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Report of Forsyth Dental Infirmary for Children*
Department o f Dental Health Education
1527
REPORT OF FORSYTH DENTAL INFIRMARY FOR CHILDREN* By HAROLD DeW . CROSS, D.M.D., F.A.C.D., Boston, Massachusetts H E F orsyth D e n ta l In firm a ry f o r C h ild re n w as fo u n d ed by Jo h n H a m ilto n and T h o m a s A lex an d er Forsyth in m em ory o f th e ir brothers Jam es B e n n ett and G eorge H e n ry F o r syth, and was incorporated in 1910 by a special act o f the M assachusetts L e g islature, f o r the purpose o f establishing an d m a in ta in in g an in firm ary f o r the reception and o ral tre a tm e n t, d ental, m edical an d surgical, o f ch ild ren u n d er the age o f 16 years, and o f such other persons as the corporation m ig h t fro m tim e to tim e determ ine. I t w as dedi cated in N ovem ber, 1914, and the clinics w ere opened soon a f te r, and w ere in f u ll operation in Ja n u a ry , 1915, so th a t it has now been in oper ation m ore than eleven years. I n fo rm u la tin g a w o rk in g policy fo r its developm ent, the T ru ste e s decided at the outset th a t, to accom plish the g rea t est good, the new institution m ust aim a t som ething higher than the m ere re pair, tre a tm e n t and extraction o f carious teeth , the correction o f oral d e fo rm i ties or the rem oval o f diseased tonsils an d adenoids. I t was recognized th a t the prevention o f disease w as as im por ta n t as, if n o t m ore im p o rtan t than, its trea tm e n t, and it was f u rth e r th o u g h t th a t the clinical w ork o f the institution should be developed on a plane o f tech nical p erfec tio n sufficiently high th a t it
T
*Read before the Section on Mouth Hy giene, Preventive Dentistry and Public Health at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 26, 1926.
should stand in the same relatio n to the d en tal profession th a t the hospital bears to the m edical profession. W ith o u t g oing in to these subjects at tedious le n g th , it w as believed th a t, con ducted on th e plan in d icated , th e insti tu tio n w o u ld be o f inestim able hygienic value to the risin g g eneration o f the ch ild ren o f Boston, an d its vicinity; th a t it w o u ld in stru ct th em , n o t only in dental hygiene but in g en eral hygiene as w e ll; th a t it w o u ld im prove their n u tritio n , an d consequently th e ir physi cal and m en tal g ro w th ; th a t it w ould lessen th e ir liability to co n tra ct conta gious an d o th er diseases, an d w ould place them in a better position to resist disease i f contracted. I n order to obtain a suitable u n d er sta n d in g o f the type o f w o rk carried out in the F o rsy th clinics, it is necessary to know th a t prevention is the fac to r first considered, ra th e r th an the cu re or repair o f established conditions. I t was the o riginal in ten tio n o f the trustees to carry out, as f u lly as possible, a ll clini cal factors o f a preventive n a tu re deal in g w ith tooth diseases, an d this has been done to as g rea t an ex ten t as the present status o f k n ow ledge has per m itted. O ld e r practices have been given up and n ew ones adopted as rapidly as some procedure has been fo u n d to have a la rg e r proportion o f features o f prevention. P re v en tio n is here used in the sense o f real avoidance o f a condition or occurrence, as it is in m edicine, and n o t w ith the usual dental m ean in g o f m erely an im p ro v em en t in
1528
The Journal o f the American Dental Association
a n alread y established technic or proce dure. C onsequently, the present practice does not include the dev italizatio n o f pulps, the tre a tm e n t o f root canals, or th e insertion o f extensive fillings in the attem p ted restoration o f badly broken dow n and neglected teeth, but rath e r involves the early tre a tm e n t o f develop m e n ta l defects and incipient cavities, eith er by dental procedure or by n u tri tio n al im provem ent in a m edical or system ic sense. T h e usual and m ore com plicated d en tal technic is discarded fo r a sim ple type w hich is all th a t is needed in ca r in g f o r the early and sim ple tooth de fects. T h e lack o f com plicated technic an d the care o f extensively and badly broken dow n teeth has fre q u en tly been rem ark ed on to the exclusion o f the continued m aintenance o f good tooth conditions and the avoidance o f defects. I n order to accom plish results th a t are a t all preventive in ch aracter, it is n o t only necessary to carry out certain sim ple technical procedures, b u t the case m ust be in a suitable condition