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55 Lakeside Drive, Larchmont, NY 10538, USA; n.triege{at}verizon.net
Martin Taubman, Editor
KEY WORDS: graduate education • hospital dentistry
Progress in dentistry is dependent not only on scientific discovery but also on the systems which determine where and how we care for patients, conduct research, and educate future dentists. Most of my professional life has been spent in a Department of Dentistry in a large teaching hospital (Montefiore Medical Center-MMC), affiliated with a medical school (Albert Einstein College of Medicine-AECOM).
The relationship between these two major health care institutions in the Bronx was often competitive and disputatious. The two Departments of Dentistry had a close working relationship, but were deeply affected by the wider battle and by history. Dentistry at Montefiore—considered academically and clinically comparable with all other departments, fully involved in multiple aspects of patient care, teaching, and research—grew and flourished for 65 years before the Medical School opened. Dentistry at AECOM began in 1955, but was not recognized as an academic department until 1983, when the two Departments were officially unified, and the Montefiore Chairman of Dentistry was appointed Chair of the Unified Department.
In the first decade of the 21st century, the Unified Department, stretching across the two campuses and other teaching sites in the Bronx, was the largest graduate training program for dentists in any teaching hospital-medical school complex in the United States that did not include an undergraduate dental school. The Department was notable for the extension of oral health care to the medically compromised and those with physical or mental disabilities, with a greater emphasis on the biological aspects of dentistry than on the mechanical. Residents, fully accepted as members of the medical staff, experienced the broad range of hospital activities in Emergency Rooms, Outpatient Clinics, Operating Rooms, and Intensive Care Units in both public and voluntary hospitals.
A teaching hospital provides an ideal setting for the highest levels of patient care and research into the fundamental problems of oral health and disease. The dentistry practiced in hospitals often differs from that which takes place in private offices. Hospital cases are usually more complex. The patients suffer from debilitating conditions. They may be sick, weak, elderly, wheelchair-bound, or unable to leave their beds. They may be psychologically or mentally compromised. Often they are trauma victims arriving from street accidents or violent encounters. Some have facial deformities, such as cleft palate syndrome, or skeletal deformities requiring complicated surgery. Hospital dentists work in enhanced settings with other medical specialists, oral surgeons, plastic surgeons, and oncologists. Referrals come from dentists in private practice and from other physicians, surgeons, cardiologists, geriatrists, and pediatricians.
Both AECOM and Montefiore began their dental activities as a service to indigent patients who could not afford to pay for care. From the beginning, both were interested in graduate training for dentists: Montefiore at a time when no national standards existed for dental education at any level; AECOM at a time when undergraduate and graduate standards were clearly defined by the Commission on Accreditation of the American Dental Association. Both had a strong and continuing interest in patients with special needs: Montefiore from a long tradition of working with the chronically ill and those with disabilities; AECOM from involvement with the Rose Fitzgerald Kennedy Center for Research in Mental Retardation and Human Development.
Dentistry began at Montefiore as a service to inpatients. The institution opened in 1884 as a Home for Chronic Invalids, a charity offering free care in a rented house. A few years later, a new modern building in upper Manhattan housed 230 patients, and in 1890 a part-time dentist was hired to care for their teeth. The Board of Trustees provided the latest in technology, sending off to Berlin for an x-ray machine in 1896, the year after Röentgen announced his discovery. A few years later, the Board provided radium for treatment and research. The number of dentists on staff increased, as a Sanitarium opened in Westchester County in 1898 to care for 230 early cases of tuberculosis, and the main hospital moved to a 630-bed building in the Bronx in 1913. The dentists filled and extracted teeth, fitted dentures, and performed root canal procedures. They published both individual case studies and research results.
David Tanchester, Chief of Dentistry at Montefiore from 1925 to 1970, built a successful private practice in General Dentistry and Prosthodontics in Manhattan and was appointed a Clinical Professor of Oral Surgery at New York University’s College of Dentistry. He traveled twice a week to the Bronx to supervise dentistry at Montefiore, where he worked to bring the discipline to a higher level, integrating dentistry with general health and medicine. The young dentists serving at Montefiore came in search of useful experience. Tanchester formalized the quest as an official residency program. Each year, three or four graduates of grade A United States dental schools were accepted for training in caring for chronically ill patients. In most years, one of the Residents was a graduate of Howard University (Washington, DC), at a time when most African-Americans were barred from such opportunities. Tanchester urged the passage of the American Dental Association’s recognition of Hospital Dentistry as an important phase of dental education.
