[Published in the Washington Post, March 1, 2004]

I was born in Detroit, Michigan, and got my first cavity when I was six years old, on my fourth dentist visit – at least, that’s when it was first identified. Actually, I got my first four cavities then, all of them hidden away in the dark recesses of my tiny mouth. I don’t remember that visit to the dentist (did I sit in a child-sized dentist chair?) – in fact, the only thing I remember from that age is one afternoon when I fell off my bicycle and ran home with a raw, bloody knee. My father cleaned up the wound, then sat down next to me on the front steps, and let me drink Coke out of a can. I remember how red that can was, and I remember how as I drank the soda out of that can I no longer felt the searing pain in my knee, and I think this memory, more than anything else, has something to do with the problem with my teeth.

My poor dental record lends itself to statistical analysis much in the way that baseball does. Dentists refer to every patient’s teeth by number: 1 through 16 are my top teeth, from my right to left, and 17 to 32 are the bottom teeth, from left to right. By age six, I had cavities in 3, 14, 19, and 30 – an eerily symmetric pattern of hard-to-brush molars. I had been to the dentist four times, and had dental work once. My dental batting average, then, was .250. Assuming that I will live to 75, at age six, I’d lived 8% of my life and damaged 12% of my teeth. Already, it seemed unlikely that I would reach my deathbed with a healthy tooth in my mouth.

Dentally speaking, Detroit was a fortuitous place to have grown up in the late ‘70s, because of the fluoridated water supply. Thirty-five years earlier, Dr. H. Trendley Dean, head of the Dental Hygiene Unit at NIH, had begun thinking about adding fluoride to drinking water, in order to reap the benefit from its known decay-resistant properties. Scientists by then had determined, to their surprise, that the right concentration of fluorine strengthened children’s teeth. Hereford, Texas, which Collier’s Magazine had called “the town without a toothache” in 1942, boasted the lowest tooth decay rate of schoolchildren in any city in America on account of naturally occurring fluoride in the local water. In 1944 the Michigan Department of Health agreed to let Dr. Dean test the effects of fluoride on the citizens of Grand Rapids, Michigan. The study began in 1945, and involved monitoring 30,000 schoolchildren over 15 years. It was cut short early, in 1956, when results overwhelmingly showed that the children drinking fluoridated water suffered 60% less decay than those without it. Detroit followed suit, fluoridating its water in 1967.

Until 1931, however, almost nobody considered the potential medical value of fluoride, in part because fluorine is so dangerous. It is the single most reactive chemical element. It reacts with nearly all organic and inorganic materials, including gold and platinum, and it reacts explosively with hydrogen. Combined with water, fluorine forms hydrofluoric acid, which dissolves glass. Even the salts of fluorine (fluorides) are extremely dangerous when inhaled or ingested. Early scientists who tried to isolate fluorine – by pouring mild acid over minerals – were notoriously unsuccessful. The lucky chemists got away with severe burns, while the unlucky ones died. Not until 1886 was the element finally isolated safely by using electrolysis. Early applications of elemental fluorine took advantage of its caustic and explosive properties. It was used in the formation of a World War II incendiary agent, and also exploited to separate the uranium isotopes that were integral in the first atom bombs.

Today, about 60 percent of public water is fluoridated, reaching almost 200 million Americans. In many rural areas without a public water supply, including most of the West, schoolchildren take daily fluoride pills. On those rare dentist visits that didn’t involve oral surgery my dentist gave me a cupful of pink fluoride to rinse around in my mouth for two minutes. I remember swooshing until my cheeks began to hurt, the whole time hoping that the liquid would do good for my poor teeth.

As a kid I consumed sweets without restraint. I climbed up on the kitchen counters to sneak Entenmanns’s Cookies from the uppermost cabinet when my parents weren’t looking, and I could eat a whole box of them at one time. I drank a lot of soda, too. My Yiddish grandparents didn’t help. They had led difficult lives — they had lost their past to the holocaust, and were still dealing with it — and they must have imagined that their role as grandparents was to ensure that my childhood would be sweeter than theirs had been. Every time I visited them, my grandfather gave me packs of Luden’s coughdrops – candy cleverly masked as “medicine.” My grandmother, meanwhile, encouraged me to eat hard candy from a supply in a glass bowl that never seemed to dwindle. It was a year-round Halloween.
By the time I was 15, my family had moved to Chevy Chase, Maryland (whose water has been fluoridated since 1952), and I had been to the dentist 30 times. I had developed new cavities on numbers 2, 4, 15, 18, 29, and 31 – as usual, hard-to-brush rear molars. I had also chipped number 25, and had it smoothed and repaired. My dental batting average was up to 33%, and with 20% of my life behind me, 34% of my teeth had seen some sort of oral surgery. An enemy began to emerge: it was a bacterium called Streptococcus mutans.