to m ake these procedures possible, as w ell. T h is involves chiefly the opportunity to tre a t the cases b efore conditions have developed beyond a very early stage, an d consequently the age o f the child is o f as m uch im portance as are the clin i cal procedures. In other w ords, it is necessary to have both the technic and the tim e o f applying it correlated, in o rd er to obtain the definite advantages th a t are possible. A s the first p erm anent m olar is re sponsible f o r a g rea ter am o u n t o f trouble than any other one tooth, it be com es necessary to consider the age o f its eruption as m a rk in g the latest tim e w h en tre a tm e n t m ay be considered prophylactic in character, alth o u g h , fo r the succeeding p erm a n en t teeth, the
eruption tim e may be sim ilarly con sidered. W h ile the age o f 6 years m a thus be indicated as the m axim um age, there is no definite lim ita tio n to the earliest, an d there m ay be some ques tion as to w h eth e r w e should consider it to be the age o f eruption o f the p rim ary teeth— early in fan c y — b irth , or the p ren atal period, or should go back to the g randparents. T h e greatest difficulty has been, and is still fo u n d , in g ettin g parents, nurses, physicians and dentists to appreciate the im portance o f early atten tio n , so that, in any com m unity, the age question is still m ore o f a problem th an th a t o f clinical procedures w hich have been w ell stan d ard ized an d p u t to a success fu l test. H o w ev er, this p lan o f early (6 years o f ag e) tre a tm e n t has been carried out to the ex ten t o f approxi m ately 75 per cent f o r the last fo u r or five years, but a definite advance has been m ade d u rin g the last year, w hen practically every new p atien t has n ot been m ore th a n 6 years o f age. T h is has m ade it possible p ractically to elim i nate all root canal w o rk , as teeth th a t are c a re fu lly filled w h en the cavities are o f a sim ple ch a racter do n o t come to the condition o f req u irin g large fillings, pulp an d root canal w ork, u n til late in life , i f a t all. W ith this p relim in ary explanation as to the g en eral policy o f the clinic, it w ill n o t be necessary to explain in de tail f o r each clinic the reasons f o r cer tain procedures or technic, as these w ill be the same in each instance. N o t only is substitution m ade f o r com plicated trea tm e n t, w hich results in b rin g in g prevention n earer, but also m edical and den tal procedures are adopted, such as n u tritio n , an d endocrine or m axillary orthopedic trea tm e n t, ra th e r th an the elaborate an d repeated fillings and
Department o f D ental Health Education tre a tm e n t in cases o f excessive caries or n a rro w and undeveloped arches. T h e clinics are carried on u n d er the fo llo w in g departm ents an d clinics: 1. D e n ta l: F illin g , clean in g an d ex tra c tin g ; m ax illary orthopedics. 2. M edical : P ed iatric, n u tritio n , food an d habits, and endocrine. 3. S urgical: T o n sil an d adenoid, and o ral surgery. 4. R esearch: (a) L abo rato ry — bacteriologic; chem ical; fe e d in g ; (b ) clinical— observing, reco rd in g and co r rela tin g clinical data. 5. S tatistical: F o r reco rd in g an d filing records o f a ll clinical w o rk o f a ll d epartm ents and clinics. 6. P re n a ta l: T re a tm e n t in d en tal, endocrine an d fo o d an d habit clinics. 7. R oentgen R ay an d P h o tography: F o r a ll departm ents; principally f o r m edical an d m ax illary orthopedic clinics. 8. Social Service and R e g istra tio n : F o r reg istration an d ad m ittance to all d ep artm ents; the principal fe a tu re be ing to d eterm ine the financial eligibility. T h e clinical dental w o rk is done by f u ll tim e in tern s w ho are cu rren t-y ea r graduates o f the various dental schools, an d are supervised by a fu ll-tim e p er m a n en t ch ief and tw o assistants. T h e m edical and surgical clinical w o rk is done by m edical m en on service, three m onths a t a tim e. T h e d ental cleaning (odontexesis) is done by the students o f the tra in in g school, u n d er direction o f a grad u ate supervisor. A ll patients, except in em ergency cases, first have the necessary cleaning, fillin g and ex tractin g done, and are th en given rou tin e exam inations f o r the m edical and surgical w o rk w hich is show n to be necessary, such as the r e
