanced dental simulator units, video demonstrations of clinical procedures, and other high-tech resources, is a national model. Faculty, residents, and students provide a full range of dental services to some 9,000 patients, resulting in about 118,000 patient visits a year. Students in the Kirkwood Dental Hygiene Program practice in the UI College of Dentistry’s clinics.

"Parents nowadays want good treatment for their kids, stuff that wasn’t available to them,” says Ann Harris. The Harrises are among some 1,000 UI College of Dentistry alumni who make up three-quarters of Iowa’s dentists and provide care valued at more than $500 million a year. But, while dentists abound in Iowa’s cities and towns, their numbers dwindle in rural areas. Some patients have to drive more than an hour to get to the nearest dentist. Attracting new, younger dentists to these rural areas is difficult. Even thriving practices can languish on the market for years before a new practitioner is found. “The public haven’t really become aware of the problem yet,” says Jim Harris, “but they will when they can’t find a dentist in their local town.”

Each year, the UI’s dental school graduates about 75 new dentists. (Iowa enjoys such a good reputation that more than 600 applicants, with an average GPA of 3.5, compete for places.) While some of them choose to stay in the state, others pack up and head out. Partly, they’re motivated by what they perceive larger cities can offer in terms of better career opportunities—and bigger salaries.

After four years of dental education, students from Iowa are likely to have amassed some $85,000 of debt, while out-of-state students will owe about $145,000. Although such debts can seem overwhelming, they represent a good career investment. According to the American Dental Association, general practitioners earned about $165,000 in 2000, while specialists’ salaries averaged $260,000. But, as most dentists are self-employed, the personal and financial commitment of setting up a practice can seem prohibitive to students who are just starting out. That’s another reason some choose to enlist in the military, with its debt repayment programs, or to work as a salaried employee in a large practice.

If Allen “Skip” Carrell, 87DDS, had the chance, he’d convince those new dentists to try small town life. When he left his hometown of Shenandoah at age 18, he thought he’d never return. Ten years later, married and with two small children, he had a different perspective on the slower pace of life, smaller community, and safe environment. “It’s great to have people waving at you when you walk down the street,” he says. “And, people are excited to have you back.”

	One of thousands of UI dental graduates who've chosen to stay in the state after graduation, Skip Carrell (left) is nonethless something of a rarity—a dentist who practices in a rural community. David Johnsen (right), dean of the UI dental school, says such scarcity of care in rural communities is becoming a serious concern.

In fact, such is the demand for dentists in rural areas that Carrell says he could work ten hours a day, seven days a week, and his office phone would still be ringing. As a general dentistry practitioner, he serves a wide range of patients. “Last Wednesday morning, I saw a three-year-old girl, followed by an Alzheimer’s patient in a wheelchair, followed by someone on lunch break,” he says. “Now that I’ve been here for 15 years, the people I treated when they were teenagers are bringing in their own kids. Some day, I’ll be seeing their grandkids.”

Although she’s originally from the Chicago suburbs, Ann Harris agrees about the particular rewards of small town life and dental practices. “I have friends who are dentists in Chicago. They don’t live in the same town as their patients, and it does make a difference,” she says. “Patients are just that—patients. They’re not their child’s teacher or softball coach. You have a much more personal role in your community in a small town.”

Wherever they work, most dentists would agree that being able to help people—especially dental phobics—is one of the most rewarding aspects of their jobs. “It’s very satisfying to see people begin to trust you,” Carrell says. “Some doze off in the chair while you’re working on them. That’s a great compliment.”

Now that he has a partner, Carrell works only four days a week. Like most dentists, he keeps regular office hours and rarely, if ever, works evenings or weekends. “It sounds cushy, working in a nice job in a nice environment,” says Jim Harris. “But, dentistry requires a lot of focus and concentration, which is tiring, especially when you’re working in awkward positions. Even though you sit down most of the day, you’re on a schedule. You don’t take time out for coffee or to shoot the breeze in the middle of the morning. It can wear you down.”

Keeping up-to-date with the new materials, procedures, and technology also takes time. Most states require dentists to complete continuing professional education, so many UI alumni return to Iowa City several times a year for workshops and seminars. The Internet is another valuable resource. “I can log onto a professional organization’s website, ask a question on a chatboard, and by the next day, 20 dentists will have sent me an answer,” says Carrell.

To prepare him for the challenges of general dentistry, Carrell completed the UI’s yearlong Advanced Education in General Dentistry program. “It shows you how to deal with tougher cases,” he explains. “Many of my patients are already driving 45 minutes to get to me, and I don’t want to have to send them farther away to a specialist.”

Sometimes, though, a referral is in a patient’s best interest. As well as intensivetraining and expertise in certain areas of dentistry, specialists also have specialized equipment and tools. At Eva Dahl’s endodontics clinic in Onalaska, Wisconsin, each treatment room is equipped with a $10,000 surgical microscope for use in root canal treatments. “It’s challenging keeping up with new technology, especially with the greater computerization of dental equipment and offices in the last ten years,” says Dahl, 73BA, 76DDS, 79MA, 82MS, 82EndoS. “The transition hasn’t been easy, but it results in better care and service for patients.”

Some of Dahl's patients are aged 80 or older. “When I was in dental school, about half the patients over the age of 60 had dentures. People used to think, ‘I’m 60 years old. Why should I invest time and money in my teeth?’” Dahl says. “Now, partly because of our culture’s emphasis on youthful appearance, but also because natural teeth feel better than dentures, people are choosing to look after and keep their teeth.”