The ancient Babylonians attributed toothaches to divine displeasure, while Europeans believed that toothaches and cavities were caused by a creature called the toothworm. One popular wives’ tale suggested burning noxious substances near the teeth to drive away the creature, while another advised carrying a mixture of crushed animal bones and wolf excrement in a pouch around one’s neck as protection. To stave off toothaches, some recommended washing the teeth with tortoise blood three times a year, and others advised rubbing a mixture of ashes from rabbit heads, ox heels, and goat’s feet on the gums. Hippocrates, ever the rationalist, suggested that sweet foods caused decay, but not much changed until a Frenchman named Pierre Fauchard, the founder of modern dentistry, rejected the popular toothworm theory in his 1728 book, “The Surgeon Dentist, or Treatise on the Teeth.” Unfortunately, Fauchard offered no better alternative theory; he also continued to urge patients to rinse their mouths each morning with fresh urine. Finally, in 1889, Willoughby Miller claimed in his book, “Micro-Organisms of the Human Mouth,” that bacteria caused decay. Researchers later found that Streptococcus mutans converted sugars into lactic acid, which at away at tooth enamel. This chemo-parasitic theory gained acceptance in 1954, when researchers in Notre Dame’s famous Germ-Free lab showed that rats’ teeth, sans bacteria, didn’t decay.

In the particulars of dentistry, however, change has come much more slowly. Toothpastes, for example, have traditionally relied upon gritty materials to mechanically scrub teeth clean. Ancient doctors (Egyptian, Greek, Roman, Indian, and Persian) made abrasive dentifrices by mixing together powdered ashes of ox hooves, myrrh, pumice, and water, later incorporating talc, emery, ground alabaster, coral powder, and iron rust. With time, toothpaste recipes called for crushed eggshells mixed with honey, while others incorporated burnt snail and oyster shells, powdered salt, pepper, mint leaves, and iris flowers. By the 17th century, dentifrices sold in Great Britain — powders or pastes available in ceramic pots — contained brick dust, china, and earthenware. In 1686, Charles Allen, who authored the first English dental treatise, “The Operator for the Teeth,” suggested this recipe for toothpaste: “Take Magistery of Pearls, Powder of Coral, and Dragons-Blood, of each equal quantity, and as much Red-Rose-Water as will incorporate them together; and make the Compound of a mean confluence, between hard and soft.” Often, the resulting toothpaste’s “mean confluence” was excessively abrasive – so much so that it wore away much more than plaque.

Over the next 200 years, chemists added borax, burnt bread, charcoal, chalk, cinnamon, sage, clove oil, eucalyptus, and chlorophyll (to give teeth a “fresh green color”), but still, most people rarely brushed their teeth, and when they did it was with their fingers, a stick, or a rag. The first modern toothbrush — with bristles made from the skin of pigs’ necks, bound together with thin wire, protruding from a handle made of cattle bone — wasn’t manufactured until 1780, by an Englishman named William Addis. By the time Du Pont introduced the first synthetic nylon toothbrush, called the Miracle Tuft Toothbrush, in 1938, dentistry still hadn’t changed much. Toothpastes were essentially refined, finer versions of ancient recipes, and amalgam fillings were based on a 19th century formula, though they no longer contained mercury, nor did they have to be poured into the mouth molten hot, and, since 1847, they could be placed with the aid of anesthesia. One dentist, Dr. Weston Price, rightly blamed the modern diet for excessive tooth decay, and recommended a teaspoon of cod liver oil, three times a day, as the best defense against dental caries.

World War II soldiers were the first to brush their teeth regularly — they were ordered to do so, as dental defects had been the most common reason keeping draftees out of the service — and when they returned home their good habits caught on. At about the same time, Dr. Dean’s study on the benefits of fluoride was getting lots of attention, and in 1952 Proctor and Gamble introduced Crest, the first toothpaste-cum-fluoride.

We still clean our teeth mechanically, the same way we sweep a floor or scrub dishes. Bacteria creep in, take hold, and we try to pick them off. But this may change; Florida-based Oragenics, Inc. has bio-engineered a strain of Streptococcus mutans that doesn’t produce lactic acid, and hence, should not cause decay. Dr. Jeffrey Hillman, the company’s founder, believes that introducing the new strain (via a mouth rinse) just once will all but end tooth decay. Of course, the new “replacement therapy” has yet to be approved by the FDA, and be clinically tested.