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m oval o f diseased tonsils o r trea tm e n t in the n u tritio n , fo o d an d habit, en docrine or m ax illary orthopedic clinics. A ll o f the clinics are definitely cor related and conducted as one w ith several branches, an d are coordinated to the ex ten t th at, as ro u tin e, each child w ho enters fo r w h atev er p articu la r type o f tre a tm e n t (except fo r em ergencies) is required to go th ro u g h a ll o f the clin i cal exam inations. In this w ay, all nec essary data p erta in in g to an individual child are obtained an d co rrelated , inde pendently o f either the p atien t or the physician in some clinic w hose casual notice m ay detect necessary w o rk to be done in an o th er one. P atients show ing such evidence o f m a ln u tritio n as approxim al or cervical caries, u n d erw eig h t, endocrine dystro phies, or g en erally poor physical con dition, are re fe rre d f o r a physical exam ination an d th en recom m ended to the suitable m edical or surgical clinic f o r trea tm e n t. A ll m edical trea tm e n t, in clu d in g food an d hab it reg u latio n , is preceded, in every instance, by a com plete physical exam ination so th a t the exact condition o f each child is k n o w n , in o rd er n o t to carry out any tre a tm e n t w hich m ig h t be contraindicated. T h e prim ary teeth o f a larg e n um ber o f ch ild ren fro m 2 to 3 years 4 o f age are treated f o r pits and fissures. I t is the aim to fill all cavities w ith in six weeks a f te r eru p tio n , w h eth e r in p ri m ary or secondary teeth. I t is' n o t yet possible to do this f o r the p rim a ry teeth to the same ex ten t as fo r the secondary, because o f the difficulty o f g e ttin g in touch w ith ch ild ren o f this age. T h ro u g h in f a n t hygiene an d preschool age ch ild re n ’s associations, a definite gain is being m ade each year an d large
1530
The Journal o f the American Dental Association
num bers o f this age are n o w treated. M ore tim e probably w ill be required to place the tre a tm e n t o f prim ary teeth on a par, in num bers, w ith th a t o f the first p erm a n en t m olars, than w as required f o r secondary teeth, but it w ill u n doubtedly be accom plished w ith in a fe w years. T h e results obtained by the early fillin g o f fissures an d pits w ith in a short tim e a f te r eruption o f the teeth has prom pted the adoption o f a plan to see children only at stated interv als f o r routine fillings. T h ese intervals are n o t determ ined by the calen d ar, age or school grade, b u t according to the eru p tion o f each corresponding pair o f teeth, and are sufficiently fre q u e n t to fo restall any possible rapid extension o f a devel opm ental d efect. T o m ake the w ork successful, it is necessary th a t this period be very short, and the nurses are in structed th a t w ith in “ six w eeks” is the only safe tim e. In this w ay, detailed school exam inations become unneces sary, as all th a t is required is fo r the nurse to keep w atch fo r new teeth, o f w hich the child is usually aw are, and see th a t a ll n ew teeth receive prophy lactic care and fissure and pit fillings, if required. In g en eral, the routine ages at w hich w e m ay expect to find eru p tin g pairs o f teeth are 2, 6, 9 and 12 years respec tively, v ary in g in each instance ac cording to the physiologic age and developm ent o f the child. T h u s , only three re g u la r periods o f visits fo r fill ings are needed d u rin g the school life o f the child. E ach child receives an odontexesis (to o th clea n in g ) once each year, at w hich tim e special appointm ents are m ade i f any fillings require replace m ent, or any new (approxim al or cer v ical) cavities are noted. T h e num ber
o f such cavities is quite sm all, except in cases o f m alnourished ch ild ren suffer ing fro m a serious lack o f lim e salts, or w ith endocrine com plications. I n these instances, the child n o t only has the fillin g s done, but is given appropriate m edical atten tio n fro m a n u tritio n al standpoint, such as endocrine, food and habits, etc. I n a recen t checkup, it w as fo u n d th a t 82 per cent o f the ch ild ren in the eighth an d n in th grades w ho h ad n o t been given adequate early care, but w ho had received tre a tm e n t either as first, second or th ird grade pupils, had fo u r first p erm a n en t m olars in good condi tio n ; 11 per cen t h ad three first p erm a n e n t m olars, an d these an d the balance w ere those in w hom these teeth w ere rath e r early in eru p tin g , or w h o did n o t receive tre a tm e n t u n til the end o f the th ird school year. W h ile m ost o f the cases n o t treated u n til the th ird g rad e show ed large occlusal fillings in the first m olars, these teeth w ere still being preserved, alth o u g h undoubtedly