As Chief, he assembled a prestigious and remarkably well-qualified cadre of voluntary dentists interested in teaching and research. They found the numerous patients with conditions such as tuberculosis or diabetes appropriate for large-scale research surveys of the relationship of particular conditions to oral health, such as an early study of the relationship of sugar to tooth decay. Probably the most productive of these researchers was Irving Sheppard, who graduated from Tufts University Dental School, came to Montefiore as a Resident, and became Montefiore’s first Research Fellow in Dentistry. As a member of the voluntary attending staff, he ran a Temporomandibular Joint Center for 35 years. Among other studies, he surveyed 3200 denture-wearers to assess their problems, and published more than 100 research-based articles.
Ephraim Michel Bluestone, MD, left private practice for a career as a hospital administrator, first at Hadassah Hospital in Jerusalem, then at Montefiore, where he served as Director from 1928 to 1950. He was especially interested in dentistry, spending generously to equip the dental offices and laboratories, and writing about the importance of dentistry in a hospital.
Charity-based care of the chronically ill remained the chief concern at Montefiore until after the Second World War, when Bluestone introduced programs innovative for their time, such as Home Care, the Montefiore Medical Group (one of the earliest pre-paid non-profit HMOs), and the first Department of Social Medicine in any hospital in the United States. To direct these programs he chose Martin Cherkasky, who had completed a Montefiore residency in 1938 and returned after war service for another residency. When he became Director in 1951, the younger man, charismatic, driven, imaginative, and with a social philosophy formed by the suffering he saw during the Great Depression, hastened the pace of transformation to a modern high-tech tertiary-care medical center with a broad interpretation of a social mission.
Tanchester’s dental service was caught up in some of the changes. When Montefiore cooperated with the Teamsters’ Union to improve medical services for the membership, the Union financed the building and equipping of an expanded, up-to-date dental unit. In 1960, Montefiore signed an official contract with Morrisania, a municipal hospital, to improve care, including limited dental care. Most of New York City’s municipal hospitals provided emergency room dentistry. [New York City has long had a multi-hospital system, with more than 20 at its maximum. In 2006, the Health and Hospitals Corporation of New York City was responsible for 11 acute-care hospitals, six diagnostic and treatment centers, four long-term-care facilities, a certified home health care agency, and more than 80 community health clinics, including Communicare Centers and Child Health Clinics.] Bernard Cohen, head of Oral Surgery at the municipal hospital (Morrisania) when Montefiore took on the responsibility for Resident education, won approval for a Residency in Oral Surgery, and in 1967 was appointed Director of the Oral Surgery Residency Training Program.
In 1955, AECOM, the only medical school under Jewish auspices in the Diaspora (community of Jews living outside of Israel), opened in the east Bronx on a campus that included, as the principal teaching sites for the College, two municipal hospitals, Jacobi and Van Etten, ultimately known together as the Bronx Municipal Hospital Center (BMHC). The Medical School was under the auspices of Yeshiva University, which had also received a charter for a dental school that was never built. In its early years, AECOM did not establish an academic Department of Dentistry, but the dentists at BMHC were appointed to the Medical School Faculty.
AECOM, established by men excluded by prejudice from leadership positions in major medical schools and hospitals, attracted professionals eager to donate their talents. Among them was William Rakower, an oral surgeon practicing in Manhattan, who began coming to BMHC one morning a week in 1955, finding fulfillment of two of his passions: adding to the intellectual capital of the School, and improving the dental care of the poor who came to municipal hospitals. While enjoying teaching and supervising Residents, he published widely, chiefly on technical problems of Oral Surgery. Harold Diner, a colleague of Rakower’s when both were in private practice, added another dimension to dentistry at AECOM, when he arrived to take charge of Pediatric Dentistry. He was especially interested in the patients with developmental disabilities at the Kennedy Center. [The Center was established with the help of the Kennedy family. Harry Gordon, the Chairman of Pediatrics at AECOM, had cared for President John F. Kennedy’s infant children.]
When I followed Tanchester in 1970 as the first full-time Chairman of Dentistry at Montefiore, the terms of my contract allowed me to fulfill a long-held ambition: to complete the requirements for a degree of Doctor of Medicine. (The first two years were covered by my early courses at the Harvard School of Dental Medicine.) Enrolled at AECOM, I spent two years of 18-hour days, racing from classrooms on one side of the Bronx to dental chairs and ward rounds on the other. I was tired all the time, finding that it was possible to be a half-time Chairman but not a half-time medical student. I postponed the necessary internship until I was eligible for a sabbatical leave in 1979.
Montefiore was in a period of expansion, with an administration interested in developing and implementing new ideas, including my long-term agenda. I wanted to retain and expand the possibilities of the General Dentistry Residency, but with the great increase in the knowledge base and the technology of Dentistry, I was anxious to establish specialized residencies. In that same year, 1970, a new public authority, the Health and Hospitals Corporation (HHC), took over the management of the 18 municipal hospitals in New York City, with 16,000 beds and a strong emphasis on outpatient services. Dentistry at Morrisania moved to an innovative purpose-built Neighborhood Family Care Center (NFCC) and expanded to include General Dentistry, Pediatric Dentistry, Oral Surgery, and Prosthodontics. The number of Residents immediately expanded.