On January 5th, 1993, a contractor working on a utility trench not far from my dentist’s office, just West of Massachusetts Avenue, in a neighborhood called Spring Valley, dug up a live mortar round. The Washington, D.C. Department of Health got word of it, as did the EPA, and soon, so did the U.S. Army Corps of Engineers. Quick research revealed that during World War I, the U.S. Government had established the American University Experiment Station on 92 acres of leased land to investigate the effects of chemical warfare agents, including mustard gas and Lewisite (which contains arsenic). Most were explosive, or carcinogenic, or at least irritants. Fearing a mustard gas explosion and poisonous gas cloud drifting east into the heart of the city, the Army Corps called and warned Vice President Dan Quayle, who was less than three miles away. The Army Corps then launched Operation Safe Removal, which, over the next few years, called for the evacuation of 72 homes, and eventually extracted nearly 700 buried weapons, including poison gas shells with fuming sulfuric acid, from the neighborhood.

A year and a half later, on August 23rd, 1994, I drove myself, alone, to the dentist for the first time. I was 16, had just gotten my driver’s license, and hadn’t driven much in Washington, D.C., but I knew very well from memory how to get to Dr. Philips’ office. I drove past American University on Western Avenue, and then turned south on to Massachusetts Avenue. I remember that first solo dentist visit because many of the roads in the area were still barricaded, with official-looking vehicles parked everywhere. I remember thinking that if the government wouldn’t let me in to Dr. Philips’ office, it was fine with me. It was the perfect excuse.

That portentous visit, though, went perfectly. Operation Safe Removal may have been going on outside, but no such procedure took place in my mouth.

I saw Dr. Philips another 27 times over the next nine years, until I was 24. The next two visits went well, but after that, every one produced bad news: more cavities. Once confined to the occipetal (chewing) surfaces of the molars, the caries had invaded the full extent of my upper teeth, hiding away in the tight gaps between them, known as the mesial and dystal surfaces. I never wore braces, though should have, and because my teeth were crammed together, these surfaces made great hideouts for the bacteria. First they moved in on the left side (13 and 12), then the right side (5 and 6), and then, relentlessly, they conquered the middle teeth (7,8, 9,10,11). The assault came so fast, and with such tact, that it seemed like a planned war. Shock and awe and decay. I was 21.

The next year was worse. In June, while biting into a granola bar at 10,000′ in Colorado, I chipped number 31. It didn’t hurt, but the tooth was sharp and jagged, and I was worried about heading into the backcountry for a couple of weeks with such a glaring dental problem. I could deal with wounds, infections, even broken bones in the wilderness, but emergency, do-it-yourself, on-the-spot dentistry did not seem appealing. So I stashed my backpack, and hiked out, and found a dentist down the valley, in Gunnison, to fix me up. The next time I saw Dr. Philips, he put a gold crown on the tooth. The very next day, I had a root canal done on # 20.

By then I had only 5 untouched teeth left (22, 23, 24, 26, and 27). I had 70% of my life ahead of me, and only 16% of my teeth in good, natural order. My overall dental batting average was up to .665.

Two years later, while cycling on a cold morning in Vermont, I bit into a power bar and chipped #18. It didn’t hurt, so I kept riding, trying to ignore it and enjoy myself. I remember that no matter how hard I tried to restrain it, my tongue kept wandering over to inspect the contours of the jangly tooth, and kept reminding me, like an alarm, that things were not right inside of my mouth.

There are no healthy sets of teeth in my family. My grandmother’s mouth is mostly gold, and my parents estimate that they have cavities in half of their teeth. My mother remembers her first dentist as “a butcher.” According to my dentist, I have many times as many cavities as most people my age. I’ve inherited a family legacy in which Ambrose Bierce’s definition of a dentist as someone who pulls metal out of your pocket and puts it in your mouth is all too fitting.

For the last year and a half, I’ve been getting work done at BU’s Goldman School of Dental Medicine, where I’m patient number 14-83-65. I go regularly, without hope or despair, much as I would approach most household maintenance. You’ve got to do it if you want to keep your house in working order. That’s the sad part about all the dental work in my mouth: it will, until the end of my life, need to be maintained, just as the Golden Gate Bridge always needs painting. Natural, untouched teeth — of which I have five left — are still far superior than anything artificial.

I’ve never broken a bone, I don’t have any huge scars, and I lack any other standard war wounds. In a way, I’ve compensated for those injuries with my poor teeth. In that way, my teeth define me. They make me forensically easy to identify. My teeth tell many stories, about microscopic bacterial wars (in which I always lose) and great chemical wars (in which my family has always lost) and how those two have collided in personal and scientific and world history. My teeth make me human and real.

As a kid, I used to think that all of the dental work in my mouth was normal, just a part of life, and then I learned to write it off as genetic bad luck. Now I see that I’m a dental specimen, like George Washington, who had only one tooth left when he was elected, and soon lost it. (He had many sets of dentures, made from gold, hippopotamus tusk, elephant ivory and from the teeth of pigs, cows, elk, and humans.)

My teeth may be my weakness, the very bane of my existence, but learning to deal with them has been strangely formative. I have learned to suppress embarrassment about my dental flaws because I know these imperfect teeth are part of my history, and given my sad dental statistics, part of my future.