m any w ill re quire atten tio n , possibly involving tre a t m en t o f the pulp and root canals, in the n ear fu tu re . T h o se treated early in the first g rad e show only sm all fissure fillings and w ill n o t require atten tio n fo r m any years. E v en then, they w ill only reach the stage o f req u irin g sm all occlusal fillings. A n o th er phase o f the benefits o f early tre a tm e n t was as fo llo w s: In 1915, one first p erm an en t m o lar was extracted to every three teeth. T h is was g rad u ally reduced, in 1918, by early atten tio n , to one first p erm an en t m o lar to every five teeth , an d , in 1924, only one first p erm an en t m o la r in each 2 00 teeth extracted, in the groups w hich received reasonably early care a f te r the tim e o f eruption o f the first p erm an en t
Department o f Dental Health Education m olars. F ro m 1915 to 1918, a t least 50 per cent o f the first p erm a n en t m olars w ere given ro o t canal tre a t m e n t; w hile, since th en , this fo rm o f tre a tm e n t has been p ractically discarded. T h is m eans th a t the only first p erm a n e n t m olars w hich require extraction now are those in the m ouths o f children w ho, fo r one reason or ano th er, did n o t receive sufficiently early care f o r de velopm ental defects. T h e fo re g o in g F orsyth plan, w hile extrem ely sim ple an d n ontechnical in ch aracter, is g iving “ en d -resu lts” a t 16 years o f age, in h ealthy teeth w hich have had the m in im u m o f dentistry, as early repair w o rk ; and fo u r first per m a n en t m olars w ith vital pulps and sm all fillings are the satisfactory re sults. T h is is a resu lt w hich technical (o rth o d o x ) dentistry has never pro duced and nev er can, because it does not aim to prevent, but to cure an d repair. W h ile the orig in al in ten tio n w as to care f o r ch ild ren up to the sixteenth year, and this w as necessary w hen “ orthodox” dentistry w as practiced, it has been fo u n d th a t there is now no d ental reason f o r co n tin u in g this care fo r children beyond the tw e lfth year, o r the tim e th a t the second perm an en t m olars are in place an d the fissures and pits filled. T h e only exception is fo r children w ith m arked m a ln u tritio n ; but w ith the F orsyth plan, these cases usu ally have been b ro u g h t up to the stand ard o f n u tritio n b efore the tw e lfth year, so th a t, in the n ex t fe w years, there should n o t be m uch occasion fo r rep air or replacem ent o f fillings. T h e w o rk done u n d er the nam e o f m ax illary orthopedics is an o th er phase o f early tre a tm e n t w hich is g iving very satisfactory results in p rev en tin g the need o f orthodontic trea tm e n t. T h is w ork consists in expanding the m ax il
1531
lary bones at the usual age (5 -6 years) w hen this g ro w th usually takes place, in cases w hich, th ro u g h lack o f suitable g ro w th stim u li, f a il to develop. T h e tooth positions are n o t changed, as the teeth m erely provide attach m en ts fo r the appliance th a t expands the qrch o f the m ax illary bones; w hich assures am ple room fo r the eruption an d alin em e n t o f the six p erm a n en t teeth. A p ren a tal clinic is carried on to aid in preserving the m o th e r’s teeth an d in developing good d en tal organs fo r the child by oversight an d tre a tm e n t in the m edical, d en tal, endocrine an d fo o d and habits clinics. T h is w o rk is being carried o u t fo r prospective m others, in cooperation w ith several o f the p ren atal organizatio n s o f the city, an d .is as n ea r early tre a tm e n t an d prev en tio n as w e m ay expect to get, alth o u g h , as our know ledge increases, it should be pos sible to apply it w ith m o re certain results. O n e im p o rta n t phase o f this clinic is the m ain ten an ce, in the m o th er, o f a state o f n o n to x icity ; the reg u latio n o f her food an d other habits f o r adequate m ineral an d vitam in m etabolism , an d assurance to the endocrine organs o f any support needed to enable h e r to give to the ch ild ’s teeth every possible ad vantage o f developm ent. I t is, o f course, too soon to be able to determ in e th e results o f the p ren atal dental care phase, or to atte m p t to d raw conclusions fro m either the effect o f the endocrine or fo o d an d habits tre a t m en t a n d supervision. I t is reasonable to expect conserva tion o f the m o th e r’s teeth an d an im provem en t in the d en tal organs o f the child fro m these various activities if , as is alm ost assured, they resu lt in im proved n u tritio n , fro m the standpoint o f m in e ral m etabolism .