In 1976, HHC replaced Morrisania Hospital with a 17-story, 400-bed tower, North Central Bronx Hospital, built next to Montefiore. Corridors and bridges connected the two hospitals. The NFCC dental programs were moved to the new setting, with eight Residents. Jack Kabcenell, Director of Prosthetic Dentistry, who trained at New York University School of Dentistry, where he later became a Professor, implemented an innovative program for practicing dentists, enabling them to advance their education and training in Prosthodontics by providing four years of half-time study, so that they could continue to practice and earn a living in their private offices.
During the late 1970s, the numbers of both Residents and training sites increased. The sites varied widely in the types of patients the Residents encountered: two hospitals (Montefiore and NCBH) where Residents worked on inpatient and outpatient services, including 24/7 emergency rooms; Beth Abraham, a facility for the care of the severely chronically ill; and Spofford Juvenile Detention Center, where many of the detainees had never met a dentist. For many of the Residents, unfamiliar with the effects of gunshot wounds or violent traffic accidents, the most memorable part of their training occurred with the urgent demands of the emergency room of a public hospital in the Bronx. Faculty and Residents constantly conducted funded research and published widely. I also continued to write about my own particular interests: the basic causes of periodontitis, orthognathic correction, and the role of anesthesia in dentistry.
In 1981, the Centers for Disease Control (CDC) alerted professionals and the public to AIDS, the deadly infectious disease that revolutionized much of medical practice. Dentists had pioneered the sterilization of instruments, but had practiced barehanded and unmasked, even when tuberculosis was endemic throughout the United States. In the late Twentieth Century, intravenous drug use was endemic in the Bronx, and hepatitis was even more common than AIDS. The duties of a Chairman included re-assuring dental Residents, Faculty, and other personnel by implementing universal precautions and reminding them of their professional duty to provide treatment.
Close collaboration grew among the dentists at Montefiore and AECOM. In the late 1970s, a process began of unifying the clinical departments across both campuses one by one, culminating in the creation of a Unified Department of Dentistry. (A necessary preliminary was the formation of an academic Department of Dentistry at AECOM during the preceding year.) Appointed Chairman of this large enterprise, with 30 Residents in four programs and a faculty of 150, I found myself struggling with budgets, schedules, and a heavy load of continuing education programs much in demand in an era of innovative treatments such as implants. The number of patients treated each year increased from 39,479 in the mid-1980s to more than 70,000 in the mid-1990s. The salaries of full-time faculty were augmented by their private practice, on the premises, as a professional group, fully encouraged by the administration.
Donald Sadowsky, who followed Rakower as Director of Dentistry at BMHC, had long experience in private practice and held a Master’s Degree from Columbia University’s School of Public Health and Administrative Medicine, and another Master’s and a Doctoral Degree from Columbia’s Graduate Faculty Division of Sociomedical Sciences. He researched and wrote about such public health issues as dentists’ compliance with official guidelines for the treatment of patients at risk of bacterial endocarditis, and their willingness to treat HIV-positive patients. Victor Badner completed a General Practice Residency at Montefiore before going on to two years of further training in Dental Public Health. Subsequently, after becoming Director of the Dentistry Departments at BMHC and NCBH, he researched and wrote about such issues as the education of dentists, the waiting room experiences of patients, the use of AIDS infection control measures in dental offices, perceptions of dental health, and the rate of use of topical fluoride applications. Accommodation was made to establish a two-year Orthodontic Residency for four graduate trainees, with George Cisneros as Director in 1986.
By the year 2001, the Unified Department had provided graduate education for over 1100 dentists. In that year, the Department received 85,000 patient visits, and conducted six approved specialty residency programs with a house staff complement of 81 and a faculty of 120 salaried and voluntary dentists. I left the Chairmanship the next year satisfied that hospital-based dentistry was providing the best in patient care, the education of Residents, and the opportunity to explore the most urgent questions of our discipline.
ACKNOWLEDGMENTS
This article is based on the book, A History of the Unified Department of Dentistry of Montefiore Medical Center and the Albert Einstein College of Medicine, co-authored by Dr. Trieger and Dorothy Levenson. The book, which includes numerous illustrations and a listing of staff and alumni, can be obtained from the publisher, The Albert Einstein College of Medicine of Yeshiva University, Office of Institutional Advancement, 165 Morris Avenue, Room 307, Bronx, NY 10461, USA, Att: Fern Schwartz, Senior Major Gifts Officer. Proceeds go to the "Oral Research Diseases Fund".
Received March 28, 2007; Last revision May 16, 2007; Accepted May 17, 2007
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