	Endodontist Eva Dahl works on a patient in her technologically advanced clinic in Onalaska, Wisconsin.

Indeed, public education campaigns over the last few decades—in addition to fluoridated water and the availability of aggressively marketed toothpastes, mouthwashes, floss, and other dental hygiene products—have proved successful. “When I was a kid, it wasn’t unusual to go to the dentist and have three or four teeth fixed at once,” remembers Jim Harris. “Now, we get kids leaving high school who haven’t had that many teeth worked on in total.”

Despite such success stories, dentists aren’t worried about going out of business. Apart from the increasing popularity of aesthetic services such as teeth whitening and straightening, some segments of the population still require care: the elderly, children, people with special needs or those with financial hardship, who often miss out on dental services. Government programs such as Medicaid cover only about five percent of dental care expenditures, compared to 30 percent of the expenditures for physicians and 50 percent for hospitals. Medicare doesn’t cover dental care at all. “Essentially, dentistry is a private system,” says David Johnsen, 73MS, 73PedoS, dean of the UI College of Dentistry. “The underserved population is a real issue, but dental care doesn’t seem to get on the political radar screen.”

To respond to the need, the UI dental school operates a mobile clinic that provides care to residents of long-term care facilities, but demand for its services outpaces the college’s capacity to provide them. Elsewhere, dentists routinely volunteer at school dental health drives and public clinics, or simply absorb the costs for needy patients. “If someone comes into your clinic in pain but they can’t pay for treatment, you’re not going to turn them away,” says Eva Dahl.

Dentists’ other best customers are young adults who overdo sugary drinks and snacks. Jim Harris speaks ruefully of the “rampant decay” he sees in such patients, who may end up with 15 cavities all at once. “Often, they lack the financial means to have that much treatment, so they put it off, which just makes matters worse. And they’re setting themselves up for even more problems when they’re older,” he explains. The easy availability of soda and candy, especially in schools, concerns many dental health professionals. “The refined sugars and acids in soda cause a lot of decay, as does the increased popularity of eating several small meals a day,” says Dahl. “From a dental health point of view, not eating between meals is better.”

The patients who visit Dahl’s clinic are simply grateful that she can ease their pain and save their teeth. The fact that she’s a woman is immaterial, but it wasn’t always that way. As one of only two women students at the UI dental school in her class of 1976, Dahl was a pioneer in her profession. Then, just 0.1 percent of American dentists were female. Today, about 40 percent of dental students are women (in fact, half of this year’s freshman class at the UI are women), and the gender gap in practices is slowly closing. Dahl remembers male students openly saying that she shouldn’t be in the dental program because she was taking the place of a man. And, when the school moved into its new building on the west side of the river in 1972, she discovered that the student lounge lacked women’s bathrooms. “As well as not thinking about current students, the architect hadn’t even considered the possibility that women might be admitted to the school in the future,” she says.

Dahl, who graduated at the top of her class, remembers that it wasn’t easy being seen as “an oddity.” “Women students had to be better than—not simply as good as—male students. That was a lot of pressure,” she says. “But women I knew from dentistry have since gone on to leadership roles within the profession.”

Now, when she returns to campus as an adjunct faculty member in the dental school, Dahl is pleased to see more women professors, department heads, and administrators. Janet Guthmiller, 88DDS, is one of them. An associate professor of periodontics, Guthmiller enjoys the best of three worlds—teaching the next generations of dentists, serving patients in the college’s clinic, and carrying out research. As director of the UI’s dental student research program, she enjoys seeing students blossom. “It’s so rewarding when you see students excited about their research or their presentation at a conference,” she says.

Working as a professor, researcher, and practising dentist at the UI College of Denistry allows Janet Guthmiller (left) to feel that she's using her skills and education to make a difference in many people's lives.

Although some of her colleagues are deterred from entering academic dentistry because of lower salaries and less contact with patients, Guthmiller says that the benefits, retirement packages, and vacation do compensate. Then there’s the collegial atmosphere and the buzz of being surrounded by so many professors, researchers, and students. Because she specializes in periodontal disease, which requires regular, ongoing treatment, Guthmiller gets to know her patients better than if she saw them just once a year for a routine checkup. As part of her work, she performs surgery to regenerate bone and replace tissue that was lost due to the disease. “Of course I’m pleased when I’ve successfully accomplished something technically difficult,” she says, “but knowing that I’m helping someone and that they appreciate my work, that’s how I measure success.”

Another exciting aspect of her job takes place in the lab. A P.h.D. graduate of the National Institute of Health’s five-year Dental Scientist Program at the University of Texas, San Antonio, Guthmiller’s research includes studying defensins—small proteins produced by tissues in the mouth that have antibacterial properties and also trigger a person’s immune system. “Ultimately, we could possibly use these defensins in a toothpaste or mouthwash to help prevent gum disease,” she says.

Research is finding even more connections between oral health and overall well-being. Scientists now know that gum disease may be linked to heart disease and that it can be a factor in premature, low-birthweight babies. “People don’t realize all these potential health benefits from taking care of their teeth. It’s not just about having a nice smile, even though that’s known to contribute to a person’s social and psychological well-being,” says Guthmiller. As a clinician and a scientist, Guthmiller is able to see her research work translate into treatments that help her patients. “I might not see the benefits ofmy research in my lifetime,” she says, “but I know that I’m making a difference.”

So are her fellow alumni—in colleges, research labs, specialty clinics, and private practices around the country. Just down the hall from Guthmiller’s office in the dental building, a plaque on the wall proclaims both the college’s mission and the accomplishments of its alumni—“Education. Research. Service.”