1527
REPORT OF FORSYTH DENTAL INFIRMARY FOR CHILDREN* By HAROLD DeW . CROSS, D.M.D., F.A.C.D., Boston, Massachusetts H E F orsyth D e n ta l In firm a ry f o r C h ild re n w as fo u n d ed by Jo h n H a m ilto n and T h o m a s A lex an d er Forsyth in m em ory o f th e ir brothers Jam es B e n n ett and G eorge H e n ry F o r syth, and was incorporated in 1910 by a special act o f the M assachusetts L e g islature, f o r the purpose o f establishing an d m a in ta in in g an in firm ary f o r the reception and o ral tre a tm e n t, d ental, m edical an d surgical, o f ch ild ren u n d er the age o f 16 years, and o f such other persons as the corporation m ig h t fro m tim e to tim e determ ine. I t w as dedi cated in N ovem ber, 1914, and the clinics w ere opened soon a f te r, and w ere in f u ll operation in Ja n u a ry , 1915, so th a t it has now been in oper ation m ore than eleven years. I n fo rm u la tin g a w o rk in g policy fo r its developm ent, the T ru ste e s decided at the outset th a t, to accom plish the g rea t est good, the new institution m ust aim a t som ething higher than the m ere re pair, tre a tm e n t and extraction o f carious teeth , the correction o f oral d e fo rm i ties or the rem oval o f diseased tonsils an d adenoids. I t was recognized th a t the prevention o f disease w as as im por ta n t as, if n o t m ore im p o rtan t than, its trea tm e n t, and it was f u rth e r th o u g h t th a t the clinical w ork o f the institution should be developed on a plane o f tech nical p erfec tio n sufficiently high th a t it
T
*Read before the Section on Mouth Hy giene, Preventive Dentistry and Public Health at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 26, 1926.
should stand in the same relatio n to the d en tal profession th a t the hospital bears to the m edical profession. W ith o u t g oing in to these subjects at tedious le n g th , it w as believed th a t, con ducted on th e plan in d icated , th e insti tu tio n w o u ld be o f inestim able hygienic value to the risin g g eneration o f the ch ild ren o f Boston, an d its vicinity; th a t it w o u ld in stru ct th em , n o t only in dental hygiene but in g en eral hygiene as w e ll; th a t it w o u ld im prove their n u tritio n , an d consequently th e ir physi cal and m en tal g ro w th ; th a t it w ould lessen th e ir liability to co n tra ct conta gious an d o th er diseases, an d w ould place them in a better position to resist disease i f contracted. I n order to obtain a suitable u n d er sta n d in g o f the type o f w o rk carried out in the F o rsy th clinics, it is necessary to know th a t prevention is the fac to r first considered, ra th e r th an the cu re or repair o f established conditions. I t was the o riginal in ten tio n o f the trustees to carry out, as f u lly as possible, a ll clini cal factors o f a preventive n a tu re deal in g w ith tooth diseases, an d this has been done to as g rea t an ex ten t as the present status o f k n ow ledge has per m itted. O ld e r practices have been given up and n ew ones adopted as rapidly as some procedure has been fo u n d to have a la rg e r proportion o f features o f prevention. P re v en tio n is here used in the sense o f real avoidance o f a condition or occurrence, as it is in m edicine, and n o t w ith the usual dental m ean in g o f m erely an im p ro v em en t in
1528
The Journal o f the American Dental Association
a n alread y established technic or proce dure. C onsequently, the present practice does not include the dev italizatio n o f pulps, the tre a tm e n t o f root canals, or th e insertion o f extensive fillings in the attem p ted restoration o f badly broken dow n and neglected teeth, but rath e r involves the early tre a tm e n t o f develop m e n ta l defects and incipient cavities, eith er by dental procedure or by n u tri tio n al im provem ent in a m edical or system ic sense. T h e usual and m ore com plicated d en tal technic is discarded fo r a sim ple type w hich is all th a t is needed in ca r in g f o r the early and sim ple tooth de fects. T h e lack o f com plicated technic an d the care o f extensively and badly broken dow n teeth has fre q u en tly been rem ark ed on to the exclusion o f the continued m aintenance o f good tooth conditions and the avoidance o f defects. I n order to accom plish results th a t are a t all preventive in ch aracter, it is n o t only necessary to carry out certain sim ple technical procedures, b u t the case m ust be in a suitable condition to m ake these procedures possible, as w ell. T h is involves chiefly the opportunity to tre a t the cases b efore conditions have developed beyond a very early stage, an d consequently the age o f the child is o f as m uch im portance as are the clin i cal procedures. In other w ords, it is necessary to have both the technic and the tim e o f applying it correlated, in o rd er to obtain the definite advantages th a t are possible. A s the first p erm anent m olar is re sponsible f o r a g rea ter am o u n t o f trouble than any other one tooth, it be com es necessary to consider the age o f its eruption as m a rk in g the latest tim e w h en tre a tm e n t m ay be considered prophylactic in character, alth o u g h , fo r the succeeding p erm a n en t teeth, the
eruption tim e may be sim ilarly con sidered. W h ile the age o f 6 years m a thus be indicated as the m axim um age, there is no definite lim ita tio n to the earliest, an d there m ay be some ques tion as to w h eth e r w e should consider it to be the age o f eruption o f the p rim ary teeth— early in fan c y — b irth , or the p ren atal period, or should go back to the g randparents. T h e greatest difficulty has been, and is still fo u n d , in g ettin g parents, nurses, physicians and dentists to appreciate the im portance o f early atten tio n , so that, in any com m unity, the age question is still m ore o f a problem th an th a t o f clinical procedures w hich have been w ell stan d ard ized an d p u t to a success fu l test. H o w ev er, this p lan o f early (6 years o f ag e) tre a tm e n t has been carried out to the ex ten t o f approxi m ately 75 per cent f o r the last fo u r or five years, but a definite advance has been m ade d u rin g the last year, w hen practically every new p atien t has n ot been m ore th a n 6 years o f age. T h is has m ade it possible p ractically to elim i nate all root canal w o rk , as teeth th a t are c a re fu lly filled w h en the cavities are o f a sim ple ch a racter do n o t come to the condition o f req u irin g large fillings, pulp an d root canal w ork, u n til late in life , i f a t all. W ith this p relim in ary explanation as to the g en eral policy o f the clinic, it w ill n o t be necessary to explain in de tail f o r each clinic the reasons f o r cer tain procedures or technic, as these w ill be the same in each instance. N o t only is substitution m ade f o r com plicated trea tm e n t, w hich results in b rin g in g prevention n earer, but also m edical and den tal procedures are adopted, such as n u tritio n , an d endocrine or m axillary orthopedic trea tm e n t, ra th e r th an the elaborate an d repeated fillings and
Department o f D ental Health Education tre a tm e n t in cases o f excessive caries or n a rro w and undeveloped arches. T h e clinics are carried on u n d er the fo llo w in g departm ents an d clinics: 1. D e n ta l: F illin g , clean in g an d ex tra c tin g ; m ax illary orthopedics. 2. M edical : P ed iatric, n u tritio n , food an d habits, and endocrine. 3. S urgical: T o n sil an d adenoid, and o ral surgery. 4. R esearch: (a) L abo rato ry — bacteriologic; chem ical; fe e d in g ; (b ) clinical— observing, reco rd in g and co r rela tin g clinical data. 5. S tatistical: F o r reco rd in g an d filing records o f a ll clinical w o rk o f a ll d epartm ents and clinics. 6. P re n a ta l: T re a tm e n t in d en tal, endocrine an d fo o d an d habit clinics. 7. R oentgen R ay an d P h o tography: F o r a ll departm ents; principally f o r m edical an d m ax illary orthopedic clinics. 8. Social Service and R e g istra tio n : F o r reg istration an d ad m ittance to all d ep artm ents; the principal fe a tu re be ing to d eterm ine the financial eligibility. T h e clinical dental w o rk is done by f u ll tim e in tern s w ho are cu rren t-y ea r graduates o f the various dental schools, an d are supervised by a fu ll-tim e p er m a n en t ch ief and tw o assistants. T h e m edical and surgical clinical w o rk is done by m edical m en on service, three m onths a t a tim e. T h e d ental cleaning (odontexesis) is done by the students o f the tra in in g school, u n d er direction o f a grad u ate supervisor. A ll patients, except in em ergency cases, first have the necessary cleaning, fillin g and ex tractin g done, and are th en given rou tin e exam inations f o r the m edical and surgical w o rk w hich is show n to be necessary, such as the r e
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m oval o f diseased tonsils o r trea tm e n t in the n u tritio n , fo o d an d habit, en docrine or m ax illary orthopedic clinics. A ll o f the clinics are definitely cor related and conducted as one w ith several branches, an d are coordinated to the ex ten t th at, as ro u tin e, each child w ho enters fo r w h atev er p articu la r type o f tre a tm e n t (except fo r em ergencies) is required to go th ro u g h a ll o f the clin i cal exam inations. In this w ay, all nec essary data p erta in in g to an individual child are obtained an d co rrelated , inde pendently o f either the p atien t or the physician in some clinic w hose casual notice m ay detect necessary w o rk to be done in an o th er one. P atients show ing such evidence o f m a ln u tritio n as approxim al or cervical caries, u n d erw eig h t, endocrine dystro phies, or g en erally poor physical con dition, are re fe rre d f o r a physical exam ination an d th en recom m ended to the suitable m edical or surgical clinic f o r trea tm e n t. A ll m edical trea tm e n t, in clu d in g food an d hab it reg u latio n , is preceded, in every instance, by a com plete physical exam ination so th a t the exact condition o f each child is k n o w n , in o rd er n o t to carry out any tre a tm e n t w hich m ig h t be contraindicated. T h e prim ary teeth o f a larg e n um ber o f ch ild ren fro m 2 to 3 years 4 o f age are treated f o r pits and fissures. I t is the aim to fill all cavities w ith in six weeks a f te r eru p tio n , w h eth e r in p ri m ary or secondary teeth. I t is' n o t yet possible to do this f o r the p rim a ry teeth to the same ex ten t as fo r the secondary, because o f the difficulty o f g e ttin g in touch w ith ch ild ren o f this age. T h ro u g h in f a n t hygiene an d preschool age ch ild re n ’s associations, a definite gain is being m ade each year an d large
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The Journal o f the American Dental Association
num bers o f this age are n o w treated. M ore tim e probably w ill be required to place the tre a tm e n t o f prim ary teeth on a par, in num bers, w ith th a t o f the first p erm a n en t m olars, than w as required f o r secondary teeth, but it w ill u n doubtedly be accom plished w ith in a fe w years. T h e results obtained by the early fillin g o f fissures an d pits w ith in a short tim e a f te r eruption o f the teeth has prom pted the adoption o f a plan to see children only at stated interv als f o r routine fillings. T h ese intervals are n o t determ ined by the calen d ar, age or school grade, b u t according to the eru p tion o f each corresponding pair o f teeth, and are sufficiently fre q u e n t to fo restall any possible rapid extension o f a devel opm ental d efect. T o m ake the w ork successful, it is necessary th a t this period be very short, and the nurses are in structed th a t w ith in “ six w eeks” is the only safe tim e. In this w ay, detailed school exam inations become unneces sary, as all th a t is required is fo r the nurse to keep w atch fo r new teeth, o f w hich the child is usually aw are, and see th a t a ll n ew teeth receive prophy lactic care and fissure and pit fillings, if required. In g en eral, the routine ages at w hich w e m ay expect to find eru p tin g pairs o f teeth are 2, 6, 9 and 12 years respec tively, v ary in g in each instance ac cording to the physiologic age and developm ent o f the child. T h u s , only three re g u la r periods o f visits fo r fill ings are needed d u rin g the school life o f the child. E ach child receives an odontexesis (to o th clea n in g ) once each year, at w hich tim e special appointm ents are m ade i f any fillings require replace m ent, or any new (approxim al or cer v ical) cavities are noted. T h e num ber
o f such cavities is quite sm all, except in cases o f m alnourished ch ild ren suffer ing fro m a serious lack o f lim e salts, or w ith endocrine com plications. I n these instances, the child n o t only has the fillin g s done, but is given appropriate m edical atten tio n fro m a n u tritio n al standpoint, such as endocrine, food and habits, etc. I n a recen t checkup, it w as fo u n d th a t 82 per cent o f the ch ild ren in the eighth an d n in th grades w ho h ad n o t been given adequate early care, but w ho had received tre a tm e n t either as first, second or th ird grade pupils, had fo u r first p erm a n en t m olars in good condi tio n ; 11 per cen t h ad three first p erm a n e n t m olars, an d these an d the balance w ere those in w hom these teeth w ere rath e r early in eru p tin g , or w h o did n o t receive tre a tm e n t u n til the end o f the th ird school year. W h ile m ost o f the cases n o t treated u n til the th ird g rad e show ed large occlusal fillings in the first m olars, these teeth w ere still being preserved, alth o u g h undoubtedly m any w ill re quire atten tio n , possibly involving tre a t m en t o f the pulp and root canals, in the n ear fu tu re . T h o se treated early in the first g rad e show only sm all fissure fillings and w ill n o t require atten tio n fo r m any years. E v en then, they w ill only reach the stage o f req u irin g sm all occlusal fillings. A n o th er phase o f the benefits o f early tre a tm e n t was as fo llo w s: In 1915, one first p erm an en t m o lar was extracted to every three teeth. T h is was g rad u ally reduced, in 1918, by early atten tio n , to one first p erm an en t m o lar to every five teeth , an d , in 1924, only one first p erm an en t m o la r in each 2 00 teeth extracted, in the groups w hich received reasonably early care a f te r the tim e o f eruption o f the first p erm an en t
Department o f Dental Health Education m olars. F ro m 1915 to 1918, a t least 50 per cent o f the first p erm a n en t m olars w ere given ro o t canal tre a t m e n t; w hile, since th en , this fo rm o f tre a tm e n t has been p ractically discarded. T h is m eans th a t the only first p erm a n e n t m olars w hich require extraction now are those in the m ouths o f children w ho, fo r one reason or ano th er, did n o t receive sufficiently early care f o r de velopm ental defects. T h e fo re g o in g F orsyth plan, w hile extrem ely sim ple an d n ontechnical in ch aracter, is g iving “ en d -resu lts” a t 16 years o f age, in h ealthy teeth w hich have had the m in im u m o f dentistry, as early repair w o rk ; and fo u r first per m a n en t m olars w ith vital pulps and sm all fillings are the satisfactory re sults. T h is is a resu lt w hich technical (o rth o d o x ) dentistry has never pro duced and nev er can, because it does not aim to prevent, but to cure an d repair. W h ile the orig in al in ten tio n w as to care f o r ch ild ren up to the sixteenth year, and this w as necessary w hen “ orthodox” dentistry w as practiced, it has been fo u n d th a t there is now no d ental reason f o r co n tin u in g this care fo r children beyond the tw e lfth year, o r the tim e th a t the second perm an en t m olars are in place an d the fissures and pits filled. T h e only exception is fo r children w ith m arked m a ln u tritio n ; but w ith the F orsyth plan, these cases usu ally have been b ro u g h t up to the stand ard o f n u tritio n b efore the tw e lfth year, so th a t, in the n ex t fe w years, there should n o t be m uch occasion fo r rep air or replacem ent o f fillings. T h e w o rk done u n d er the nam e o f m ax illary orthopedics is an o th er phase o f early tre a tm e n t w hich is g iving very satisfactory results in p rev en tin g the need o f orthodontic trea tm e n t. T h is w ork consists in expanding the m ax il
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lary bones at the usual age (5 -6 years) w hen this g ro w th usually takes place, in cases w hich, th ro u g h lack o f suitable g ro w th stim u li, f a il to develop. T h e tooth positions are n o t changed, as the teeth m erely provide attach m en ts fo r the appliance th a t expands the qrch o f the m ax illary bones; w hich assures am ple room fo r the eruption an d alin em e n t o f the six p erm a n en t teeth. A p ren a tal clinic is carried on to aid in preserving the m o th e r’s teeth an d in developing good d en tal organs fo r the child by oversight an d tre a tm e n t in the m edical, d en tal, endocrine an d fo o d and habits clinics. T h is w o rk is being carried o u t fo r prospective m others, in cooperation w ith several o f the p ren atal organizatio n s o f the city, an d .is as n ea r early tre a tm e n t an d prev en tio n as w e m ay expect to get, alth o u g h , as our know ledge increases, it should be pos sible to apply it w ith m o re certain results. O n e im p o rta n t phase o f this clinic is the m ain ten an ce, in the m o th er, o f a state o f n o n to x icity ; the reg u latio n o f her food an d other habits f o r adequate m ineral an d vitam in m etabolism , an d assurance to the endocrine organs o f any support needed to enable h e r to give to the ch ild ’s teeth every possible ad vantage o f developm ent. I t is, o f course, too soon to be able to determ in e th e results o f the p ren atal dental care phase, or to atte m p t to d raw conclusions fro m either the effect o f the endocrine or fo o d an d habits tre a t m en t a n d supervision. I t is reasonable to expect conserva tion o f the m o th e r’s teeth an d an im provem en t in the d en tal organs o f the child fro m these various activities if , as is alm ost assured, they resu lt in im proved n u tritio n , fro m the standpoint o f m in e ral m etabolism .